Health Issues in Latino Males: A Social and Structural Approach 9780813546032, 0813546036

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Health Issues in Latino Males

Critical Issues in Health and Medicine Edited by Rima D. Apple, University of Wisconsin–Madison, and Janet Golden, Rutgers University, Camden Growing criticism of the U.S. health care system is coming from consumers, politicians, the media, activists, and health care professionals. Critical Issues in Health and Medicine is a collection of books that explores these contemporary dilemmas from a variety of perspectives, among them political, legal, historical, sociological, and comparative, and with attention to crucial dimensions such as race, gender, ethnicity, sexuality, and culture.

For a list of titles in the series, see the last page of the book.

Health Issues in Latino Males A Social and Structural Approach Edited by Marilyn Aguirre-Molina, Luisa N. Borrell, and William Vega

Rutgers University Press New Brunswick, New Jersey, and London

Library of Congress Cataloging-in-Publication Data

Health issues in Latino males : a social and structural approach / edited by Marilyn Aguirre-Molina, Luisa N. Borrell, and William Vega. p. ; cm. — (Critical issues in health and medicine) Includes bibliographical references and index. ISBN 978-0-8135-4603-2 (hardcover : alk. paper) ISBN 978-0-8135-4604-9 (pbk. : alk. paper) 1. Hispanic American men—Health and hygiene. II. Borrell, Luisa N.

III. Vega, William.

I. Aguirre-Molina, Marilyn.

IV. Series: Critical issues in health and

medicine. [DNLM: 1. Minority Health—United States. 2. Health Behavior—ethnology—United States. 3. Health Status—United States. 4. Healthcare Disparities—United States. 5. Hispanic Americans—ethnology—United States. 6. Men’s Health—ethnology—United States. WA 300 AA1 H4344 2010] RA448.5.H57H393 2010 362.1089—dc22

2009040065

A British Cataloging-in-Publication record for this book is available from the British Library. This collection copyright © 2010 by Rutgers, The State University Individual chapters copyright © 2010 in the names of their authors All rights reserved No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, or by any information storage and retrieval system, without written permission from the publisher. Please contact Rutgers University Press, 100 Joyce Kilmer Avenue, Piscataway, NJ 08854–8099. The only exception to this prohibition is “fair use” as defined by U.S. copyright law. Visit our Web site: http://rutgerspress.rutgers.edu Manufactured in the United States of America

Contents

List of Figures

vii

List of Tables

ix

Foreword

xi

David R. Williams

Acknowledgments

Introduction: A Social and Structural Framework for the Analysis of Latino Males’ Health

xiii

1

Marilyn Aguirre-Molina, Luisa N. Borrell, Miguel Muñoz-Laboy, and William Vega

Part I

Key Issues Affecting the Health of Latino Men

Chapter 1

Demographic Transformations, Structural Contexts, and Transitions to Adulthood

17

Rubén G. Rumbaut Chapter 2

The Implications and Impact of Race on the Health of Hispanic/Latino Males

32

Luisa N. Borrell and Clara Rodríguez Chapter 3

Improvements in Latino Health Data

53

Olivia Carter-Pokras and Alexander H. Fischer

Part II

The Life Cycle and Latino Males’ Health

Chapter 4

Latino Boys: The Early Years

67

Marilyn Aguirre-Molina and Gabriela Betancourt Chapter 5

The Sexual and Reproductive Health of Young Latino Males Living in the United States

83

M. Antonia Biggs, Claire D. Brindis, Lauren Ralph, and John Santelli

v

vi Chapter 6

Contents

Alcohol, Tobacco, and Other Drugs

99

Andres Gil and William Vega Chapter 7

The Causes and Consequences of Poor Health among Latino Vietnam Veterans: Parallels for Latino Veterans of the War in Iraq

123

Valentine V. Villa, Nancy Harada, and Anh-Luu Huynh-Hohnbaum Chapter 8

Health of Incarcerated Latino Men

139

Sandra P. Arévalo, Laia Bécares, and Hortensia Amaro Chapter 9

Emergent Chronic Conditions

158

Sandra Echeverria and Ana Diez-Roux Chapter 10

Psychiatric Disorders and Mental Health Service Use among Latino Men in the United States

183

Antonio Polo and Margarita Alegría Chapter 11

Social Determinants of HIV/AIDS: A Focus on Discrimination and Latino Men Who Have Sex with Men

212

George Ayala Chapter 12

Health Coverage, Utilization, and Expenditures among Latino Men

229

Russell Homan, Patricia A. Homan, and Olveen Carrasquillo Chapter 13

Mental Health of Elderly Latino Males

249

Cynthia Alford and David Espino

Conclusion: New Directions for Research, Policy, and Programs Addressing the Health of Latino Males

261

William Vega, Luisa N. Borrell, and Marilyn Aguirre-Molina

Appendix: An Overview of Latino Males’ Health Status

268

Olivia Carter-Pokras and Mariano Kanamori

Contributors

307

Index

311

Figures

I.1 Analytic framework of the health and well-being of Latino men

7

1.1 Age-sex pyramid for Hispanics in the United States

21

1.2 Age-sex pyramid for non-Hispanic whites in the United States

22

1.3 Age-sex pyramid for foreign-born Hispanics in the United States

23

1.4 Age-sex pyramid for native-born Hispanics in the United States

24

4.1 Race/ethnicity of gang members

78

8.1 Drug use among inmates in local jails

144

8.2 Drug use among inmates in state and federal prisons

145

9.1 Structural and cultural factors related to chronic disease among Latino men

170

10.1 Mental health and employment of immigrant Latino men and non-Latino white men

201

10.2 Psychiatric disorders for immigrant Latino men and non-Latino white men by U.S. region 10.3 Rates of unmet need across race/ethnicity

201 202

10.4 Insurance status of U.S.-born Latino men and non-Latino white men

206

12.1 Health insurance coverage among Latinos by income and citizenship status

234

12.2 Health insurance coverage among men in states with large Latino populations

235

12.3 Sources of health insurance coverage among men age nineteen to thirty-five

237

12.4 Sources of insurance coverage among elders

238

12.5 SCHIP/Medicaid coverage among male children

239

12.6 Median health expenditures for Latinos and non-Hispanic whites

244

vii

Tables

I.1 HIV/AIDS death rates

2

I.2 Leading causes of death for Latino and white males

2

I.3 Employment status of males over age sixteen by race/ethnicity

4

I.4 Poverty status of males in labor force for twenty-seven weeks or more 2.1 Education and income according to race/ethnicity

4 38

2.2 Age-adjusted prevalence estimates according to gender and race/ethnicity

40

4.1 Selected characteristics of young males according to race/ethnicity

68

4.2 Selected health outcomes of young males according to race/ethnicity

71

5.1 Sexual health and behavior characteristics of Latino males and females age fifteen to twenty-four

86

5.2 Predicted reproductive health outcomes for Latino males and females age fifteen to twenty-four

93

6.1 Drug abuse by substance, DSM-IV disorders, ethnicity, and gender

106

6.2 Developmental transitions of prevalence of substance use among Latino males

108

6.3 Odds ratios for DSM-IV substance disorders predicted by structural factors among males

110

6.4 Odds ratios for DSM-IV substance disorders predicted by structural factors among Latino males by nativity

112

8.1 Physical and mental health conditions reported among inmates in local jails

146

8.2 Physical and mental health conditions among inmates in federal and state prisons

149

9.1 Select chronic conditions among Latinos, non-Latino whites, and the total population

162

10.1 Demographics of NCS-R non-Latino white and NLAAS Latino males 10.2 Demographics of NLAAS Latino males

185 187

ix

x

Tables

10.3 Stressors, supports, gender roles, and immigration characteristics of NLAAS Latino males

190

10.4 DSM-IV disorders for NCS-R non-Latino white and NLAAS Latino men

194

10.5 DSM-IV disorders of NLAAS Latino men across subethnic groups

196

10.6 Sociodemographic and sociostructural factors among NLAAS and NCS-R men

198

10.7 Sociodemographic and mental health factors associated with past-year service use

203

11.1 AIDS cases in states with concentrated Latino populations

214

12.1 Health insurance coverage of Latino males

233

12.2 Uninsured rates among Latino males and females

236

12.3 Proportion of elders without recommended screening tests

243

13.1 Leading causes of death for Latino males and white males over age sixty-five

250

13.2 Demographics of HEPESE elders

252

13.3 Chronic diseases in older Latinos

253

13.4 Dementia and depression in older Latinos

253

A.1 Health indicators in the United States by race

269

A.2 Infant mortality rates by selected characteristics of infants and mothers

275

A.3 Leading causes of death for Latino males ranked by ethnicity, race, and gender

277

A.4 Age-adjusted cause of death by race, Latino origin, and sex

278

A.5 Death rates by age, Latino origin, race, and gender

279

A.6 Leading causes of death for Latino males by age

280

A.7 Health behaviors among youth by age, race, and gender

285

A.8 Health behaviors among adults by age, race, and gender

288

A.9 Health care access indicators by race and ethnicity

291

Foreword

One of the largest but most neglected disparities in health is the poorer health of men compared to that of women. In the United States, for example, the gap in life expectancy between men and women is larger than the life expectancy differences between blacks and whites and between persons high in income and education compared to those of low socioeconomic status. There may be a biological contribution to the sex differences in health. In virtually every country of the world, more boys than girls are born each year, but fewer infant boys survive to see their first birthday, and this pattern of elevated health risk persists across the life course. Undoubtedly, though, there is also a large social and cultural component to gender differences in health. The ways in which men are socialized, their role opportunities, obligations, and demands differentially expose them to health risks or resources. The Hispanic population has emerged as the largest minority population in the United States, but there is still much that we do not understand about the health of Hispanics in general and the determinants of the health of Latino males in particular. And there is reason to be concerned about the health of Latino males. In many large cities, the high school dropout rate for Latino males exceeds 50 percent. Early academic failure can often place one on a trajectory not only for restricted socioeconomic mobility and increased risk of incarceration, but also for elevated health risks. A recent Pew report revealed that one in every one hundred Americans is in jail or prison. For Latino males, it is one in every thirty-six. Many factors contribute to the lack of information on Hispanic men. One has been the historic neglect of the inclusion of identifiers for Hispanic identity in our health and demographic data systems. Another has been inattention to subgroup variations within the Hispanic population, which is diverse in terms of race, ethnicity, sociodemographic factors, and nativity. One of the unique features of this volume is that the editors have brought together an outstanding multidisciplinary group of academic leaders who have combined their research expertise of studying the Latino population with their personal experience of being members of the Hispanic community themselves. They are thus able to provide a portrait of the challenges faced by Latino males with uncommon insight and sensitivity.

xi

xii

Foreword

This nuanced account of the health experience of Latino males also indicates that there is considerable reason for hope and numerous areas of opportunity. The Latino population is heavily made up of immigrants, who arrive in the United States with many cultural and psychological resources. Those who come to this country for economic reasons are highly motivated and capitalize on the opportunities of the American society. How can we ensure that Latino males have access to opportunities and experience positive milestones in development in childhood and early adulthood? How can we better understand and reverse the downward trajectory evident for multiple immigrant populations in which health worsens with increasing exposure to American society? How can we replicate some of the initial successes of immigrants in the second generation and beyond? The answers to all of these questions are not yet in, but this volume provides a previously unavailable roadmap of how to think about and to begin to effectively address these complex issues. It provides an indispensable foundation for a new generation of sorely needed research and interventions focused on the health of Latino males. David R. Williams Florence and Laura Norman Professor of Public Health Harvard School of Public Health

Acknowledgments

Many people have contributed to the production of this book. Without their collaboration and dedication, this work on Latino men’s health would not have come to fruition. I would like to acknowledge their contributions and express my deep appreciation. I would especially like to thank the W. K. Kellogg Foundation for the support provided to convene a panel of experts on the health of Latino males. The meeting provided a great deal of insight that informed the preparation of this book. As such, I would like to thank colleagues, researchers, practitioners, and policy experts who took time from their busy schedules to contribute to the project. Their support has been invaluable. This book would not exist if it were not for the contributions of the authors. Each author is an authority in his or her respective field; therefore, I want to thank them not only for their insights, but also for the time and dedication that has given life and meaning to the issues surrounding the health of Latino men. The authors’ cooperation and response to our suggestions and requests for revisions made the editing process manageable and productive. Mil gracias for your commitment. I would especially like to thank my research team at the Mailman School of Public Health, Columbia University, which managed the endless but absolutely essential details and logistics surrounding this project. To my team—Rafael Rodriguez, Gabriela Betancourt, Claudia P. Llanten Morales, and Madeline Martinez—un abrazo, and many, many thanks for making this happen! They each played an essential and integral role that assured the completion of the many tasks, procedures, and hunts for citations required in the early phases. Additionally, a special acknowledgment to my team at Lehman College, City University of New York—Ida Shiela Salusky and Juan David Gastolomendo—who edited and formatted each of the chapters. Their dedication, attention to detail, and endless hours of work made the final stages of preparation possible. Last but not least is deep appreciation to Luisa Borrell and Bill Vega, long time colleagues and friends who made it possible to collaborate on an issue to which we are deeply committed and that has been, for too long, under looked.

xiii

xiv

Acknowledgments

This acknowledgment would not be complete without recognizing the editors’ home institutions for valuing this work: Lehman College at the City University of New York and David Geffen School of Medicine at the University of California, Los Angeles. Marilyn Aguirre-Molina

Health Issues in Latino Males

Marilyn Aguirre-Molina, Luisa N. Borrell, Miguel Muñoz-Laboy, and William Vega

Introduction A Social and Structural Framework for the Analysis of Latino Males’ Health

Over the next fifty years, the racial and ethnic composition of the United States is projected to dramatically change. Currently, the Latino population makes up approximately 14 percent (41.3 million) of the total U.S. population, excluding the residents of Puerto Rico and many undocumented Latinos. It is estimated that 75 percent of all Latinos residing in the United States are immigrants or children of immigrants. The Latino community is projected to grow annually by at least 2 percent until 2030. By 2050, population growth estimates forecast that Latinos will double in size, becoming almost 25 percent (102.6 million) of the total U.S. population (U.S. Census Bureau 2002, 2004). As the Latino population in the United States increases, so will the significance of its economic and workforce contributions. Maintaining the health of Latinos will have major implications for society as Latinos are increasingly represented among consumers, business owners and workers, taxpayers, voters, and public officials. Given the growth of their collective voice, the Latino community will become a powerful social, political, and economic constituency with major influence on the trajectory of this nation. Therefore, focusing on their health and well-being, including an improved understanding of the factors that affect and influence their health, is ultimately in the community’s and the nation’s best interests. Why a Focus on Latino Males

Although the health of the American population has improved over the past thirty years, these improvements have not occurred equally across all segments of the population. Specifically, the health status of minority groups such as 1

Table I.1

HIV/AIDS Death Rates per 10 0,0 0 0, 20 04 Non-Hispanic

Hispanic/non-Hispanic

Hispanic

white

white ratio

All, men (age-adjusted)

8.2

3.1

2.6

All, women (age-adjusted)

2.4

0.6

4.0

Ages

25–44, men

9.3

5.5

1.7

25–44, women

3.1

1.3

2.4

19.4

6.0

3.2

5.0

0.9

5.6

45–64, men 45–64, women Source: CDC 2004, table 42, p. 236.

Table I.2

Leading Causes of Death for Latino and White Males, 20 04 (in Percent)

Age

Latino

White

15–19

Accidents—44.5

Accidents—55.7

20–24

25–34

35–44

45–54

55–64

Assault—26.8

Intentional self-harm—15.6

Intentional self-harm—10.2

Assault—9.1

Accidents—43.7

Accidents—51.9

Assault—25.1

Intentional self-harm—17.1

Intentional self-harm—11.7

Assault—9.7

Accidents—38.1

Accidents—39.7

Assault—18.6

Intentional self-harm—17.1

Intentional self-harm—10.3

Assault—7.3

Accidents—24.3

Accidents—23.9

Diseases of the heart—12

Diseases of the heart—16.5

Malignant neoplasms—10.1

Malignant neoplasms—12.3

Diseases of the heart—18.6

Diseases of the heart–24.2

Malignant neoplasms—18.5

Malignant neoplasms—23.3

Accidents—11.5

Accidents—11.5

Liver diseases—9.8

Intentional self-harm—5.5

HIV—5.3

Liver diseases—5.3

Malignant neoplasms—27.3

Malignant neoplasms—34.2

Diseases of the heart—25.7

Diseases of the heart—27.6

Diabetes—6.5

Accidents—4.2

Liver diseases—6.0

Lower respiratory diseases—4.1

Accidents—5.1

Diabetes—3.7 (Continued)

Introduction Table I.2

3

Continued

Age

Latino

White

65

Diseases of the heart—31.1

Diseases of the heart—30.6

Malignant neoplasms—24.2

Malignant neoplasms—25.2

Cerebrovascular diseases—6.6

Lower respiratory diseases—6.7

Diabetes—5.6

Cerebrovascular diseases—6

Chronic lower respiratory diseases—4.2

Influenza/pneumonia—2.9 luenza/pneumonia—2.9

Note Percentages represent total deaths in the age group due to the cause indicated. Source: CDC 2004.

African Americans and Latinos has not benefited from these improvements; in fact, it has worsened when compared to that of their white counterparts. While health services utilization data indicate that, on average, women experience worse health outcomes when compared to men, a detailed review of health data suggests that the disparities among males are more fundamental and result in higher mortality rates. Ethnic/racial minority males are also at a significant disadvantage with respect to white males. For example, Latino male’s life expectancy on average is five years less than white males (69.6 vs. 74.5) (Meyer 2003). These data reflect the increased death rates for several disease categories among Latinos. For instance, in 2003 Latino males were twice as likely as white males to die from HIV/AIDS-related causes (25.5 vs. 12.5 per 100,000 people) (Center for Advancement of Health 2003). Further, between the ages of 15–34, deaths due to assaults were higher than they are for whites (table I.2). Clearly, the numerous burdens of morbidity and mortality that Latino men face demonstrate the urgent need to conduct innovative research and analysis to identify the specific determinants affecting these disparities, and to generate effective means to overcome them. Social and Structural Vulnerability of Latino Males

There is overwhelming evidence that economic inequality creates unequal health in modern human populations’ net of access or quality of medical care received (Marmot 2006). Gradations in social position produce robust differences in chronic illness and mortality, with differences apparently attributable to social arrangements that minimize the personal autonomy and social participation of poor people and maximize exposure to chronic social stress and traumatic events (Berkman and Glass 2000; Hemingway et al. 2005). It is also well

4 Table I.3

Aguirre-Molina, Borrell, Muñoz-Laboy, and Vega Employment Status of Males over Age Sixteen by Race/Ethnicity: 20 04 Annual Averages Employed

Unemployed

Total

% of

Total

% of

(thousands)

population

(thousands)

labor force

White

62,712

70

3,282

5

Hispanic or Latino

10,832

75

755

7

Race/ethnicity

Source: U.S. Department of Labor, Bureau of Labor Statistics 2005.

Table I.4

Poverty Status of Males in Labor Force for TwentySeven Weeks or More, 20 03 (in Thousands)

Age

White

Hispanic or Latino

16–19

7.2

12.3

20–24

7.1

9.0

25–34

6.2

13.7

35–44

4.6

11.9

45–54

2.7

7.7

55–64

2.2

6.6

65

1.4

4.6

Source: U.S. Department of Labor, Bureau of Labor Statistics 2005.

established that the pathophysiology of disease, which involves social and biological mechanisms and their interaction, is distinctive by sex. Thus, there are strong reasons to examine how sex and structured inequality operate in tandem to shape lifestyles and long-range physical and existential well-being. Although males, compared to females in all socioeconomic groups, are disadvantaged in terms of health, males of low socioeconomic status are particularly vulnerable. Low socioeconomic status is one of the strongest known determinants of health disparities (Adler 1999; Williams 1995). In addition, among low-income males, those who belong to a racial or ethnic minority group are at a particularly high risk for negative health outcomes (Williams 2003). As such, racial and ethnic disparities among males have their roots in social and structural factors (Johnson and Smith 2002). For example, marginalized men are more likely to experience unemployment, undereducation, poverty, and incarceration, all of which contribute to poor health outcomes compounded by barriers to healthcare (Brown et al. 2000).

Introduction

5

Over the last thirty years, unemployment rates have increased among minority males and in particular among Latinos (see table I.3). Among those who are employed, Latino males are overrepresented in work sectors characterized by limited job security, part-time or seasonal employment, low wages, no benefits, and numerous occupational risks (Bourgois 1995; Brown and Yu 2002; Wilson 1997). These data are particularly concerning, because research has demonstrated that unemployment and job insecurity are associated with higher rates of stress, illness, disability, and mortality (Williams 2001). Further, marginal employment or lack of employment significantly reduces the possibility of having health insurance and access to health care. When compared to white males, a much greater proportion of Latino males are uninsured (17 percent vs. 46 percent) (Brown et al. 2000). Marginal employment and unemployment reduce Latinos’ access to preventive and primary health care services and increase their risk for premature mortality. Furthermore, data suggest that limited access to health care appears to contribute to Latino males’ increased risks of dying from chronic illnesses (e.g., HIV/AIDS, diabetes, and cardiovascular and heart diseases) and other disorders (Aguirre-Molina and Pond 2003). Latino males are more likely than whites to report low socioeconomic status and higher rates of poverty (20 percent versus 7 percent). Between the ages of eighteen and sixty-four, Latinos are twice as likely as whites to be classified as poor or near poor (43 percent vs. 19 percent). Further, 24.1 percent of Latino children and adolescents under age eighteen fall into this category— a number considerably greater than the 7.2 percent among white children and adolescents (National Center for Health Statistics 2004). In addition, working Latino males are more likely to experience poverty than white males (see table I.4). Consequently, Latino males’ increased likelihood of low socioeconomic status significantly increases the probability for health disparities because they are male, unemployed, or low-income status; and, as previously indicated, they are likely to be uninsured. Low-income adult males are less likely to have health insurance primarily because they are not enrolled in Medicaid and because they are more likely to work in jobs that do not offer health insurance (Guttmacher Institute 2005; Meyer 2003). Comprehensive Analysis of Latino Males’ Health Status

Reflection on the role of social and structural factors is key to achieving a comprehensive approach to understanding the health of ethnic minorities in general, and it is particularly important when addressing the health status of

6

Aguirre-Molina, Borrell, Muñoz-Laboy, and Vega

Latino males. Traditionally, the study of males’ health—and Latino male in particular—has emphasized the role of the social construction of masculinity. Although the relationship between beliefs about masculinity and health behaviors (cultural and behavioral) is established (e.g., Bracero 1998; Marín 2003; Peters 1999; Sternberg 2000; Torres 1998), a more comprehensive approach is needed that incorporates the role of materialist and structuralist factors (e.g., poverty, low socioeconomic status, unemployment, racial characteristics, urban contexts, migration, etc.) and moves beyond interventions of limited efficacy. Therefore, a comprehensive approach investigates the importance of “cultural/ behavioral” and “materialist/structuralist” explanations for socioeconomic inequalities in health and examines the interrelationship between them (Stronks et al. 1996). In doing so, such an analysis distances itself from a pure “culturalist” perspective that overemphasizes the role of Latino culture (e.g., “machismo”) as a determinant of Latino males’ health behaviors and related health disparities. Structural Model to Analyze Latino Males’ Health

To illustrate this approach, a conceptual framework comprised of three domains analyzes how health outcomes, negative or positive, are influenced, shaped, and amplified by societal factors. The three domains are the individual, the community, and the structural environmental (see fig. I.1). The model posits that as Latino males age, they may disproportionately encounter and experience disrupted and unstable familial structures (e.g., single-parent households or low incomes) that can mediate, diminish, or amplify the effects of other social and biologic risk factors (e.g., quality of education, level of poverty, available role models, discrimination, racism, segregation, and personal resilience). Further, the experiences encountered are nested in the social environment and involve the confluence of social networks and political and economic climates, which are uniquely expressed in each community. The assumption of this volume is that processes that result from unequal access to resources, combined with each individual’s interactions with institutions and groups, systematically create a hierarchy of social position and a health gradient in American society. Undertaking a comprehensive structural analysis of the factors affecting the health of Latino males ultimately serves to identify comprehensive, efficacious interventions and enables policies that reduce disparities, as well as improves health and well-being. The most effective health outcomes are based on programmatic initiatives that flow directly from policies that address structural disparities and respond to the community’s needs. They are not reliant on the assumption that personal behaviors and choices are independent or

Community sociocultural contextual factors/ community and familial factors

Historical-political economic factors/ social inclusion— exclusion

Structural

Figure I.1

Factors affecting health status and well-being

Negative Requires 1,2,3 prevention

Individual health initiatives

Programmatic and community

Policy

Analytic framework of the health and well-being of Latino men.

Biopsychosocial processes

Sociodemographic characteristics

Individual

Positive Must be maintained or enhanced

Health outcomes

Targets for advocacy

Health and well-being of Latino men

8

Aguirre-Molina, Borrell, Muñoz-Laboy, and Vega

sufficient to address the health and social maladies affecting Latino males. The model presented here is intended to provide the foundation for a comprehensive analysis of factors contributing to health disparities among Latino males, through which effective interventions and policies can be developed. Social Predictors Structures

Structural factors refer to the ordered interrelationships between different elements of a social system that shape the lives and health of Latino males. They constitute social systems that influence social conditions and health at the population level (Giddens 1981). In other words, the institutions and social systems of a society (e.g., kinship, religious, political, and economic) differentially influence health behaviors and risk practices, as well as access to health care, of subgroups that compose the population in a society. In the United States, structures have a profound impact on the health status of Latinos. These structures comprise the histories of Latinos, including conquests and domination, colonization, and immigration trajectories; religious traditions, including moral values and norms, indoctrination, and resistance; gender systems, including ideologies about masculinity and femininity, marriage, and sexuality;1 political-governmental systems, including social policies, immigration regulations, criminal and civil laws, and human rights; and economic systems, including economic transformations from agricultural to industrial to postindustrial service economies, underground economies, and globalized economies. Because of the prevailing view that structures are seldom changeable, they are nominally acknowledged in public health analyses and are often ignored in the exploration of the factors that shape health and produce risk. This omission has made it all too easy to justify poor health status as a simple outcome of the individual’s self-will and behavior, or to place sole reliance on individual change interventions as a public health modus operandi. Community

The community refers to a particularly constituted set of social relationships or social ties based on shared interests or conditions. It would be conceptually incorrect to declare that Latino males in the United States are a single community. Across the country, Latino males participate in diverse communities that constitute their social milieu. It is within the community domain that decisive and immediate factors occur to shape the lives and health of Latino males. Social networks, friendships, kinships, or intimate contacts can influence

Introduction

9

health and have an effect on outcome, which can vary if analyzed from the perspective of different kinds of networks (e.g., social circle of family and friends, fraternal groups, and the shapes and flows within networks). Social capital, the capacity of individuals to obtain resources by virtue of their membership in networks, is therefore a property of the individual’s relationships with others in their community (Portes 1995). Social cohesion—the extent of connectedness and solidarity among groups in society—however, refers to two broader intertwined features of society: the absence of latent social conflict and the presence of strong social bonds (Berkman and Glass 2000). And then there is cultural capital, which involves a variety of linguistic and cultural competencies learned in the familial and community space that are required to succeed in educational and work environments. Cultural capital, like other forms of capital, is usually inherited and unequally distributed within Western capitalist societies. Therefore, it is typically controlled by the dominant socioeconomic classes of the social system (Bourdieu 1973). Finally, gender norms, the socially learned and culturally defined rules about how males and females should behave in specific contexts and spaces, are often referred to as norms of masculinity and femininity within the cultural environment of the community and family. Gender ideologies (structures) are normalized, practiced, and regulated by the social networks (Williams and Stein 2002). By identifying community factors and their influence on Latino males’ status and health, we gain an understanding of the immediate social and material contexts that facilitate or protect males from health risks. Equally important, this insight enables the development of a course of action to improve the situation of the individual within the community. Individual

The structural and community contexts directly influence individual factors, as illustrated in the analytical framework. Although individual factors are typically conceptualized by the cognitive and genetic configuration of the individual, the concept of individual-level factors utilized in the present model includes unique personal characteristics that contribute to one’s health and well-being. Within the current framework, individual-level factors are seen as belonging to two categories. The first category includes fixed factors, or those characteristics of the individual that cannot be changed. These include, but are not limited to, factors such as race, age, birth weight, early life trauma exposures, household composition during childhood, parental death, and genetic predisposition (innate resilience) to chronic and mental illness.2 The second category comprises individual factors amenable to change, including

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Aguirre-Molina, Borrell, Muñoz-Laboy, and Vega

years of education, age at first sex, attitudes, beliefs, expectancies, and health behaviors. In addition, within the realm of individual factors, social and structural factors are mediated by bio-psychosocial processes, which refer to the interplay of three key domains of human experience: the biological (bio), psychological (psycho), and social aspects of the self. The conceptual model moves beyond the more traditional definitions of bio-psychosocial process in that the structural and community factors impact Latino men’s health through the mediating effects of bio-psychosocial processes. The independent effects of structural and community health determinants uniquely interact for a given individual and constitute a process versus a static condition. These process experiences result in bio-psychosocial changes in an individual that are neither outcome nor time specific, nor do they translate into the same results across all individuals. For some, these changes accumulate longitudinally across their life course. For example, many factors contribute to the onset and prevalence of depressive disorders in individuals. The etiology of clinical depression may be in part biological (a chemical imbalance), in part psychological (sadness resulting from the death of a loved one), or the result of the social domain (strained interactions with family or friends). In addition, bio-psychosocial processes may be impacted by structural factors (e.g., discriminatory policies). The later conceptualization reflects a more complex and appropriate way of applying the model to the health of Latino males. It is inclusive of systemic interactions rather than solely individual level interactions, and it is more consistent with the conceptual framework. Given this perspective, entire populations may experience health outcomes resulting from structural factors such as poverty, lack of health insurance, community violence, or discriminatory policies. Lastly, bio-psychosocial changes within the individual domain are not limited to creating negative outcomes alone. Health and wellness are also logical outcomes associated with this process and are consistent with individuals being differentially impacted by structural, community, and individual factors. The disparate outcomes between individuals exposed to similar environments are not often understood, but they have been described in several bodies of literature as resiliency or “subjective life control” (Green, Betancourt and Carrillo 2002). Resiliency refers to an individual’s ability to positively adapt to adverse conditions. The term “subjective life control” refers to an individual’s ability to exert influence in his or her life through tangible (e.g., financial resources, job security and benefits, health insurance, and education) and intangible means (e.g., personal and psychological factors, such as family and social supports and spirituality).

Introduction

11

Programs and Interventions

Policy initiatives are most suited to addressing the social and economic roots of disparities. At each of the levels identified in the model, there are corresponding programmatic interventions to address the factors affecting the health and well-being of the individual, community, and larger social system. This entails, for example, structural-level policies (fair employment and living wage initiatives and improvements in access to care and educational reform); community-level policies (supportive community development, environmental justice, and housing reforms); and individual-level policies (supportive public health policies such as early screening for learning disabilities, reduced youth access to tobacco products, interventions with youth at high risk for inadequate transitions into adulthood, and attention to reproductive health services for males). The most effective health and social outcomes are based on programmatic initiatives that flow directly from policies that address structural disparities. Programmatic interventions to address health and social disparities are often individually driven—that is, they rely on changes in men’s health beliefs and practices. Such interventions operate on the assumption that personal behaviors and choices are sufficient to address the health and social maladies affecting Latino males. Unfortunately, any policies and interventions that focus on the individual alone are limited in both scope and potential to effect positive change. Additionally, policies and interventions that do not reflect or respond to the needs of the community or population are also of limited value. In contrast, the model presented here provides a foundation to conduct a comprehensive analysis of the multiple factors (i.e., individual, community, and social) contributing to health disparities among Latino males. Above all, the demographic imperative of Latino population structure must be placed front and center in any consideration of health and social policies. It is the rapidly expanding second generation of Latino males who are young, disproportionately poor, and faced with many barriers and inadequate resources who will endure the harshest health impacts of the structural factors addressed in this volume. It is only through a careful analysis that the multiple factors resulting in health disparities among Latino males can be adequately recognized, understood, and, more importantly, addressed. Notes 1. Gender is included here as an example of a structural factor because it operates within an unequal structural field to limit the access resources among certain groups, such as women and persons of nonnormative gender identities. While ideologies and norms are often understood as purely social or cultural, we consider

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them as structural when they have consequences for the material conditions of particular marginalized groups. 2. Although race and ethnicity are traditionally viewed as fixed characteristics of the individual, evidence suggests that the social construct nature of these concepts are fluid depending on context and social structure arrangements. References Adler, N. E., M. Marmot, B. S. McEwen, and J. Stewart, eds. 1999. Socioeconomic status and health in industrial nations: Social, psychological and biological pathways. Vol. 896. New York: Annals of the New York Academy of Sciences. Aguirre-Molina, M., and A. Pond. 2003. Latino access to primary and preventive health services: Barriers, needs and policy implications. New York: Columbia University. Berkman, L. F., and T. Glass. 2000. Social integration, social networks, social support and health. In Social epidemiology, ed. F. Berkman and I. Kawachi. New York: Oxford University Press. Bourdieu, P. 1973. Cultural reproduction and social reproduction. In Knowledge, education, and social change: Papers in the sociology of education, ed. R. Brown, 71–112. London: Tavistock. Bourgois, P. 1995. In search of respect: Selling crack in El Barrio. New York: Cambridge University Press. Bracero, W. 1998. Intimidades: Confianza, gender, and hierarchy in the construction of Latino-Latina therapeutic relationships. Cultural Diversity and Mental Health 4 (4): 264–277. Brown, E. R., V. D. Ojeda, R. Wyn, and R. Levan. 2000. Racial and ethnic disparities in access to health insurance and health care. Los Angeles: UCLA Center for Health Policy Research and the Henry J. Kaiser Family Foundation. Brown, R., and H. Yu. 2002. Latinos’ access to employment-based health insurance. In Latinos remaking America, ed. M. Suarez-Orozco and M. Paez, 236–253. Berkeley: University of California Press. Center for Advancement of Health. 2003. The forgotten population: Health disparities and minority males. Facts of Life: Issue Briefings for Health Reporters 8 (5). http://www.cfah.org/factsoflife/vol8no5.cfm. Centers for Disease Control and Prevention (CDC). 2004. Leading causes of death in males: United States, 2004. http://www.cdc.gov/men/lcod.htm. Giddens, A. 1981. Agency, institution, and time-space analysis. In Advances in social theory and methodology: Toward an integration of micro- and macro-sociologies, ed. K. D. Knorr-Cetina and A. V. Cicourel, 161–174. Boston: Routledge & Kegan Paul. Green, A., J. Betancourt, and C. Carrillo. 2002. Integrating social factors into crosscultural medical education. Academic Medicine 77 (3): 193–197. Guttmacher Institute. 2005. Issues in brief: Looking into men’s sexual and reproductive health needs. http://www.agi-usa.org/pubs/ib_4–02.html. Hemingway, H., M. Shipley, E. Brunner, A. Britton, M. Malik, and M. Marmot. 2005. Does autonomic function social position to coronary risk? The Whitehall II Study. Circulation 111: 3071–3077 Johnson, J. C., and N. H. Smith. 2002. Health and social issues associated with racial, ethnic, and cultural disparities. Generations 26 (3): 25–32. Marín, B. V. 2003. HIV prevention in the Hispanic community: Sex, culture, and empowerment. Journal of Transcultural Nursing 14 (3): 186–192. Marmot, M. G. 2006. Status syndrome: A challenge to medicine. JAMA 295: 1304–1307.

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Meyer, J. 2003. Improving male’s health: Developing a long-term strategy. American Journal of Public Health 93 (5): 709–711. National Center for Health Statistics . 2004. Advance data: Access to health care among Hispanic/Latino children. United States, 1998–2001. Number 344. http://www.cdc .gov/nchs/data/ad/ad344.pdf. Palloni, A., and E. Arias. 2004. Paradox lost: Explaining the Hispanic adult mortality advantage. Demography 41 (3): 385–415. Peters, S. 1999. Machismo and mortality: Why are males reluctant to seek health care? Advance for Nurse Practitioners 7 (4): 51–52. Portes, A. 1995. Children of immigrants: Segmented assimilation and its implications. In The economic sociology of immigration, ed. A. Portes, 248–280. New York: Russell Sage. Sternberg, P. 2000. Challenging machismo: Promoting sexual and reproductive health with Nicaraguan males. Gender and Development 8 (1): 89–99. Stronks, K., H. Dike Van de Mheen, C. W. N. Looman, and J. P. Mackenbach. 1996. Behavioral and structural factors in the explanation of socio-economic inequalities in health: An empirical analysis. Sociology of Health and Illness 18 (5): 653–674. Torres, J. B. 1998. Masculinity and gender roles among Puerto Rican males: Machismo on the U.S. mainland. American Journal of Orthopsychiatry 68 (1): 16–26. U.S. Census Bureau. 2002. Current Population Survey, March 2002. Washington, DC: U.S. Census Bureau. ———. 2004. Census Bureau projects tripling of Hispanic and Asian populations in 50 years; non-Hispanic whites may drop to half of total population. http://www .census.gov/Press-Release/www/releases/archives/population/001720.html. U.S. Department of Labor, Bureau of Labor Statistics. 2005. Washington, DC: U.S. Bureau of Labor Statistics. Williams, C., and A. Stein, eds. 2002. Sexuality and gender. Oxford: Blackwell. Williams, D. R. 1995. U.S. socioeconomic and racial differences in health: Patterns and explanations. Annual Review of Sociology 21: 349–386. ———. 2001. Race and health: Trends and policy implications. In Income, socioeconomic status and health: Exploring the relationships, ed. J. A. Auerbach and B. K. Krimgold. Washington, DC: National Policy Association. ———. 2003. The health of males: Structured inequalities and opportunities. American Journal of Public Health 93 (5): 724–731. Williams, D. R., and C. Collins. 2001. Racial residential segregation: A fundamental cause of racial disparities in health. Public Health Reports 116: 404–416. Wilson, G. 1997. Pathways to power: Racial differences in the determinants of job authority. Social Problems 44 (1): 38–54.

Chapter 1

Rubén G. Rumbaut

Demographic Transformations, Structural Contexts, and Transitions to Adulthood

A new era of mass immigration, accelerating since the 1970s and largely coming from developing countries of Latin America and Asia, has transformed the ethnic composition of the U.S. population. Today about 70 million people are of foreign birth or parentage—23 percent of all Americans, including 90 percent of all Asians and 76 percent of all Hispanics (Portes and Rumbaut 2006). They include nearly 70 million foreign-born persons—of whom 12 million are estimated to be undocumented immigrants, mostly from Mexico and Central America (Passell 2006)—and another 40 million of foreign parentage. This immigrant-stock population, the largest ever, is a youthful one—and today’s U.S.-born second generation, with a median age of twelve, is poised to explode into adulthood in the coming ten to twenty years. They are coming of age in an otherwise aging society undergoing profound social and economic transformations, a process that is straining the social contract between natives and newcomers and raising questions about how the commitment to democratic values of equity and inclusion will be met (Myers 2007; Tienda 2002). The incorporation of these newcomers has coincided with a postindustrial period of economic restructuring and rising inequality, during which the returns to education and advanced educational credentials have sharply increased. Simultaneously, the U.S. labor market has become bifurcated into high-tech/high-wage and manual/low-wage sectors—attracting distinct streams of immigrant workers, from skilled professionals to undocumented laborers. As the post–World War II era of sustained economic growth, low unemployment, and rising real wages ended for most workers by the early 1970s, men with only a high-school degree or less were hardest hit. For example, the 17

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proportion of those workers who failed to earn enough in a year to support a family of four at the poverty line grew between 1975 and 1993 from 25 to 50 percent among Hispanics, from 31 to 45 percent among non-Hispanic blacks, and from 14 to 24 percent among non-Hispanic whites (Danziger 2004). Postsecondary schooling significantly lengthened for young people, with the years from eighteen to the mid- and even late twenties becoming increasingly devoted, often with continuing parental support, to the accumulation of human capital and college credentials. Many changes occurred at this time—women entered the labor market in large numbers and worked longer hours, twoincome families became the norm, and the baby boom was followed by a baby bust and delayed childbearing. Additionally, there were changes in family forms, including what has come to be called a “retreat from marriage,” with high divorce rates (which peaked in 1980 but have remained high since) and sharp increases in cohabitation and nonmarital childbearing (Landale et al. 2006). In short, social timetables that were widely observed a half century ago for accomplishing adult transitions have become less predictable and more prolonged, diverse, and disordered (Settersten et al. 2005). The new era of mass immigration has also coincided with an era of mass imprisonment in the United States, which has further transformed paths to adulthood among young men with low levels of education (Pettit and Western 2004). The number of adults incarcerated in federal or state prisons or local jails in the United States skyrocketed during this period, quadrupling from over 500,000 in 1980 to 2.2 million in 2005 (U.S. Department of Justice 2006). The majority are young men between eighteen and thirty-four. Those figures do not include the much larger number of those on probation (convicted offenders not incarcerated) or parole (under community supervision after a period of incarceration). When they are added to the incarceration totals, over 7 million adults were under correctional supervision in the United States in 2006. Imprisonment rates vary widely by gender (over 90 percent of inmates in federal and state prisons are men); by racial-ethnic groups (there were 4,834 black male prisoners per 100,000 black males in the United States, compared to 1,778 Hispanic males per 100,000 and 681 white males per 100,000, although since 1985 Hispanics have been the fastest growing group being imprisoned); and by education. This is most salient among racial minorities for whom becoming a prisoner has become a modal life event in early adulthood. Stunningly, as Pettit and Western (2004) have noted, a black male high school dropout born in the late 1960s had a nearly 60 percent chance of serving time in prison by the end of the 1990s, and recent birth cohorts of black men are more likely to have prison records than military records or bachelor’s degrees. Whether the future

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of Latino men without a high school diploma will approximate those patterns or not remains an open empirical question. During the years of the transition to adulthood from the late teens through the twenties, as postsecondary educational attainment has become critical to social mobility for both men and women, incarceration (for young men) and early childbearing (for young women) have emerged as two turning points— albeit fundamentally different ones—that can derail life course trajectories by blocking or disrupting educational and occupational opportunities to develop human capital and move into the economic mainstream. Having a prison record is not only linked to unemployment, lower wages, marital and family instability, and severe restrictions on social and voting rights (including lifetime disenfranchisement in many states), but also to stigmatized identities and pathways to criminal recidivism (Laub and Sampson 2003). In a cycle of cumulative disadvantage, young men and women with low levels of education are significantly more likely to become prisoners or young parents, respectively, than same-age and same-sex peers with higher levels of education. The Demographic Momentum of the Hispanic Population

According to the U.S. Census Bureau (2004a, 2004b), the Hispanic population of the United States reached 40 million in 2003.1 It had been estimated at only 4 million in 1950, but is now projected to grow to an estimated 103 million by 2050 and account for 25 percent of the national total, significantly exceeding the proportions of other ethnic or racial minorities. Hispanics can claim a history and a territory in what is now the United States that precedes the establishment of the nation. At the same time, it is a population that has emerged seemingly suddenly, its growth driven both by accelerating immigration from the Spanish-speaking countries of Latin America—above all, from Mexico— and by high rates of natural increase. Indeed, 45 percent of the total Hispanic population of the United States today is foreign-born, and another 31 percent consists of a rapidly growing second generation of U.S.-born children of immigrant parents. Immigration and generation are crucial dimensions of the Hispanic population and of their incorporation processes and outcomes. Hispanics accounted for half of U.S. population growth between 2000 and 2004, although they comprise 14 percent of the total population (U.S. Census Bureau 2004a, 2004b). By contrast, non-Hispanic whites accounted for only 18 percent of the increase in population over the same period, though they comprised more than two-thirds of the total population. Relatively high rates of immigration and fertility have shaped the growth and the creation of an especially youthful age structure among most Hispanic groups (the Cubans are

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an older group and a notable exception to this pattern). While their expansion was due primarily to immigration in the 1980s and 1990s, births are now outpacing immigrants as the driver of Hispanic population growth and will increasingly become the most important component of growth (Telles et al. 2006). The birth rate of Hispanics is much higher than that of non-Hispanic whites. Among U.S. women between the ages of fifteen and forty-four, the mean number of children a woman bears (the total fertility rate) is 1.8 for nonHispanic whites and 2.8 for Hispanic women (Saens 2006). Among the various national origin groups, Mexican women had the highest fertility, with a rate of 3.3 in 2000, while Cuban women had only 1.9 children. Moreover, while only 5 percent of Hispanics are age sixty-five or older, among non-Hispanic whites the proportion of older people is three times larger. As a result of these significant differences in age structure and fertility, there is a huge difference in the ratio of births to deaths between these two populations. Among non-Hispanic whites there is approximately one birth for every death. Among Hispanics, the ratio is eight births for every death. The youthfulness of the Hispanic population will thus supply much of the United States’ population growth in the decades to come (Haub 2006). These contrasting dynamics in the age structures of Hispanics and nonHispanic whites can be seen clearly in the two population pyramids shown in figures 1.1 and 1.2. The non-Hispanic white population is concentrated in the older age groups (its median age is 40.4), which will expand further as aging baby boomers (the large bulge of the generation born after World War II) start reaching sixty-five in 2011. The pyramid for Hispanics, on the other hand, is concentrated in the younger age groups (its median age is twenty-seven), reflecting both their higher birth rates as well as the immigration of working-age young adults with children, and a disproportionate number of males in the younger working ages (as is typically seen in labor migrations, especially among undocumented migrants; this pattern is most pronounced among Mexicans, Salvadorans, and Guatemalans). Almost 40 percent of the total Hispanic population is under age twenty, and 65 percent is under age thirtyfive. The smaller proportion of Hispanics in the older age groups also explains why at present there are not many deaths in this population in comparison to the much older non-Hispanic white and black populations. As figures 1.3 and 1.4 further show, immigrants among the Hispanic population dominate the twenty to thirty-nine-year-old age bars; indeed, half of them are in their twenties and thirties, and males predominate among them. In sharp contrast, their U.S.-born children fill the ranks of the youngest age

6

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Age-sex pyramid for Hispanics in the United States.

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Figure 1.1

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Age-sex pyramid for non-Hispanic whites in the United States.

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Figure 1.2

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Age-sex pyramid for foreign-born Hispanics in the United States.

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Figure 1.3

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Age-sex pyramid for native-born Hispanics in the United States.

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Source: Based on data from the 2006 Current Population Survey.

Figure 1.4

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Demographic Transformations

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brackets; over half of them are under twenty. A large, diverse Hispanic component born and socialized in the United States is now and will increasingly be entering the labor force; in parts of the country it will dominate the blue-collar workforce for at least the next forty years. The Latino proportion of the U.S. electorate is also certain to grow, which can have measurable impacts on U.S. leadership early in the twenty-first century. Overall, this infusion of young persons into the U.S. population will allow it to keep a relatively young age profile, in sharp contrast to the aging populations of most industrialized countries, particularly in Europe and Japan. Hispanics are thus coming of age in an aging society. Although the Hispanic population will continue to grow through immigration, it is primarily the U.S.-born children and grandchildren of immigrants—the rising second generation and their offspring—who will shape its economic and social destinies. The impact of the youthful age structure and above-average birthrates of Hispanics is already being felt in schools today; it will be felt tomorrow in higher education and in labor markets. Comparisons by Gender, Panethnicity, and National Origin

In 2006, there were over 66 million young adults eighteen to thirty-four in the United States, evenly divided by gender. However, among Hispanics—unlike all other groups—there is a much greater proportion of males than females. In fact, Latino men make up more than 20 percent of all males eighteen to thirty-four in the country—compared to 12 percent of blacks and 5 percent of Asians. Significantly, non-Hispanic whites and blacks are overwhelmingly long-term natives (nearly 90 percent), whereas 95 percent of Asian and 80 percent of Hispanic nationalities are of foreign birth or parentage. Those newcomers in turn are situated at the polar ends of the opportunity structure. Educational and occupational inequalities between non-Hispanic whites and blacks seem narrow compared to the gulf that separates Asians and Hispanics. Asian men are at the top of the educational hierarchy, with 62 percent having college or advanced degrees (of those twenty-five and older) and only 8 percent failing to complete high school (and those tend to be preponderantly from low-socioeconomicstatus Cambodian and Laotian refugee groups); Latino men are at the bottom, with 41 percent of young adult males having less than a high school diploma and less than a tenth having college or advanced degrees (of those twenty-five and older). The educational deficit is most pronounced among foreign-born Latin Americans, many of whom came to work in their teens and had not completed secondary schooling in their country of origin (it is not so much that they “dropped out” of high school as that they never “dropped in”). Latino men

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are also mired in the lowest rungs of the U.S. labor marker, with nearly two out of three employed in low-wage labor; while 54 percent of Asian young men are employed in the highest status jobs. On the other hand, Hispanics have the highest labor force participation rate and are the most likely to be working full time, to be married, and to have children; in fact, they are half as likely as young black men to be jobless (19 percent to 39 percent), and much less likely to be incarcerated (3.3 percent to 11.2 percent). The question of imprisonment will be examined in more detail below. Among the major Hispanic groups (Mexicans, Puerto Ricans, Cubans, and Central/South Americans and others), large disparities by gender (with males predominating) are seen for Mexicans and Central Americans (but not for Puerto Ricans or Cubans, reflecting their different modes of migration and incorporation). Between 20 and 25 percent of Mexicans and Puerto Ricans were third-or-higher generation old-timers; by contrast, about 95 percent of the Cubans and the Central and South Americans were either foreign-born or of foreign parentage. There are significant educational and occupational differences between the various Hispanic groups, underscoring the diversity within the panethnic category. Cuban men are at the top of the Hispanic educational hierarchy, with more than 25 percent having college or advanced degrees (of those twenty-five and older) and one in six failing to complete high school (those tend to be found mainly among the Mariel and later arrivals); Mexican men are at the bottom, with 45 percent of young adult males having less than a high school diploma (followed closely by Central Americans) and only 7 percent having college or advanced degrees (of those twenty-five and older). Mexican and Central American men are also mired in the lowest rungs of the U.S. labor market, with two out of three employed in low-wage labor; while 45 percent of Cuban women were employed in the high status jobs. On the other hand, the Mexicans had the highest labor force participation rate and were the most likely to be working full time (followed by the Central Americans), to be married and to have children; in fact, they were almost half as likely as young Puerto Rican men to be jobless (17 percent to 31 percent), and less likely to be incarcerated (2.1 percent to 5.1 percent). Ethnic differences in educational attainment hold by gender, but females outperform males for every ethnic group almost without exception (U.S. Census Bureau 2006). Comparisons by Generation and National Origin

For each of the major Hispanic ethnic groups, it is critical to examine differences by generational cohorts: from the “1.0” generation (foreign-born who arrived at age thirteen or older) and the “1.5” (foreign-born who came as

Demographic Transformations

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children under thirteen) to the second generation (U.S.-born of foreign-born parents), and, in the case of the Mexicans and Puerto Ricans, to the third and higher generations (U.S.-born with U.S.-born parents). (For the Cubans, Dominicans, and the Central and South Americans, there are scarcely any adult members of a third generation yet formed.) This generational perspective, drawn from merged Current Population Surveys from 2003 to 2006, adds depth and complexity to the picture of Latino males that emerges here. Among Mexicans, for example, there is solid evidence of intergenerational social mobility, especially in educational attainment but also in occupational and economic status. For example, among Mexican men eighteen to thirty-four, 63 percent have no high school diploma in the 1.0 generation, but that rate declines to 45 percent in the 1.5 generation, 26 percent in the second generation, and 22 percent in the third-and-beyond generation. College graduation rates quadruple from 3.5 percent in the 1.0 generation to more than 12 percent by the third. Occupational status data, earnings, and poverty rates similarly move in a linear direction across generational cohorts (cf. Batalova 2006). Among Puerto Ricans, however, there are no significant differences across the generational cohorts—the patterns remain stable throughout, suggesting less selectivity in migration from the island to the mainland. And among Cubans, yet another pattern is revealed—a very significant break between the foreignborn (who at ages eighteen to thirty-four are mainly those who came during the Mariel boatlift or later) and the second generations (the U.S.-born children of those who came in the first waves after the revolution). For example, over 40 percent of second-generation Cuban men have college degrees and only 12 percent failed to finish high school, whereas their foreign-born compatriots were twice as likely to be high school dropouts as college graduates. Furthermore, despite the evidence of socioeconomic progress over time and generation in the United States, the data also show a worsening of incarceration rates over time and generation in this country—a paradoxical finding that mirrors similar epidemiological paradoxes in the areas of health status and other dimensions of well-being. These data underscore both the importance of immigration and generation in the social situation of Latino men, as well as the fact that the meaning of immigration and generation differs from group to group, corresponding to different migration histories and distinct contexts of exit and reception (Portes and Rumbaut 2006; Rumbaut 2004). Inasmuch as conventional theories of crime and incarceration predict higher rates for young adult males from ethnic minority groups with lower educational attainment—characteristics that describe a much greater proportion of the foreign-born population than of the native born and of Latinos in

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particular—it follows that immigrants would be expected to have higher incarceration rates than natives. And immigrant Mexican men—who comprise fully a third of all immigrant men between eighteen and thirty-four—would be expected to have the highest rates. The results, however, turn those expectations on their head. Here data from the 5 percent PUMS (Public Use Microdata Sample) of the 2000 census are used to measure the institutionalization rates of immigrants and natives, focusing on males eighteen to thirty-four, among whom the vast majority of the institutionalized are in correctional facilities (Rumbaut 2005). Nationally, the incarceration rate of U.S.-born males (3.5 percent) was five times the rate of the foreign-born (0.7 percent). The latter, in turn, was well below the 1.7 percent rate for non-Hispanic white natives and nine times less than the incarceration rate for native black men. The advantage for immigrants vis-à-vis natives is observed for every ethnic group—with the sole exception of Puerto Ricans, who are not immigrants since they have birthright citizenship, for whom the rates between the island born and the mainland born are almost identical. All of the Asian immigrant groups have lower incarceration rates than the Latin American groups, with the sole exception of the foreign-born Laotians and Cambodians, whose rate of 0.9 percent is still well below that for non-Hispanic white natives. The lowest incarceration rates among Latin American immigrants are seen for the least educated groups: the Salvadorans and Guatemalans (0.5 percent) and the Mexicans (0.7 percent). However, those rates increase significantly for their U.S.-born co-ethnics. That is most notable for the Mexicans, whose incarceration rate increases to 5.9 percent among the U.S.-born; for the Vietnamese, whose rate increases from 0.5 percent among the foreign-born to almost 6 percent among the U.S.-born; and for the Laotians and Cambodians, whose rate moves up to more than 7 percent, the highest of any groups except for native blacks. The risk of imprisonment is clearly highest for native-born young men who are high school dropouts. Among the U.S.-born, almost 10 percent of all male dropouts were in jail or prison in 2000, compared to 2.2 percent among those who had graduated from high school. But among the foreign-born, the incarceration gap by education was much narrower: only 1.3 percent of immigrant men who were high school dropouts were incarcerated, compared to 0.6 percent of those with at least a high school diploma. The advantage for immigrants held when broken down by education for every ethnic group (a main exception were island-born Puerto Rican dropouts, whose incarceration rate was above 10 percent)—indeed, for every group, the longer immigrants had resided in the United States, the higher were their incarceration rates. Among U.S.-born men

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29

who had not finished high school, the highest incarceration rate by far was seen among non-Hispanic blacks, 22 percent of whom were imprisoned at the time of the census; that rate was triple the 7 percent among foreign-born black dropouts. The finding that incarceration rates are much lower among immigrant men than the national norm, despite their lower levels of education and greater poverty, but increase significantly among the second generation, suggests that the process of Americanization can lead to downward mobility and greater risk of involvement with the criminal justice system for a significant segment of this population. Conclusions and Implications

The infusion of young Hispanics into the United States is a potentially positive development, slowing the nation’s overall population aging while partially offsetting the rising burden of dependency of an aging majority—what can be seen as a demographic dividend (see Tienda and Mitchell 2006). As Marta Tienda and her colleagues observe in a report of the National Research Council on the Hispanic population of the United States, in 1960 less than 10 percent of the total U.S. population was of retirement age or older, compared with less than 3 percent of the Hispanic population. Today these proportions are 15 percent and 5 percent, respectively. A generation from now—by 2030, when most of the surviving baby boomers will have retired—about 25 percent of non-Hispanic white Americans will have reached retirement age or beyond, compared with only 10 percent of Hispanics—just when the burgeoning Hispanic second generation, with a median age of just over twenty-one, will have reached its prime working years. But labor market impacts will occur well before this time as a result of Hispanics’ younger average age at first employment and growing share of the working-age population. Immigrant labor can help to support the costs of an aging population, but their potential contributions will depend on earnings capacity, which in turn depends on educational investments. On the other hand, the potential dividend offered by working-age (and hard-working) Hispanic immigrants and their future offspring is tempered by their relatively low average earning capacity on arrival—which contrasts sharply with that of Asian and other immigrants. As we have seen, Latino males have by far the lowest levels of education in the United States, and sizable segments of the foreign-born have less than a high school education. Given the very substantial differences in education, earnings, legal status, and other characteristics between foreign-born and native-born Hispanics, the economic and social repercussions of the generational transformation now under way will hinge on social investments in U.S.-born Hispanics. The degree of Hispanic

30

Rubén G. Rumbaut

upward mobility that can be expected from future educational investments may be uncertain, but—as the data reviewed here amply suggest—a sustained presence in low-wage jobs in the absence of significant educational attainment seems certain. That, in turn, will add to ethnic segmentation and widening socioeconomic inequalities, with their attendant sequelae. Acknowledgment I gratefully acknowledge Golnaz Komaie and Charlie V. Morgan of the University of California, Irvine, for their valuable research assistance in this study. Note 1. The ethnic groups subsumed under the “Hispanic” or “Latino” category—Mexicans, Puerto Ricans, Cubans, Dominicans, Salvadorans, Guatemalans, Colombians, Peruvians, Ecuadorians, and the other dozen nationalities from Latin America and from Spain itself—were not “Hispanics” or “Latinos” in their countries of origin; rather, they only became so in the United States. That catchall label has a particular meaning only in the U.S. context in which it was constructed and is applied—and where its meaning continues to evolve (Rumbaut 2006). References Batalova, J. 2006. Mexican born persons in the U.S. civilian labor force. Immigration Facts 14 (November). Washington, DC: Migration Policy Institute. Danziger, S. 2004. Poverty and low-wage work 40 years after the declaration of war on poverty. Ann Arbor: National Poverty Research Center, University of Michigan. Haub, C. 2006. Hispanics account for almost one-half of U.S. population growth. Population Reference Bureau Report (February). Landale, N. S., R. S. Oropesa, and C. Bradatan. 2006. Hispanic families in the United States: Family structure and process in an era of family change. In Hispanics and the future of America, ed. M. Tienda and F. Mitchell, 138–178. Washington, DC: National Academies Press. Laub, J. H., and R. J. Sampson. 2003. Shared beginnings, Divergent lives: Delinquent boys to age 70. Cambridge, MA: Harvard University Press. Myers, D. 2007. Immigrants and boomers: Forging a new social contract for the future of America. New York: Russell Sage Foundation. Passell, J. 2006. Size and characteristics of the unauthorized migrant population in the U.S.: Research report (March). Washington, DC: Pew Hispanic Center. http://pewhispanic .org/files/reports/61.pdf. Pettit, B., and B. Western. 2004. Mass imprisonment and the life course: Race and class inequality in U.S. incarceration. American Sociological Review 69 (2): 151–169. Portes, A., and R. G. Rumbaut. 2006. Immigrant America: A portrait. 3rd ed. Berkeley: University of California Press. Rumbaut, R. G. 2004. Ages, life stages, and generational cohorts: Decomposing the immigrant first and second generations in the United States. International Migration Review 38 (3): 1160–1205. ———. 2005. Turning points in the transition to adulthood: Determinants of educational attainment, incarceration, and early childbearing among children of immigrants. Ethnic and Racial Studies 28 (6): 1041–1086.

Demographic Transformations

31

———. 2006. The making of a people. In Hispanics and the future of America, ed. M. Tienda and F. Mitchell, 16–65. Washington, DC: National Academies Press. Saens, R. 2006. Latino births increase in non-traditional destination states. Population Reference Bureau Report (February). Settersten, R. A., F. F. Furstenberg, and R. G. Rumbaut, eds. 2005. On the frontier of adulthood: Theory, research, and public policy. Chicago: University of Chicago Press. Telles, E., J. Durand, and J. Flashman. 2006. The demographic foundations of the Latino population. In Hispanics and the future of America, ed. M. Tienda and F. Mitchell. Washington, DC: National Academies Press. Tienda, M. 2002. Demography and the social contract. Demography 39 (4): 587–616. Tienda, M., et al., eds. 2006. Multiple origins, uncertain destinies: Hispanics and the American future. Washington, DC: National Academies Press. U.S. Census Bureau. 2004a. Census Bureau projects tripling of Hispanic population in 50 years. http://www.census.gov/Press-Release/www/releases/archives/population/ 001720.html. ———. 2004b. Hispanic and Asian Americans increasing faster than overall population. http://www.census.gov/Press-Release/www/releases/archives/race/ 001839.html. ———. 2006. New population profiles: American community survey data iterated by race, Hispanic origin, ancestry and age. http://www.census.gov/Press-Release/www/ releases/archives/american_community_survey_acs/007748.html. U.S. Department of Justice, Bureau of Justice Statistics. 2006. Adult correctional populations in the United States, 1980–2007. http://www.ojp.usdoj.gov/bjs/glance/tables/ corr2tab.htm.

Chapter 2

Luisa N. Borrell and Clara Rodríguez

The Implications and Impact of Race on the Health of Hispanic/Latino Males

Given the history of slavery and racism in the United States, it is no surprise that race has played an important role in the lives of individuals living there, for Latinos as well as Africans and African Americans. Early ethnographic and descriptive studies of Puerto Ricans consistently noted the role that “race” or “color” played in their experiences and socioeconomic outcomes (Rodríguez 1996). Puerto Ricans of darker skin color were found to experience greater difficulty obtaining access to good quality housing, education, and employment, as well as other socioeconomic outcomes than lighter-skinned individuals. For decades, scholars and writers have described such disparities. For example, Gosnell-Aran (1945), who wrote about the Puerto Rican community in New York City’s East Harlem during World War II, and Chenault (1970), who described the period just prior to the war, both cited the important role that color played in Puerto Ricans’ life chances. Others examining the post–World War II Puerto Rican community found similar effects (Mills, Senior, and Goldsen 1950; Senior 1961; Padilla 1958; Berle 1958; Fitzpatrick 1971; Glazer and Moynihan 1970; Katzman 1968). Memoirs and literary works on the Puerto Rican migration also noted the personal and social costs occasioned by darker color and race, as well as their influence on socioeconomic outcomes and psychological damage (Colon 1982; Iglesias 1984; Rivera 1983; and Thomas 1967). The more recent literature on Latinos has also found similar but more complex associations between race and socioeconomic position or social class. Black Latinos continue to show a general pattern similar to that of blacks, 32

The Impact of Race on the Health of Latinos

33

whereas those who classify themselves as white, or who are described as white or light by others, tend to have better socioeconomic outcomes. However, there are also other socioeconomic variables influenced by race: labor market conditions, human capital differences, and geographic concentration or distribution of particular groups. Evidence also exists that health differentials by race and national origin vary among Latinos. As in the United States, racial constructions throughout Latin America and the Spanish Caribbean are based on historical social constructions that involved slavery, conquest, and colonialist regimes. Latino societies were built on European elites exploiting Africans and indigenous people. This model, with its implications of power and privilege, still has salience in popular culture in Latin America and among some Latinos in the United States. Torres and Whitten (1998) have written about the depreciation and denial of African and Amerindian characteristics that are so widespread in Latin America. As they say, there is in Latin America, “. . . a pyramidal class structure, cut variously by ethnic lines, but with a local, regional and nation-state elite characterized as ‘white.’ And white rules over color within the same class; those who are lighter have differential access to some dimensions of the market” (23). Even in those countries where a racial ideology of mestizaje has been articulated, such as Mexico, racial and class hierarchies have often been maintained that favor upper-class interests and political agendas; privilege the European components; ignore the racialism practiced; and neutralize expressions of pluralism by indigenous or African-descended groups within these countries (Martinez-Echazabal 1998). Colorism has not been limited just to Puerto Ricans or Latinos. It also occurs within other groups. The term “color credit” has been used to describe how those with lighter skin color have tended to have or achieve higher socioeconomic outcomes. Other terms, such as an “economic rent” or “tax paid,” which imply that those with darker skin have an additional burden, have been used to describe the opposite outcomes for those with darker skin color. This has been found in the case of blacks in the United States (see Freeman et al. 1966; Krieger, Sidney, and Coakley 1998; Keith and Herring 1991; Hughes and Hertel 1990; Ransford 1970). Less research has been done on the role that colorism, or deviations from the Eurocentric norm, play in other groups. Latino immigrants—as well as other immigrant groups—bring with them different views of what “race” is. It is not just phenotype; it is also influenced by class, language, and socialization experiences. However, Latino immigrants may have their own prejudicial attitudes and preferences for group affiliation that may be related to skin color and phenotype. Although relatively overlooked

34

Luisa N. Borrell and Clara Rodríguez

in the research literature, these attitudes may reinforce the endogenous structured inequality that already existed along color or racial lines in the United States. As Rodríguez (2000) notes, “race” as understood by many Latinos is not without its own racism, colorism, and other biases. Race, Hispanics, and the U.S. Census Categories

It is only recently that we have been able to utilize decennial census data—the largest data set available—to examine Latinos by racial self-classification. It was in 1980 that the U.S. census introduced—in response to political pressure from Hispanic organizations—what it called “the Hispanic Identifier” (Choldin 1986). This specific question asked all residents whether they were Hispanic or not. If the respondent said “yes” to Hispanic, they then checked one of four boxes, “Mexican,” “Cuban,” “Puerto Rican,” and “Other Hispanic (specify),” to indicate the Hispanic subgroup they represented. Prior to 1980, Latinos or specific national origin groups had been counted by the census in smaller area samples. With self-reporting in 1980, Latinos and all other U.S. residents also gave or chose their “race” as opposed to having it described by census enumerators. The major categories provided for race in the 1980 and 1990 census were white, black, Asian or Pacific Islander, American Indian, or “other race.” They followed the Hispanic Identifier question. In the 2000 census, some changes were made; for example, the “other race” category became “some other race” and “African American” was added to the black category, but the basic five major category grouping was retained. It is worth noting that the question used in the U.S. census to discern people’s Hispanic origin has evolved since its inception in 1980. In the 1980 census, the question was, “Is the person of Spanish/Hispanic origin or descent?” For the 1990 census, the word “descent” was dropped. For the 2000 census, “origin” was deleted and the question was slightly restated as, “Is this person Spanish/Hispanic/Latino?” Incidentally, although the terms Hispanic and Latino are sometimes used interchangeably, a Bureau of Labor Statistics study of over sixty thousand adults found that 58 percent of the Hispanic population preferred the term “Hispanic,” while 12 percent preferred the term “Latino” (Tucker et al. 1996). In the year 2000, 47.9 percent of Latinos indicated they were white, 2.0 percent reported they were black, 1.2 percent said they were American Indian, and less than 1.0 percent said they were Asian, Native Hawaiian, or Other Pacific Islander. A surprising 42.2 percent chose the “other race” category and many of these wrote in a Latino descriptor, such as Mexican, Chicano, Puerto

The Impact of Race on the Health of Latinos

35

Rican, Boricua (U.S. Bureau of the Census 2001, 10). This number is surprising because the proportion of non-Hispanics in the “some other race” (SOR) category is only 0.2 percent (Jones and Symens Smith 2001). Indeed, the tendency among Latinos to choose the “other race” category and to write in Latino descriptors has been a consistent pattern for the last three decennial censuses. The proportion who reported they were black or African American has also remained about the same over this period. Specifically, the proportion of Hispanics self-classified as black has been consistent for the U.S. censuses of 1980 (2.6 percent), 1990 (2.9 percent), and 2000 (2.7 percent) (Logan 2004). In the year 2000 census, respondents were also allowed to choose more than one race category. Only 6.3 percent of all Latinos chose more than one race category; this was higher than the 2.4 percent of the total population that chose more than one category. Although the U.S. Census Bureau’s overall assessment of the quality of data on the item reporting Hispanic origin found it to be quite good (Cresce, Schmidley, and Ramirez 2004; Del Pinal 2003; Schneider 2003), other research finds that many Hispanics respond to the U.S. census racial categories differently than other groups (Denton 1997; Evinger 1996; Grieco and Cassidy 2001; Rodríguez 1974, 1992, 2000; Rodríguez and Cordero Guzman 1992; Rodríguez et al. 1991; Saenz 2004; Tafoya 2003; Tafoya 2004); that is, more Hispanics choose the “some other race” category and eschew the traditional race categories of white, black, etc. Research also shows that this Latino exceptionalism is not new; rather, it has been consistent over time. The tendency of Latinos to avoid reporting themselves in traditional U.S. race categories, and instead to choose the “some other race” category and to volunteer Latino referents such as national origin, has been a consistent finding regardless of the data sources used and the historical variations in the U.S. census questions on race (Rodríguez 2006). Race as a Structural and Contextual Factor among Hispanics/Latinos

Although race has been considered a social construct for years, the genomic era has created some confusion around the concept of race. There is renewed concern that race may be reified as representing an individual’s biology or genetic makeup. This threat is emerging despite the evidence that race is devoid of scientific meaning and an invalid proxy for genetic and continental ancestry. Investigating the issue of a race effect among Hispanics, as a social construct, could help elucidate the role of race and discrimination in the creation of social and health inequalities in U.S. society.

36

Luisa N. Borrell and Clara Rodríguez

In the United States, racial classification has been found to be associated with social advantages or disadvantages. Researchers have found that Latinos, who report that they are “white,” or who are classified as white (or light) by interviewers, fare better with regard to earnings, hourly wage, education, and other socioeconomic variables. For instance, analyzing Public Use Microdata Samples (PUMS) census sample of 27,999 Puerto Ricans in New York City, Rodríguez (1990) found that Puerto Ricans who reported they were black had lower mean household income and were more likely to live below the poverty level as compared to their counterparts who reported they were white. Puerto Ricans who reported that they were white or black in the New York City census in 1980 had higher socioeconomic status attainments than those who reported they were “some other race.” These findings were observed regardless of gender. Also, using the same data set, Rodríguez found that racial reporting was a negative and significant predictor of hourly wages for men, even after controlling for those elements that might be interacting with race reporting, such as language, disability, work experience, inner-city residence, the presence of children, and industrial and occupational location (Rodríguez 1991). Race was not a significant predictor for women, suggesting that women faced different labor markets than men at the time. More recently, Gomez, using data from the Boston Social Survey Data of Urban Inequality, which included mostly Puerto Ricans and Dominicans, also found that dark skin was negatively associated with earnings in men but not in women (Gomez 2000). Similarly, among Mexican Americans, those who were classified by others as having dark skin or a physical appearance thought to resemble American Indians were most likely to be discriminated against, receive less education, and hold occupations with lower prestige than their light skin/European-looking counterparts (Arce, Murguía, and Frisbie 1987). This relationship also was observed with regards to earnings (Telles and Murguía 1990). The authors attributed this finding to discrimination in the labor market. Moreover, Allen, Telles, and Hunter (2000) found that skin color was associated with lower educational attainment and annual incomes in Mexican Americans and blacks. Finally, Espino and Franz (2002) examined the association between skin color and occupation among Mexican Americans, Puerto Ricans, and Cubans. The study compared light- and dark-skinned Latinos in a multistage area probability sample of 1,736 employed or recently employed Latinos. This study found that darker-skinned Mexicans and Cubans had “significantly lower occupational prestige scores” (612) when controlling for sex, education, age, religion, language, citizenship, and birth country. Similar results were found in an analysis of the 1979 National Chicano Political survey data (621). However,

The Impact of Race on the Health of Latinos

37

Espino and Franz (2002) did not find conclusive evidence that skin-color differences impacted the occupational prestige scores for Puerto Ricans (612). Indeed, they found that it was the “medium skinned Puerto Ricans [who] had the highest occupational rankings” in their group (617). They posed the questions of whether all Latinos have the same experience in the labor market and whether labor markets are similarly affected by the local economy and political changes. For example, the passage of the Immigration Reform and Control Act (IRCA) in 1986, which targeted noncitizens, may have had a stronger effect on many Mexicans who were not citizens than it had on Puerto Ricans who arrived as citizens, or on Cubans who were welcomed as refugees. A recent analysis of the 2000 census data found that Hispanics who reported that they were white had higher “levels of education and income” (Tafoya 2004). Classification by others, such as interviewers and census takers, reveals similar patterns. Allen, Telles, and Hunter (2000, 169) analyzed both Chicano and black national databases, each of which was collected from 1979 to 1980. They find that “dark skin incurs a learning and earnings penalty” within each group, but skin color is “a more significant determinant of education and income” for black women and Chicanas (Allen, Telles, and Hunter 2000). They suggest that this may be because of the emphasis placed in our society on women’s beauty and the equating of lighter skin with beauty. The sum total of these studies indicates that Latinos, whether they self-report or are classified by others as white or as having “light” skin color, were consistently better off in socioeconomic terms than those who reported or were labeled black or other race. Although there are important intervening variables, such as labor market conditions and gender expectations, much of the literature suggests that “there may be an economic rent, color credit, or tax paid” because of one’s race, whether defined by others or oneself (Rodríguez 2000). In an attempt to update and analyze more closely race and socioeconomic status outcomes among Latinos and non-Latinos, we used data from the National Health Interview Survey (NHIS) from 2000 to 2003 on income and education. This survey, which was conducted by the National Center for Health Statistics, used a multistage random sample of approximately 30,000 to 35,000 adults, eighteen years of age and over, per year and utilized the same questions and format used by the 2000 U.S. census to collect information on race and ethnicity. We included Hispanic and non-Hispanic adults in our sample and found that, contrary to the pattern observed among non-Hispanics, Hispanic blacks are more educated and have higher income than Hispanic whites and “some other race” Hispanics. Hispanic black men were also more educated and reported earning higher income than Hispanic black women did (table 2.1).

47.2 (0.81) 26.0 (0.59) 17.2 (0.54) 9.6 (0.41) 61.5 (1.14) 30.7 (1.01) 7.8 (0.59)

(4.01) (4.81) (5.88) (3.89)

50.7 (5.32) 40.5 (5.64) 8.8 (3.67)

31.3 23.3 33.3 12.1

47.4 (0.94) 37.3 (0.82) 15.4 (0.67)

33.2 (4.88) 48.0 (5.99) 18.7 (6.20)

Other

64.7 (1.88) 29.7 (1.80) 5.6 (0.87)

45.8 (1.55) 26.8 (1.28) 18.3 (1.09) 9.1 (0.88)

47.8 (1.68) 39.8 (1.50) 12.5 (1.19)

50.3 (1.77) 25.6 (1.40) 16.6 (1.30) 7.5 (0.92)

( n ⴝ 3769)

Black

(0.83) (0.83) (0.94) (0.61)

(0.70) (0.61) (0.77) (0.58) 50.4 (0.88) 37.8 (0.82) 11.8 (0.70)

25.7 33.8 25.1 15.4

37.2 (1.04) 41.9 (1.03) 20.9 (0.82)

25.1 36.6 24.6 13.6

( n ⴝ 17226)

Sample sizes are unweighted.

a

(0.32) (0.38) (0.34) (0.33)

(0.29) (0.38) (0.32) (0.32) 45.6 (0.46) 37.5 (0.37) 16.9 (0.35)

14.9 38.6 24.9 21.5

25.4 (0.39) 36.8 (0.42) 37.8 (0.46)

15.3 36.7 34.3 23.6

( n ⴝ 83272)

White

Non-Hispanic

Percentage estimates are weighted to account for the complex sampling design in NHIS; figures in parenthesis represent standard errors.

Note

Education Less than high school High school/GED Some college Complete college or higher Income $20,000 $20,000–$44,999 $45,000

Women

49.9 (0.97) 26.1 (0.68) 14.7 (0.60) 9.3 (0.45)

(4.87) (5.20) (4.07) (5.27)

29.1 34.5 20.9 15.5

White ( n ⴝ 16971)

Black

( n ⴝ 356) a

Hispanic

Education and Income According to Race/Ethnicity, 20 0 0–20 03

Education Less than high school High school/GED Some college Complete college or higher Income $20,000 $20,000–$44,999 $45,000

Men

Table 2.1

Other

(4.82) (6.45) (5.52) (4.25)

(6.45) (9.33) (8.61) (5.48) 54.9 (9.15) 31.9 (8.15) 13.2 (5.56)

20.5 27.7 37.6 14.1

30.2 (6.31) 47.5 (7.55) 22.2 (5.13)

20.0 36.0 27.3 16.6

( n ⴝ 145)

The Impact of Race on the Health of Latinos

39

Some research has found that black Hispanics do fare better than other race Hispanics. For example, Rodríguez found that in New York City, Puerto Ricans who reported they were black on the 1980 census had higher socioeconomic status outcomes than those who reported they were other race. However, cell sizes were small, and those who reported they were white were highest in socioeconomic status (Rodríguez 1990). Itzigsohn, Giorguli, and Vazquez (2005) also found that those Dominicans in New York and Rhode Island who identify as black or Hispano are in higher occupational positions, while those who identify as white or Indio are in lower positions. In addition, as noted above, using NHIS data, our analyses show that Hispanic blacks (both men and women) are more educated and have higher income than Hispanic whites and some other race Hispanics. These findings are in contrast to the general thrust of the literature, which has found that Hispanics who are white or lighter in color tend to fare better than other Hispanics. See, for example, Telles and Murguía, who using data from the National Chicano Survey (NCS), found support for the relationship between lighter phenotypes and income differences among Mexican Americans (Telles and Murguía 1990). Despite the findings from these studies, the general thrust in the literature indicates that Hispanic blacks tend to be more disadvantaged with regard to socioeconomic status variables (Logan 2004). The discrepancy in the findings of these studies could be a reflection of the sampling selection. It is also possible that the sample used by NHIS is not representative of the income distribution for the Hispanic population in the United States. Race, Phenotype, and Health

We set out to determine whether the higher income and education of Hispanic black men in our sample translated to better health outcomes. This is an important issue given that race and socioeconomic status are both independently associated with health outcomes. Thus, if the high income and education of Hispanic black males does not translate to better health, the findings raise the question of what is it about being black that leads to poorer health outcomes? We speculate that race, as a social construct, is a proxy for an array of unmeasured exposures in U.S. society, such as discrimination and segregation, that may lead to poor health. The impact of segregation and discrimination has been well documented for blacks. Although the evidence on race and health among Hispanics is not as extensive as that for non-Hispanic blacks, our findings indicate that in general Hispanic black men exhibit worse health outcomes than other Hispanics on each of the dimensions measured. Table 2.2 shows higher proportions of Hispanic black men (as compared with white and other

7.4 (0.35)

3.9 (2.49)

Black (n  6,423)

Other (n  85)

20.0 (0.23)

21.6 (1.22)

7.8 (0.63)

9.9 (0.33)

7.0 (3.22)

Other (n  60) 21.2 (5.94)

35.0 (0.62)

18.4 (0.27)

20.3 (0.24)

18.2 (6.07)

18.6 (0.50)

9.1 (0.20)

10.3 (0.18)

18.6 (0.93)

14.5 (2.57)

16.7 (0.47)

16.9 (0.40)

10.4 (4.55)

14.5 (0.54)

7.6 (0.20)

8.4 (0.18)

13.0 (1.14)

16.1 (5.18)

12.2 (0.48)

12.4 (0.44)

(fair/poor)

Self-rated health

19.7 (5.27)

18.2 (0.50)

12.6 (0.21)

13.5 (0.19)

23.6 (1.14)

17.7 (2.45)

16.7 (0.47)

18.0 (0.43)

9.5 (3.85)

11.6 (0.47)

8.3 (0.18)

8.8 (0.16)

14.2 (1.17)

11.0 (3.23)

9.5 (0.41)

10.4 (0.42)

Feeling sad

Sample sizes are unweighted.

a

Prevalence estimates and standard errors (parentheses) are weighted to account for the complex sampling design in NHIS.

Note

4.8 (0.12)

White (n  46,316)

Black (n  10,788)

Non-Hispanic (n  60,024)

5.3 (0.12)

7.6 (2.23)

Other (n  2117)

19.9 (3.11)

7.5 (0.34)

White (n  9,426)

Black (n  223)

19.8 (0.57)

7.5 (0.31)

20.0 (0.52)

18.2 (4.72)

27.8 (0.68)

19.3 (0.25)

Hispanic (n  12,095)

Women

4.7 (0.14)

White (n  36,874)

5.1 (0.12)

6.9 (0.74)

Non-Hispanic (n  45,789)

25.8 (5.27)

9.1 (4.38)

Black (n  131)

Other (n  1,650) 15.6 (1.18)

15.1 (0.52)

6.9 (0.34)

6.9 (0.40)

White (n  6,423)

15.3 (0.48)

Hypertension

Hispanic (n  9,566)a

Men

Race/Ethnicity

Diabetes

Age-Adjusted Prevalence Estimates According to Gender and Race/Ethnicity, 20 0 0–20 03

Gender and

Table 2.2 Feeling

8.2 (3.24)

8.3 (0.34)

6.6 (0.16)

7.0 (0.15)

12.4 (0.81)

9.2 (1.85)

9.4 (0.37)

10.1 (0.34)

6.1 (2.93)

5.0 (0.32)

4.8 (0.14)

4.9 (0.13)

6.7 (0.75)

6.5 (2.30)

6.1 (0.35)

6.2 (0.31)

hopeless

Serious

1.5 (1.54)

4.2 (0.24)

3.4 (0.11)

3.6 (0.10)

6.3 (0.61)

3.6 (1.23)

4.5 (0.25)

4.8 (0.23)

0.7 (0.69)

2.2 (0.21)

2.4 (0.11)

2.4 (0.09)

2.6 (0.46)

3.2 (1.45)

2.2 (0.22)

2.3 (0.20)

mental illness

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41

Hispanics) reporting diabetes, hypertension, rating their health as poor, feeling sad or hopeless, and having a serious mental illness. (Black Hispanic women did not, however, follow this pattern.) Although Hispanics as a whole exhibited better outcomes than non-Hispanics when race was accounted for, Hispanic blacks were found to be doing worse than Hispanic whites, and socioeconomic status and their health statuses were close to non-Hispanic blacks. More extensive research with larger samples, and holding other variables constant, is necessary in order to determine the extent to which these results are statistically significant. Although the sample size does not allow inferences beyond the groupings in table 2.2, analyses (not shown) indicate that Puerto Rican and Dominican men who identified as black exhibited higher prevalence of hypertension than their white counterparts—as is the case with non-Hispanic black men—and than Mexican Americans, Cubans, and other Hispanics regardless of their gender and racial identification. These are initial but important findings and they suggest that it is important to further explore the effect of race among Hispanics on health outcomes. Ignoring racial heterogeneity among Hispanics may result in missing a great deal of information with regard to the role that race or color play in the health status of these individuals. Despite the interest in racial disparities, very little research has been done to investigate the role of race on the health of Hispanics. Only a few studies have examined the effect of skin color or race on health among Hispanics (Borrell 2006; Costas et al. 1981; Landale and Oropesa 2005; Sorlie, Garcia-Palmieri, and Costas 1988). For example, studies using skin color tiles show that dark-skinned Puerto Rican men had a higher prevalence of left ventricular hypertrophy and slightly higher systolic blood pressure than their light-skinned counterparts (Costas et al. 1981; Sorlie, Garcia-Palmieri, and Costas 1988). In addition, Borrell, Crespo, and Garcia-Palmieri (2007) found that dark-skinned Puerto Rican men living in urban areas in Puerto Rico have a higher risk of dying from all-cause mortality than their light-skinned counterparts. This association was not observed between skin color and cardiovascular disease-related mortality in men living in urban areas. There was no association between skin color and all-cause or cardiovascular disease related mortality for Puerto Rican men living in rural areas. This interaction could reflect the social dynamic of skin color among Puerto Ricans. Although Puerto Ricans, at the time of the study (1965–1981), retained many of their traditional values, culture, and lifestyle, there were still sharp differences in the social and economic characteristics of urban versus rural residents.

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Borrell investigated the effect of race on hypertension among Hispanics and non-Hispanics (2006). This study found that Hispanic blacks had a higher prevalence of hypertension than Hispanic and non-Hispanic whites, but there was no difference in the prevalence of hypertension between Hispanic and non-Hispanic blacks. Although Hispanics are more likely than non-Hispanics to rate their health as poor, when compared to non-Hispanic whites, Hispanic blacks tend to rate their health as fair/poor more frequently than Hispanic whites (Borrell and Crawford 2006). Moreover, an earlier study by Friedman et al. (1993) examining birth weight among blacks of different national origins found that Hispanic black women had children with higher birth weights than American black women, but still lower than that of non-Hispanic whites. Finally, with regard to birth weights, Landale and Oropesa (2005) found that mothers’ skin color was associated with low birth weight in Puerto Rican infants in selected states in the Northeast region of the United States, but not in Puerto Rico or New York City. Several studies suggest that skin color and/or racial identity may be associated with perceived discrimination among Hispanics (Arce, Murguía, and Frisbie 1987; Espino and Franz 2002; Gomez 2000; Telles and Murguía 1990, 1992; Rodríguez 1990, 1991). Specifically, recent evidence shows that darkskinned Dominicans in Washington Heights, New York, and Providence, Rhode Island, report a discrimination prevalence of 38.6 percent (Itzigsohn, Giorguli, and Vazquez 2005). Furthermore, although racial discrimination and mental health research among Hispanics is scant, the evidence suggests that Hispanics’ mental health may be negatively associated with racial discrimination (Araujo and Borrell 2006). As with blacks, several studies suggest an association between self-reported perceived discrimination (based on skin color or race) and mental health among Mexicans Americans, Puerto Ricans, and Dominicans (Codina and Montalvo 1994; Salgado de Snyder 1987). These studies found that self-reported perceived discrimination was associated with worse mental health (as measured by depressive symptoms). However, although some studies have found an association, this association did not always reach statistical significance (Stuber et al. 2003, Ryff, Keyes, and Hughes 2003). As with blacks, several studies suggest an association between selfreported perceived discrimination (based on skin color or race) and mental health among Mexicans Americans, Puerto Ricans, and Dominicans (Araujo and Borrell 2006; Codina and Montalvo 1994; Salgado de Snyder 1987; Stuber et al. 2003; Ryff, Keyes, and Hughes 2003; Finch, Kolody, and Vega 2000). These studies found that self-reported perceived discrimination was associated with worse mental health (as measured by depressive symptoms).

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Segregated Neighborhoods

What might account for the worse health outcomes of black Hispanic men, despite their higher education and income? This appears to be yet another paradox. Racial segregation has been proposed as a fundamental cause of health disparities for blacks (Williams and Collins 2001). Specifically, racial segregation could affect both social and physical features of areas and then influence health. Hispanics, like non-Hispanic blacks, are also likely to experience racial residential segregation, which promotes lower social and environmental conditions that may influence individual’s educational attainment quality and employment opportunity, housing quality, and access to health care (Williams and Collins 2001). These factors may further promote or deteriorate an individual’s health. Previous studies argued that Puerto Ricans were highly segregated from non-Hispanic whites as a result of their African ancestry (Massey 1979, 2001; Massey and Bitterman 1985). Further, Massey suggested that there is no evidence that the segregation of Puerto Ricans from whites declines with increasing socioeconomic status (Massey 1979). Logan found that Hispanic blacks tend to be equally segregated from nonHispanic whites as from non-Hispanic blacks. Hispanic blacks are more likely to share their neighborhoods with non-Hispanic blacks and with other Hispanics than with non-Hispanic whites (Logan 2004). Moreover, studies have found that Latinos who report that they are black are more segregated and less successful in gaining access to predominantly Anglo residential areas than their white Hispanic counterparts (Denton and Massey 1989; Massey 1988; Massey and Denton 1993, 113; Rosenbaum 1996). Denton and Massey (1989) also found support for the role of race in housing discrimination among Caribbean Hispanics. Therefore, it is possible that Hispanic blacks are more likely to be more segregated and to experience the same dynamics and access to health care issues observed for racially segregated blacks. Policy Implications and Research Suggestions

Racial discrimination has recently emerged as an important risk factor for health that is differentially distributed across races and may contribute to elevated health risks for blacks (Krieger 1999; Williams 1999; Williams et al. 1997; Williams and Collins 1995; Williams, Neighbors, and Jackson 2003). Such discrimination-health dynamics may also exist among Hispanics, since they share many discriminatory experiences with blacks. As Amaro and Zambrana (2000) have noted, in order to advance our understanding of the health status of Hispanics, it is essential to explore the complexities of the sociodemographic dynamics operating within Hispanic populations, including those associated

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with their racial classification. We also need to better understand how these dynamics interact with the U.S. social structures to influence Hispanics’ life chances, health, and well-being (Finch, Hummer, Kolody, and Vega 2001). In order to also move forward our efforts to eliminate health disparities, we need to look beyond the health advantage paradox of the aggregate Latino. We need to do this because the research to date suggests that there may be substantial differences by national origin group and by race within Hispanic groups. In addition, the initial positive reports on Hispanic health—that is, the Hispanic paradox of a positive outlook for health outcomes in the context of low socioeconomic status—is a mixed picture. In fact, although this paradox has been examined mostly among Mexican Americans (Chung et al. 2003; Franzini, Ribble, and Keddie 2001; Markides and Coreil 1986), several recent studies provided evidence contradicting the so-called health advantage or paradox (Hunt et al. 2002; Palloni and Arias 2004; Patel et al. 2004). These studies suggest that the Hispanic paradox, possibly attributed to a healthy migrant effect, healthy behaviors, and/or cultural traditions, appears to disproportionately favor some immigrant groups (e.g., foreign-born Mexicans and Central Americans) more than others. And it may be more specific for certain health problems such as behavioral disorders and cancers than for other problems, such as cardiovascular disease and diabetes. The most important fact about the health advantage attributed to the paradox is that the protective factors weaken in subsequent generations. To date, we have no effective interventions to prevent this decline in health status other than to extend preventive screenings and early medical interventions to all sectors of the Hispanic population (Palloni and Arias 2004). In terms of policy recommendations, we would advocate that more research attention be paid to the role of race and national origin as well as their interaction in the health outcomes of Latinos. Such studies will make significant contributions to the current research on Hispanics and to research on race. It will alert investigators and evaluators to the role that race may play in Hispanic health outcomes. Race as phenotype, in rare instances, may be a marker for genetic predisposition to certain diseases resulting from assortative mating among people with similar continental origin, as occurs with sickle cell anemia among African Americans. However, the evidence for this has not been compelling among black Hispanics. The use of race as social construct among Hispanics can contribute to the goal of eliminating racial/ethnic health disparities and social inequalities in the United States. The existing evidence in racial/ethnic health disparities clearly points to the detrimental effects of dark skin color in our society as a consequence of systematic social stress and excess trauma exposure. Though

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the possibility of a genetic or biologic basis for a health disadvantage can and is raised as an explanation, no convincing evidence for this has yet been produced. Furthermore, evidence suggests that people are channeled, or socially selected, into different sets of opportunities according to their perceived race or color (Borrell 2005; Williams 1999; Williams and Collins 1995). Such a channeling can have negative health consequences. Additional research in this area will also contribute to our understanding of the relationship between U.S. racial categorization and health within a group that until now many have considered homogenous and race-less. However, the actual experiences of many within the Latino group may vary because of their darker or lighter skin color and/or their greater visibility as nonwhite. Thus, it is a reasonable hypothesis that racism may have the same effect on darkskinned Hispanics’ health as it has for blacks. Therefore, to develop effective programs and policies to advance our understanding of Hispanics’ health, we must look beyond Hispanics as a monolithic group and begin focusing on their “racial” composition and the advantages and disadvantages associated with race and skin color tone in our society. This shift will contribute to a better understanding not only of the health of Hispanics but also of how race works in the creation of U.S. health disparities. Examining Latinos by race in regard to health is also important for a number of other reasons. First, measuring the impact of Latino race and phenotype (e.g., skin color) on health outcomes has not been done consistently in the past, but the idea has likely influenced the conclusions and nuanced interpretations of many studies. Researchers in the health arena tend to develop or utilize samples from large inner-city public health facilities and hospitals, social service centers, and schools where Latinos often and increasingly constitute substantial proportions of the study population. These settings are also utilized because access to such populations is often easier to obtain. Yet, research reports consistently examine populations by race and either exclude Latinos from the analysis or fail to ask Latinos separate questions about race selfidentification (Aguirre-Molina, Molina, and Zambrana 2001). Consequently, many studies that reported data on racial groups contrasted whites and blacks, with attention being paid in some cases to Asians, Pacific Islanders and Native American Indians. Latinos were not subtracted from any of these categories. Therefore, it is possible that the prevalence of white poverty in an area was distorted (overestimated) because Latinos (who average lower incomes) were included in the white category. This practice would also have affected the estimation of other black/white gaps. Consideration of whether the inclusion of Latinos in the white group (or in each of the other race groups)

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was rare. We generally do not know if these studies led to over or underestimations of various diseases (e.g., diabetes and hypertension). Even when data was gathered separately on Latinos, few Latinos were asked to indicate their race, nor was their race recorded by others. Secondly, the literature on the interaction of race, Hispanic origin, and health outcomes is fairly limited. As in the case with socioeconomic status differences by race among Latinos, there is some evidence that Latinos who report they are black have higher incidences of morbidity among women (Ramos, Jaccard, and Guilamo-Ramos 2003). We need to know how Latinos who report they are black, or who are classified as black by others, differ from other Latinos and from non-Hispanic blacks and whites. We also need to better understand the some other race group. Although a number of authors have questioned the significance of the category, Latinos continue to choose the categorical designation “Latino” in census and other studies. We need to better understand how different racial categories covary with health status: is the some other race group similar to or different from the other Latino race categories and from non-Latino groups? The “Hispanic paradox”—that is, where positive health outcomes/ indices have been found to be correlated with lower socioeconomic status and immigrant group status—has received a lot of attention, and it has left many researchers puzzled. Are those who report they are some other race in better health? Do they account for the Hispanic paradox in the main? Some recommend ignoring this category, which accounts for 42 percent of all Latinos and substantial proportions of particular groups. This is not the solution. We need to have a better sense of what we can generalize or conclude about this category. The Study of Race in Health Outcomes

There is some debate over the role of race in health outcomes (Begley 2004; Shields et al. 2005; Wade 2004). For example, is the higher incidence of hypertension among blacks related to the perhaps higher proportion of melanin in their skin or to the interaction of skin color and social stressors, such as neighborhood of residence, poor access to health care, cumulative adversity, and lack of economic resources? Focusing on race among Latinos will help us to distinguish the role played by traditional race markers, such as color and physical type, from ethnic or lifestyle choices, such as diet, physical activity, religion, family size, and social supports. Controlling for national origin will further clarify such analyses. Greater clarification of these racial, ethnic, and lifestyle effects will inform policy. Health research often differs from other types of research in that its goals and objectives are pragmatically defined toward influencing policy and practice.

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To the extent that this is the case, it is important to review findings in terms of whether Latinos, in particular Latino males and females, were part of studied populations and what their self-described or other-determined race was endorsed. This may be particularly important in some institutionalized populations, where the proportion of Latino males is increasing. For example, in the criminal justice system racial designations are generally determined by others and do not distinguish between white Hispanics and black Hispanics. Yet, in prisons we have recently heard about the increase in infectious diseases, suicides, and other ailments. Does race play a role in which Latinos, particularly male Latinos, have a higher probability of being arrested, arraigned, and sent to prison? Does the health experience of institutionalized Latino males vary by race? Although these are unanswered questions at this point, given the experience of blacks in these settings, we must investigate whether social status and health outcomes for Latino men are likely to mirror the ones for black men. In short, it is in the health arena that the issue of how Latinos are to be counted becomes particularly important because health data findings often lead to policy change and interventions to improve public health. As the Latino population grows in size and comes to constitute more substantial proportions of study populations, it will become more important to count Latinos separately. It will also be necessary to examine Latinos’ national origin, as well as what race they appear to be in order to continue to control for the effect of race and national origin. We may find yet more Hispanic paradoxes in such an approach. However, resolving such paradoxes may also prove helpful in understanding the health of non-Latinos. We will better understand the role that color and racial visibility play in health outcomes. Finally, we need to investigate to what extent race, as a structural factor, affects the health status and well-being of Latino men. Race is clearly embedded in the historical-political structures of the United States. We have observed that race has historically had economic, political, and social consequences. It has played an essential role in determining who is included and who is excluded from participation in all realms of the society. Race has also been a factor determining the boundaries, both physical and social-cultural, of distinct communities. It clearly has been at the base of community and familial networks for the greater part of the United States’ existence. We also have evidence from research that race is associated with socioeconomic and health outcomes. We need to further investigate the nexus between race and Latino male health outcomes, so that we can develop programmatic interventions to counteract racialized social behaviors and social practices, as well as more targeted policies that respond to the needs of Latino males for upward social mobility.

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Stuber, J., S. Galea, J. Ahern, S. Blaney, and C. Fuller. 2003. The association between multiple domains of discrimination and self-assessed health: A multilevel analysis of Latinos and blacks in four low-income New York City neighborhoods. Health Services Research 38 (6 Pt 2): 1735–1759. Tafoya, S. 2003. Latinos and racial identification in California. In California Counts Population Trends and Profiles, ed. H. P. Johnson. San Francisco: Public Policy Institute of California. ———. 2004. Shades of belonging. Washington, DC: Pew Hispanic Center. Telles, E. E., and E. Murguía. 1990. Phenotypic discrimination and income differences among Mexican-Americans. Social Science Quarterly 71 (4): 682–693. ———. 1992. The continuing significance of phenotype among Mexican-Americans. Social Science Quarterly 73 (1): 120–122. Thomas, P. 1967. Down these mean streets. New York: Alfred A. Knopf. Torres, A., and N. E. Whitten, eds. 1998. Blackness in Latin American and the Caribbean: Social dynamics and cultural transformations. Vol. 2, Eastern South America and the Caribbean. Bloomington and Indianapolis: Indiana University Press. Tucker, C., R. McKay, B. Kojetin, R. Harrison, M. de la Puente, L. Sytinson, and E. Robison. 1996. Testing methods of collecting racial and ethnic information: Results of the Current Population Survey Supplement on Race and Ethnicity. Statistical Notes 40. U.S. Bureau of the Census 2001. Overview of race and Hispanic origin: Census 2000 brief. Washington, DC: U.S. Bureau of the Census. Wade, N. 2004. Race based medicine. New York Times, Week in Review, 4 November, 12. Williams, D. R. 1999. Race, socioeconomic status, and health: The added effects of racism and discrimination. Annals of the New York Academy of Sciences 896: 173–88. Williams, D. R., and C. Collins. 1995. U.S. Socioeconomic and Racial-Differences in Health—Patterns and Explanations. Annual Review of Sociology 21: 349–386. ———. 2001. Racial residential segregation: A fundamental cause of racial disparities in health. Public Health Rep 116 (5): 404–16. Williams, D. R., H. W. Neighbors, and J. S. Jackson. 2003. Racial/ethnic discrimination and health: Findings from community studies. American Journal of Public Health 93 (2): 200–208. Williams, D. R, Y. Yu, J. Jackson, and N. Anderson. 1997. Racial differences in physical and mental health: Socioeconomic status, stress, and discrimination. Journal of Health Behavior 2 (3): 335–351.

Chapter 3

Olivia Carter-Pokras and Alexander H. Fischer

Improvements in Latino Health Data

Assessing the influence of structural factors on health in Latino males has been constrained in the past by poor data quality in national health surveys. This shortfall of information has severely impaired health-demographic analysis, thus posing a major barrier to needs assessments and public health interventions. Although Congress requested that federal agencies collect data on persons of Hispanic origin in the early 1970s, it was not until 1984 that the National Center for Health Statistics published Hispanic mortality data for reporting states. The number of reporting states improved over time, particularly after 1989, when Hispanic origin was added to the standard birth and death certificates recommended for use by states. Mortality data for the Hispanic population in all fifty states and the District of Columbia were not available until 1997. Items asking for the Hispanic origin of the mother and the father of the baby have been included on the birth certificates of all states and the District of Columbia, the Virgin Islands, and Guam since 1993. Puerto Rico, American Samoa, and the Northern Marianas do not collect this information. Problems in the completeness of reporting persist. In 1984, the percent of deaths for which Hispanic origin was missing or unknown varied widely among reporting states, ranging from less than 1.0 percent in Hawaii to 34.8 percent in Tennessee. By 1999, the percent of missing or unknown Hispanic origin varied little by state, ranging from 0.0 percent in seven states to 3.5 percent in New York City (National Center for Health Statistics 2004). It is important to note, however, that U.S. mortality statistics for the Hispanic population exclude Puerto Rico and the U.S. Virgin Islands. Birthplace and Hispanic origin are also not collected for Puerto Rico birth certificates. In 2004, maternal birthplace was 53

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missing from 0.0 percent (e.g., Indiana) to 3.9 percent (e.g., Pennsylvania) of birth certificates. Hispanic origin of the father of the baby was missing from 0.7 percent (e.g., South Carolina) to 35.7 percent (e.g., District of Columbia) of birth certificates, while Hispanic origin of the mother was missing from 0.0 percent (e.g., Colorado) to 13.8 percent (e.g., Rhode Island) of birth certificates (Mathews and MacDorman 2006). Hispanic Origin Reporting

The National Longitudinal Mortality Survey examined the reliability of Hispanic origin reported on 43,520 death certificates compared with that reported from twelve past Current Population Surveys conducted by the U.S. Bureau of the Census. The results suggested net underreporting of Hispanic origin on death certificates as compared with self-reports on the surveys of 7 percent (National Center for Health Statistics 2004). A recent examination of 1999–2000 death certificates from California suggests that underascertainment of deaths is likely for U.S.-born Hispanics, particularly at older ages, with more education, and in census tracts with a lower proportion of Hispanics (Eschbach, Kuo, and Goodwin 2006). Validity and reliability problems of Hispanic origin reporting can also arise from errors in population counts and estimates that comprise the denominator of death rates. Based on the 1990 Post-Enumeration Survey, the undercount ratio for the total Hispanic population was 0.95. The approximate effects of both the reporting bias and undercoverage for the total Hispanic population can be estimated by multiplying the ratio of underreporting of Hispanic origin on death certificates (1.07) by the census undercount ratio (0.95) to give a “combined ratio” of 1.02 for the total Hispanic population. This “combined ratio” can be used to estimate death rates for Hispanics that take into account both reporting bias and undercoverage. In other words, reported death rates for Hispanics underestimate true death rates for Hispanics by at least 2 percent (National Center for Health Statistics 2004). Similar concerns about underreporting of Hispanic origin on death certificates have been raised regarding the study of infant mortality. For example, since 1.7 percent of infant deaths in 1999 were of unknown origin and the percent of live births of unknown origin was 1.2 percent, infant mortality rates by specified Hispanic origin may be slightly underestimated. When birth certificate information on the Hispanic origin of the mother is linked to death certificate information on the infant (linked file), the extent of underreporting of Hispanic origin on death certificates can be estimated. In 1996, estimated infant mortality rates were 5 percent higher when the Hispanic origin of the mother

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was used from the birth certificate (linked file). For Mexicans and Cubans, the rates were about the same (ratios of 1.00 and 1.02 respectively); however, rates for Puerto Rican infants were 12 percent higher when Hispanic origin was based on the death certificate (National Center for Health Statistics 2004). Federal agencies are not required to collect data on persons of Hispanic origin for every dataset; however, federal guidelines for the collection and reporting of racial and ethnic data have existed since 1977. These guidelines allowed federal agencies to collect data on Hispanic origin as a single question, or as a combined question with race. In 1997, the revision of the federal standards for racial and ethnic data recommended that two separate questions be asked on race and Hispanic origin, with Hispanic origin placed first. This change had important implications for reporting data for Hispanics since a higher percentage of persons identified themselves as Hispanic when they were asked a separate Hispanic origin question than when there was a combined race and ethnic origin question (Office of Management and Budget 1997). The distribution of the Latino subgroups also changed depending on how race was assessed. Collection of Ethnic and Racial Data

The revision of the standards also allowed multiracial persons to identify more than one race and recommended that self-identification be used. In 2003, the U.S. Standard Certificate of Live Birth was revised to allow the reporting of more than one race and Hispanic origin. Since 2003–2004, ten states representing about 13 percent of Hispanic births in the United States have permitted respondents to select one or more Hispanic origin categories for birth certificates: Florida, Idaho, Kentucky, New Hampshire, New York State (excluding New York City), Minnesota, Pennsylvania, South Carolina, Tennessee, and Washington. In these ten states, only 1.5 percent of Hispanic mothers reported more than one Hispanic origin group. Concerns continue to be raised regarding the collection and use of racial and ethnic data. A focus on race or ethnicity may encourage researchers to disregard social or cultural processes shared across groups and raise the risk of stigmatization and marginalization (Garro 2001; Loue 2006). Significant genetic diversity exists within a given racial or ethnic group (Bonham, WarshauerBaker, and Collins 2005). Race and ethnicity are often collapsed, and data are not collected regarding language issues. Databases may not include information on relevant factors such as health status, co-morbidity, and severity of illness. Researchers often do not explain their conclusions regarding ethnicity as a risk factor not amenable to modification. Measures of socioeconomic status may not be commensurate across various groups.

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The North American Association of Central Cancer Registries noted that “information about Hispanics/Latinos, the nation’s fastest growing minority, is difficult to interpret because the data collection methods have not been uniformly applied, and have often not been well-defined. Even the terminology for referring to Hispanics may vary from region to region, and within a single area, from population to population” (North American Association of Central Cancer Registries 1996). Although self-identification is considered the gold standard for the collection of racial and ethnic data, individuals may change their selfidentification depending upon the context in which they are asked to so designate (Kaplan and Bennett 2003). Predetermined categories may be confusing or ambiguous or carry political connotations that influence individuals’ identification with them, or individuals may decide that they do not fit. Changes in Data Collection

Despite these concerns, data systems are increasingly collecting racial and ethnic data. For example, almost 80 percent of hospitals now collect data on race and ethnicity (Runy 2004). Frequent changes in the categories used by hospitals have presented difficulties in using the data (Buechner 2004). Hospitals view the collection of racial and ethnic data as beneficial to meet legal requirements, improve health care quality, ensure availability of interpreter services, improve relationships with the community, and target markets (Runy 2004). Researchers also collect racial and ethnic data for several reasons, ranging from requirements by their institutional review board or funder to describing their study population (Walsh and Ross 2003). Racial and ethnic data may also be collected to describe vital and health statistics, identify health risk factors, improve delivery of health care services, identify unmeasured biological markers, and serve as proxy markers for unmeasured social factors (Mays et al. 2003). The most comprehensive study to date of Latinos by subgroup was the 1982–1984 Hispanic Health and Nutrition Examination Survey conducted by the National Center for Health Statistics on Mexican-Americans in the southwestern United States, Puerto Ricans in the New York City metropolitan area, and Cubans in Miami-Dade County (Maurer 1985). Subsequent to this study, most reports still combine all Latinos together, or limit themselves to the largest Latino subgroup—Mexican-Americans. Relatively few reports examine the health status of Central or South Americans, or Dominicans. Although important differences can be found when Latino subgroups are examined by birthplace or generation, time in the United States, reason and age at migration, language usage, or similar indicators, few studies use these or other proxy measures of acculturation. The failure to consider these factors has contributed

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to a wide body of literature limited to simple comparisons of health indicators between Latinos and other racial/ethnic groups. Hispanic Epidemiologic Paradox

The observation in the 1960s and 1970s that Mexican Americans have, on average, better health and mortality profiles than non-Hispanic whites has been referred to as an “epidemiologic paradox,” given Mexican-Americans’ lower socioeconomic status, lower rates of health insurance coverage, and lower primary and preventive healthcare utilization patterns. However, more recent research shows that the “epidemiologic paradox” may not apply to all categories of disease and is potentially more limited for mortality rates than originally proposed. Franzini, Ribble, and Keddie (2001) found that the health advantage was limited to those zero to fourteen years of age (e.g., low infant mortality rates) and to those over forty-five years of age (i.e., not fifteen- to fortyfour-year-olds). The most comprehensive analyses of the Hispanic mortality advantage found that it was only observed for foreign-born Mexican-origin persons and foreign-born other Hispanics (with the exception of Puerto Ricans and Cubans) (Palloni and Arias 2003). Four explanations have been proposed to explain the Hispanic epidemiologic paradox for mortality: the salmon bias or return migration effect, the healthy migrant effect, the cultural or social buffering effect, and the data artifact effect (Palloni and Arias 2003, 2004). All of the hypotheses provide some explanatory power for the observed phenomenon. The salmon bias or return migration hypothesis states that the mortality advantage observed among adult Mexican-origin persons and other Hispanics is due to the return migration to their country of origin because of illness or a period of unemployment. Return migration directly affects vital statistics in the United States because of the different sources of data from which these statistics are derived. Persons who migrate back to their country of origin are likely to remain in the population count but never appear in the death count. In contrast, Palloni and Arias (2003) showed that the return migration effect does explain the mortality advantage among Mexico-born individuals at older ages. The healthy migrant effect refers to a phenomenon whereby immigrants are selected for better physical and psychological health than their counterparts in both their country of origin and their destination country (Palloni and Arias 2003). Migrants are therefore, presumably, not representative of the populations of their countries of origin. Although Stern and Wei found support for the healthy migrant effect among Mexican-origin persons participating in the San Antonio Heart Study, other investigators have found no support for this

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hypothesis (Abraido-Lanza et al. 1999, Palloni and Arias 2003, Stern and Wei 1999). The cultural or social buffering hypothesis proposes that the social network, stronger family ties, and social support experienced by new immigrant Mexican-origin persons overrides many negative influences on health including lower socioeconomic status. These protective factors may diminish with increased time in the United States, adaptation of American sociocultural values, and English language acquisition. Palloni and Morenoff (2001) stated that the cultural or social buffering effect is the most accepted argument for explaining the lower infant mortality rates among Hispanics. However, they concluded that these factors are mainly brought into play in the first month of life and do not affect the postneonatal period. Palloni and Arias (2003) also found that the social or cultural buffering effect did not explain the mortality advantage of foreign-born Mexicans or foreign-born other Hispanic adults. The data artifact effect refers to the inconsistency in ethnic classification between vital statistics and census data. Death rates are estimated from two distinct data sources: death certificates (numerator) and censuses or surveys (denominators). Racial and ethnic classification for numerators (number of deaths) are based to a significant degree on the report by the funeral director, while ethnic classification for denominators (number in population) is usually self-reported by the decedent prior to death. Based on analyses of the National Longitudinal Mortality Study (NLMS), Rosenberg et al. (1999) found that approximately 7 percent of Hispanics are not recorded as Hispanic on their death certificates, resulting in lower reported death rates for Hispanics compared to non-Hispanics. Thus, Latino mortality rates based on linkages to the U.S. National Death Index may be understated (Patel et al. 2004). Reporting Problems

A related reporting problem is the underreporting of deaths with respect to infant mortality (de la Rosa 2002; Rosenberg 1999). De la Rosa proposed some explanations for this argument. Mexican women may cross the U.S.-Mexico border to deliver their babies; therefore, these babies are U.S. citizens, but if these children die after they return to Mexico, they are not reported in U.S. vital statistics (de la Rosa 2002). Second, undocumented immigrants may not report infant deaths that occur without medical attention, for fear of deportation. The overreporting of births is a problem that occurs in Mexico, when Mexicans migrate to other states and children are registered twice in the Mexico Natality Registration System; this leads to lower reported mortality rates at young ages.

Improvements in Latino Health Data

59

Each of these potential explanations may partially explain the paradox of favorable health status for Mexican-origin persons despite their low socioeconomic status. Alternatively, the “poor as healthy” paradox for Mexican-origin persons may be an artifact of aggregated data and further reflective of a large body of literature that focuses on healthy, young, reproductive-age Mexicanorigin women. Notably, these explanations have not been tested widely among different age and gender cohorts of Mexican-origin individuals and provide important directions to examine in future research. Chronic disease patterns in middle- to late-adulthood Latinos are particularly understudied, and limited longitudinal data exist for Latino subgroups (Haffner et al. 1996; Hunt et al. 2002; Sacco et al. 2001). New Large Scale Health Data Collection Initiatives

Starting in winter 2007, the National Institutes of Health’s Hispanic Community Health Study/Study of Latinos (HCHS/SOL) plans to study the prevalence and development of disease in Hispanics/Latinos, the role of acculturation, and identification of risk factors that play protective or harmful roles in Hispanics/Latinos (see http://www.cscc.unc.edu/hchs/about.php for more information). Sixteen thousand eighteen- to seventy-four-year old Hispanic/ Latinos of Cuban, Puerto Rican, Mexican, and Central/South American origin will be recruited through four field centers in San Diego, Chicago, New York City, and Miami. Similar to the earlier Hispanic Health and Nutrition Examination Survey, participants will undergo extensive interviews, clinical examinations, and assessments to determine baseline risk factors and will be followed for two to four years to determine health outcomes of interest. Data availability can be improved at three distinct stages: collection, analysis, and dissemination. Effective recruitment and retention strategies are needed to ensure that the Hispanic Community Health Study and other studies collect valid and reliable data that represent the community. Survey nonresponse is increasing worldwide due to increasing refusals, declining contact rates (e.g., household not at home or telephone not answered, mail surveys returned not delivered, failure to locate person/household), and/or inability to participate (e.g., literacy) (Singer 2006). Refusals may be due to time constraints; lessened sense of civic responsibility or sense of reciprocity; too many survey requests; telephone calls by marketers and fund-raisers; concerns about safety, fraud, and misrepresentation; or human subjects requirements. The increase in the use of caller ID, answering machines, cellular telephones, multiple telephone numbers, unlisted numbers; gated communities and limitedaccess apartment buildings; and privacy regulations have resulted in declining

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contact rates. Previous studies assessing differences between respondents and nonrespondents in the general population have concluded that the bias is minimal, and it is thought that lack of bias and presence of high quality data should be a more important goal than obtaining a specific minimal response rate (Groves 2006). However, Hispanics may be underrepresented in survey samples, especially when the surveys are conducted only in English or by telephone (Keeter et al. 2006). The 2005 National Health Interview Survey found that Latino adults were more likely to live in a household with only wireless telephones (11.3 percent) than non-Hispanic white adults (7.0 percent) or nonHispanic black adults (8.6 percent), (Blumberg, Luke, and Cynamon 2006). Improving Response Rates

Approaches to improve response in the general population include the use of incentives, multiple contacts, sending pre-notification letters, interviewer training, using multiple modes (e.g., mail and telephone), and reducing respondent burden (e.g., shorter survey instrument). Careful consideration should be given to the selection of incentives, staff, and other aspects of data collection when conducting studies of Latino men. Prior studies have shown that nonresponse rates to household sampling among Latinos are associated with lack of outreach to community-based organizations that can inform community members of the study and participate in recruitment, the community’s fear and mistrust of outsiders, and lack of interviewers who are bilingual, bicultural, and familiar with the community (Curry and Jackson 2003; Gilliss et al. 2001; Preloran, Browner, and Lieber 2001). Other barriers to recruitment are lack of transportation and/or child care, costs related to lost time at work, family responsibilities including child care and care giving, and lack of appropriate language or cultural services (Larkey et al. 2002). Preloran, Browner, and Lieber (2001) document the difficulty in recruiting men to participate in a sensitive qualitative research study. Retaining Participants

Retaining participants also presents challenges. Serious issues with follow-up of Hispanic cohorts are usually associated with changes in names, as Latinos tend to use maternal and paternal names and or partner/spouse names at different times, in different combinations, and under different circumstances; social security numbers may be forgotten or incorrect if they do not have a card with them. Marriage or divorce over the study period may also contribute to name changes and thus difficulty in follow-up. Relocation to another area, return to country of origin due to personal issues, deportation, and/or imprisonment

Improvements in Latino Health Data

61

also represents barriers to follow-up. Researchers have also documented aspects of Latino culture and values that need to be taken into consideration when conducting research with this population, including the centrality of family and the importance of provider relationships that foster confianza, respeto, and dignidad (trust, respect, and dignity). Reassuring confidentiality and privacy is also important when conducting research on populations, which may be distrustful of government agencies and disclosing private information (Gilliss et al. 2001). Although legal status may play an important role in access to health care, collection of this information without additional safeguards to protect confidentiality and privacy could endanger the health and well-being of research participants or service recipients (Carter-Pokras and Zambrana 2006). Selection Criteria

Cohort studies such as the Hispanic Community Health Study often use the National Death Index (NDI), a centralized electronic database containing death information from U.S. death certificates maintained by the National Center for Health Statistics, to help identify deaths among participants (see http://www .cdc.gov/nchs/ndi.htm for more information). Seven NDI selection criteria are used to score whether a submitted record is a match. One criterion uses the social security number; the other six criteria use combinations of name and date of birth. Month of birth is required to match in six of seven selection criteria. However, there has been a sharp increase in the percent of survey respondents who refuse to provide social security numbers. The chances of correct NDI matches can therefore be improved by carefully considering the factors that will be used for matching. The National Center for Health Statistics suggests that collection of the participant’s name as it would appear on legal documents (e.g., driver’s license), father’s name (primer apellido) and mother’s surname (segundo apellido) be considered as well as addressing both the female name change due to marriage. Missing Data

Data from the 1997 National Health Interview Survey show that use of common names occurs more frequently among Hispanics than non-Hispanics, with 25.9 percent of Hispanics having one of the twenty-five most common last names, compared with 10 percent of non-Hispanics (pers. comm., Gloria Wheatcroft, National Center for Health Statistics). Survey data for Latinos are also more likely to be missing identification information than for non-Latinos. For example, 66.4 percent of Latinos interviewed during the 2000 National Health Interview Survey were missing their social security number, and 11.5 percent

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were missing their year of birth, compared with 59 percent and 8.8 percent, respectively, of non-Hispanics. Rates of missing information also vary by Hispanic subgroup. During the 1994 NHIS, 50.9 percent of Latin Americans and 54.1 percent of Mexicans were missing their social security number, compared with 40 percent of Puerto Ricans, 42.2 percent of Cubans, and 43.7 percent of non-Hispanics. Analysts play an important role in decisions regarding whether and how data are collected, which variables will be analyzed, how new variables will be constructed, and whether and how data will be disseminated. However, most researchers do not describe their methods for determining race or ethnicity, or what they assume the variables to mean. Conclusion

Despite a slow start, a great deal of progress has been made in the collection of Hispanic health data in the United States. Health researchers and public health planners rely on high quality biometry information. In the instance of Latino health research, this implies, beyond collecting information on structural factors, having accurate descriptors of ethnic subgroups, nativity/immigration statuses, and spoken-language dominance. There are multiple social and cultural variables of potential research interest to serve as potential covariates or for comparisons in more refined analyses. There remain several issues to be resolved. Nevertheless, there are good possibilities that the identified information needs will be addressed in the future. Addressing any health or social problem requires an understanding of the factors that contribute to it. As such, researchers have identified many of these limitations and can now begin a process aimed at closing the quality gap in Hispanic health care information. References Abraido-Lanza, A. F., B. P. Dohrenwend, D. S. Ng-Mak, and J. B. Turner. 1999. The Latino mortality paradox: A test of the “salmon bias” and healthy migrant hypotheses. American Journal of Public Health 89 (10): 1543–1548. Blumberg S. J., J. V. Luke, and M. L. Cynamon. 2006. Telephone coverage and health survey estimates: Evaluating the need for concern about wireless substitution. American Journal of Public Health 96: 926–931. Bonham, V. L., E. Warshauer-Baker, and F. S. Collins. 2005. Race and ethnicity in the genome era: The complexity of the constructs. American Psychologist 60 (1): 9–15. Buechner, J. S. 2004. Hospitalizations by race and ethnicity, Rhode Island, 1990–2003. Medicine and Health Rhode Island 87 (7): 220–221. Carter-Pokras, O., and R. Zambrana. 2006. Collection of legal status information: Caution (letter to the editor). American Journal of Public Health 96 (3): 399, author reply 399–400.

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Curry, L., and J. Jackson. 2003. The science of including older ethnic and racial group participants in health-related research. The Gerontologist 43 (1): 15–17. de la Rosa, I. A. 2002. Perinatal outcomes among Mexican-Americans: A review of an epidemiological paradox. Ethnicity and Disease 12: 480–487. Eschbach, K., Y. F. Kuo, and J. S. Goodwin. 2006 Ascertainment of Hispanic ethnicity on California death certificates: Implications for the explanation of the Hispanic mortality advantage. American Journal of Public Health 96 (12): 2209–2215. Franzini, L., J. C. Ribble, and A. M. Keddie. 2001. Understanding the Hispanic paradox. Ethnicity and Disease 11: 496–518. Garro, L. C. 2001. The remembered past in a culturally meaningful life: Remembering in cultural, social, and cognitive processes. Cambridge: Cambridge University Press. Gilliss, C. L., K. A. Lee, Y. Gutierrez, D. Taylor, Y. Beyene, J. Neuhaus, and N. Murrell. 2001. Recruitment and retention of healthy minority women into community-based longitudinal research. Journal of Women’s Health and Gender-Based Medicine 10 (1): 77–85. Groves, R. M. 2006. Non-response rates and non-response bias in household surveys. Public Opinion Quarterly 70: 646–675. Haffner, S. M., R. D’Agostino, M. F. Saad, M. Rewers, L. Mykkänen, J. Selby, G. Howard, et al. 1996. Increased insulin resistance and insulin secretion in non-diabetic AfricanAmericans and Hispanics compared with non-Hispanic whites. Diabetes 45 (6): 742–748. Hunt, K. J., K. Williams, R. G. Resendez, H. P. Hazuda, S. M. Haffner, and M. P. Stern. 2002. All-cause and cardiovascular mortality among diabetic participants in the San Antonio Heart Study: Evidence against the “Hispanic paradox.” Diabetes Care 25 (9): 1557–1563. Kaplan, J. B., and T. Bennett. 2003. Use of race and ethnicity in biomedical publication. Journal of the American Medical Association 289 (20): 2709–2716. Keeter, S., C. Kennedy, M. Dimock, J. Best, and P. Craighill. 2006. Gauging the impact of growing non-response on estimates from a national RDD telephone survey. Public Opinion Quarterly 70: 759–779. Larkey, L. K., L. K. Staten, C. Ritenbaugh, R. A. Hall, D. B. Buller, T. Bassford, and B. R. Altimari. 2002. Recruitment of Hispanic women to the Women’s Health Initiative: The case of Embajadoras in Arizona. Controlled Clinical Trials 23 (3): 289–298. Loue, S. 2006. Assessing race, ethnicity and gender in health. New York: Springer. Mathews, T. J., and M. F. MacDorman. 2006. Infant mortality statistics from the 2003 period linked birth/infant death data set. National Vital Statistics Reports: From the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 54 (16): 1–29. Maurer, K. R. 1985. Plan and operation of the Hispanic Health and Nutrition Examination Survey, 1982–84. Vital and Health Statistics Series 1 (19): 85–1321. http://www.cdc .gov/NCHS/data/series/sr_01/sr01_019.pdf. Mays, V. M., N. A. Ponce, D. L. Washington, and S. D. Cochran. 2003. Classification of race and ethnicity: Implications for public health. Annual Review of Public Health 24: 83–100. National Center for Health Statistics. 2004. Technical appendix from Vital Statistics of United States 1999 Mortality. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention. Hyattsville, MD: National Center For Health Statistics.

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North American Association of Central Cancer Registries. 1996. Final report: Subcommittee on methodologic issues of measuring cancer among Hispanics. Springfield, IL: North American Association of Central Cancer Registries. Office of Management and Budget. 1997. Revisions to the standards for the classification of federal data on race and ethnicity. Federal Register Notice. http://www.whitehouse.gov/ omb/rewrite/fedreg/ombdir15.html. Palloni, A., and E. Arias. 2003. A re-examination of the Hispanic mortality paradox. CDE Working Paper No. 2003–01. Madison: Center for Demography and Ecology, University of Wisconsin-Madison. ———. 2004. Paradox lost: Explaining the Hispanic adult mortality advantage. Demography 41 (3): 385–415. Palloni, A., and J. D. Morenoff. 2001. Interpreting the paradoxical in the Hispanic paradox: Demographic and epidemiologic approaches. Annals of the New York Academy of Sciences 954: 140–174. Patel, K. V., K. Eschbach, L. A. Ray, and K. S. Markides. 2004. Evaluation of mortality data for older Mexican Americans: Implications for the Hispanic paradox. American Journal of Epidemiology 159 (7): 707–715. Preloran, H. M., C. H. Browner, and E. Lieber. 2001. Strategies for motivating Latino couples’ participation in qualitative health research and their effects on sample construction. American Journal of Public Health 91 (11): 1832–1841. Rosenberg, H. M., J. D. Maurer, P. D. Sorlie, N. J. Johnsons, M. F. MacDorman, D. L. Hoyert, J. F. Spitler, and C. Scott. 1999. Quality of death rates by race and Hispanic origin: A summary of current research, 1999. Vital and Health Statistics. Ser. 2, Data Evaluation and Methods Research 128: 1–13. http://www.cdc.gov/nchs/data/series/sr_02/sr02 _/28.pdf. Runy, L. A. 2004. Collecting race and ethnicity data. Hospitals and Health Networks 78 (8): 30. Sacco, R. L., B. Boden-Albala, G. Abel, I. F. Lin, M. Elkind, W. A. Hauser, M. C. Paik, and S. Shea. 2001. Race-ethnic disparities in the impact of stroke risk factors: The northern Manhattan stroke study. Stroke 32 (8): 1725–1731. Singer, E. 2006. Introduction: Non-response bias in household surveys. Public Opinion Quarterly 70: 637–645. Stern, M., and M. Wei. 1999. Do Mexican-Americans really have low rates of cardiovascular disease? Preventative Medicine 29: S90–S95. Walsh, C., and L. F. Ross. 2003. Whether and why pediatric researchers report race and ethnicity. Archives of Pediatrics and Adolescent Medicine 157 (7): 671–675.

Marilyn Aguirre-Molina Chapter 4

and Gabriela Betancourt

Latino Boys The Early Years

In general, male children, regardless of race/ethnicity, face poorer health outcomes—especially those that are socioeconomically disadvantaged and uninsured (Courtenay 2003; Krieger 2003a). In particular, Latino boys disproportionately face negative physical and mental health outcomes—including diabetes, obesity, asthma, and depression—when compared with other children (Child Trends Data Bank 2009). Overall trends for Latino boys point to significant disparities in health outcomes, access to services, and the quality of health care received. Although it is well established that poverty increases the likelihood of negative health outcomes in children, there is little in the literature that looks at the interaction between and effects of socioeconomic status, race/ethnicity, and gender. Therefore, social and structural factors are rarely taken into consideration when analyzing health outcomes (positive or negative) of Latino boys. Methods

Due to the paucity of data and studies on Latino boys as a whole, this chapter utilized a number of sources for the proposed analysis. The sources included an in-depth review of the literature, interviews with key informants, and analysis of data from the National Survey of Children’s Health (NSCH) (Maternal and Child Health Bureau 2003). The combined sources provided the core of the information used for the analysis presented. Literature Review

The literature review identified the available data/studies published between 1990 and the present that investigated the health status of Latino boys zero to 67

68 Table 4.1

Marilyn Aguirre-Molina and Gabriela Betancourt Selected Characteristics of Young Males According to Race/Ethnicity, 20 03, Percent (SE) Non-Hispanic

Characteristics

Non-Hispanic

black

Hispanic

white

Total

( n ⴝ 4,855)

( n ⴝ 6,887)

( n ⴝ 36,177)

( n ⴝ 51,848)

Age 5

31.2 (1.07)

40.1 (1.11)

31.1 (0.40)

32.9 (0.37)

6–11

32.6 (1.08)

31.5 (1.05)

33.2 (0.41)

32.9 (0.37)

12–17

36.3 (1.08)

28.4 (1.01)

35.8 (0.41)

34.2 (0.36)

2.2 (0.34)

15.7 (0.81)

1.3 (0.11)

4.8 (0.21)

98.9 (0.25)

38.7 (1.07)

99.0 (0.10)

87.0 (0.32)

34.7 (1.09)

61.9 (1.11)

70.6 (0.41)

63.5 (0.39)

Foreign-born English spoken at home Family structure Two parents biological/adopted Two parents stepfamily

9.9 (0.72)

6.4 (0.56)

9.4 (0.27)

8.7 (0.22)

49.4 (1.17)

27.1 (1.02)

15.5 (0.33)

22.8 (0.35)

6.0 (0.55)

4.6 (0.43)

4.4 (0.18)

4.9 (0.18)

7.7 (0.67)

28.7 (1.07)

2.6 (0.16)

7.9 (0.25)

12 yrs.

34.1 (1.10)

35.1 (1.12)

22.7 (0.38)

26.2 (0.36)

12 yrs.

58.2 (1.14)

36.2 (1.03)

74.8 (0.40)

65.9 (0.39)

59.7 (1.13)

72.5 (0.98)

27.7 (0.43)

40.4 (0.42)

Have health insurance

92.6 (0.65)

78.5 (0.94)

94.6 (0.19)

91.2 (0.24)

Live in supportive neighborhood

68.5 (1.13)

72.5 (1.04)

86.6 (0.31)

81.1 (0.33)

Single mother no father present Other Education of parents 12 yrs.

Poverty level 200%

Source: National Survey of Children’s Health (NSCH), 2003. Note Totals include all boys regardless of race/ethnicity.

thirteen years of age in the United States. However, due to the limited number of studies and publications on the subject, as well as the focus of the studies, the literature review was organized in three sectors. First, a general review/overview regarding the health of Latino boys; second, a narrower search addressing specific health outcomes among Latino boys (e.g., diabetes, asthma, obesity); and finally, a series of searches that were informed by key informant interviews and other experts that focused on the associations between poverty, racism, violence, environmental exposure (among others), and child health outcomes.

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Qualitative Interviews of Key Informants

A series of semistructured interviews were conducted with key informants with expertise in child health and Latino families. The interviews provided valuable insight on the medical, social, and political mechanisms that affect children and the resulting health outcomes. The interviews also provided concrete examples that assisted in the analysis of the structural and systemic factors that result in the negative health outcomes and the quality of life of Latino boys. National Survey of Children’s Health

The NSCH, conducted from 2003 to 2004, is a national, random, telephone, cross-sectional survey of households with children under the age of eighteen years. It was conducted in both English and Spanish. Latino children between the ages of zero and seventeen years made up 13.2 percent (n  13,352) of the sample. See table 4.1 for characteristics of males in the survey. The primary aim of the survey was to estimate both national and state-level prevalence rates for various child health indicators and to capture information on the social characteristics of family and neighborhood. For purposes of this chapter, data were analyzed on child and family demographic profiles, child physical and mental health, insurance status and type of coverage, and family health and activities. Comparisons were made between Latino boys and nonLatino boys. Overview: Social and Economic Profile of Latino Boys

The most recent data from the U.S. Census Bureau reveals that 34 percent of all Latinos males are under the age of eighteen, and 29 percent of the boys are under the age of fifteen (U.S. Census Bureau 2004). Thus, approximately a third of Latino males are relatively young. Latinos of all ages are more likely to live in poverty when compared to non-Latino whites. Approximately 28 percent of Latino children live in impoverished households, second only to African Americans. An additional 61 percent of Latino children live in low-income families that are classified as working poor (National Center for Children in Poverty 2006). The poverty they experience is particularly salient—it affects where families can afford to live, housing conditions, resources (or the lack thereof) in neighborhoods, and hazards in the environment. Obtaining care for the resulting health problems is compromised by the ability to pay for health care or purchase health insurance. The outcome is that Latino children in the United States are the most likely group to lack health insurance (Flores, Abreu, and Tomany-Korman 2006). Despite state initiatives that offer health insurance to children under the age of eighteen, regardless of immigrant status and/or

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parental income level, Latino children continue to have low rates of insurance. These circumstances make obvious the manner by which structural factors such as income and poverty, neighborhood conditions, and insurance status have an impact on the health of Latino boys. Health Profile of Latino Boys up to Age Thirteen

The health status and health risks of Latino boys are distinct from that of their non-Latino counterparts. Existing literature clearly describes the chronic health conditions—in particular obesity, asthma, and diabetes—that disproportionately affect Latino children, especially boys under the age of eighteen. When compared to other ethnic groups, Latino children are at higher risk for common childhood illnesses that are preventable by immunization (Schempf, Politzer, and Wulu 2003). Additionally, Latino children have poorer oral health outcomes (U.S. Department of Health and Human Services 2005). Children’s place of residence—that is, urban or rural area—influences the type and rate of unintentional injury that they are exposed to (pedestrian vs. vehicular, agricultural-related, interpersonal violence, etc.), but regardless of location, Latinos’ rates remain disproportionately high (Karr, Rivera, and Cummings 2005; Pressley et al. 2007). Latino children are among those with the highest rates of unintentional morbidity and mortality and among those who are less than one year old; Latino infants have twice the unintentional injury rate than non-Latino children (Schwartz and Flores 2002). The risk of homicide is greater in the first year of life than in any other year before the age of seventeen, making it the leading cause of injury mortality in infancy. Latino males in the first year of life are more likely to be victims of homicide; male infants have an infant homicide rate of 6 per 100,000 compared to 5 per 100,000 for whites (Child Trends Data Bank 2009). Analysis of the NSCH data on self-reported/perceived health status confirms previous findings: only 64 percent of Latino parents/primary caregivers indicated that their children were in excellent/very good health, as compared to 88.3 percent of all non-Latino children. Latino children were reported to be in fair/poor health four times more often than their non-Latino counterparts, and approximately three times more likely to report fair/poor dental health. Chronic Conditions

When compared to their white and African American counterparts, as well as Latinas in the same age group, Latino boys experience disproportionately negative outcomes due to chronic conditions such as diabetes, asthma, and obesity/overweight (Hedley et al. 2004). This situation is well documented and

Latino Boys Table 4.2

71

Selected Health Outcomes of Young Males According to Race/Ethnicity, 20 03 Non-Hispanic

Non-Hispanic

black

Hispanic

white

Total

( n ⴝ 4,855)

( n ⴝ 36,177)

( n ⴝ 6,887)

( n ⴝ 51,848)

4.7 (0.49)

8.7 (0.69)

1.8 (0.12)

3.4 (0.16)

Self-rated oral health fair/poor

11.1 (0.79)

21.2 (1.01)

6.4 (0.24)

9.9 (0.27)

Overweight

39.1 (1.23)

35.6 (1.42)

23.6 (0.39)

27.5 (0.39)

Asthma

20.3 (0.91)

12.9 (0.76)

13.5 (0.30)

14.6 (0.28)

Diabetes

0.3 (0.08)

0.3 (0.13)

0.4 (0.05)

0.3 (0.04)

Depression/anxiety

3.6 (0.52)

3.8 (0.44)

5.3 (0.23)

4.7 (0.18)

Characteristics

Self-rated health fair/poor

Note Proportion (standard error); all group comparisons are significant at 0.001 with the exception of diabetes; total includes all boys regardless of race/ethnicity.

confirmed by the key informants who expressed concern over the increasing incidence. It is well established that both male and female Latino children have high rates of obesity. NSCH data indicate that Latino boys are at increased risk of becoming overweight, or of being overweight at baseline when compared to non-Latino boys of all races/ethnicities (see table 4.2). In addition, the Fragile Families and Child Well-Being cross-sectional study examined racial/ethnic differences in the prevalence of obesity among preschool children enrolled in the study. The highest prevalence of obesity was detected in Latino preschool aged boys and girls. Significant differences remained after controlling for maternal education, household income, and food security (Whitaker and Orzol 2006). In a population-based registry study that analyzed the link between obesity at the onset of diabetes, the investigators found that Latino boys seventeen and younger were overrepresented with “obese/undetermined (non-type 1) diabetes” diagnoses when compared with non-Latino whites, 33.0 percent versus 6.6 percent respectively (Lipton et al. 2005). When compared with nonHispanic boys of the same age, Latino boys between the ages of six and seventeen years are also almost twice as likely to report having zero days of participation in physical activity for at least twenty minutes in the past week. A deterrent to the development of efficacious intervention is the scarcity of analyses that consider the circumstances or context within which the growing problem of obesity is occurring among Latino children. Clearly, children are dependent on adult caregivers; as such, the life circumstances of adults determine the situation of the child with regard to income, neighborhood of

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residence, and multiple other resources available (Fuentes-Afflick 2006). Many public health campaigns address the issue of childhood obesity as a matter of individual choice or behavior and rarely consider the constraints of income, the availability of select foods (e.g., fresh fruits and vegetables, low or fat free dairy products), and nutritional awareness by the child’s family. Exercise to reduce and prevent obesity is rarely approached beyond the lens of individual behavior to take into consideration the complex structures that limit the individual and allow for safe, accessible areas to play, explore, and exercise. Latino children reside in urban areas with few safe and well-maintained playgrounds; heavy automobile traffic emitting harmful fumes on residential streets; the threat of pedestrian accidents; and neighborhoods with increased incidence of gun violence or other crime. Rarely do the parents have the option of allowing the child to just go outside and play. Undoubtedly, these structural and community factors greatly influence Latino children’s levels of risk. Asthma is another chronic condition disproportionately affecting Latino boys. A prevalence study conducted in 2000 determined that boys across all racial/ethnic categories had increased odds of becoming asthmatic than girls, but Latino boys exhibited significantly higher rates (Lwebuga-Mukasa and Dunn-Georgiu 2000). In addition to any possible genetic component associated with the etiology of the disease (Smith et al. 2005), asthma is also linked to environmental and structural factors that trigger and/or exacerbate the condition. A study conducted in New York City’s East Harlem community, which has one of the highest asthma prevalence rates in the United States, surveyed parents and guardians of asthmatic children (kindergarten through sixth grade) on medication usage. Results indicated that medication was underused among both boys and girls (boys made up 57 percent of the sample). The explanation for this situation was inadequate access to care and medication (Diaz et al. 2000). Lack of access to care or related barriers to services, especially poor continuity of care and quality services, worsen these disparities. Behavior Health Risks

According to data from the Youth Risk Behaviors Surveillance System (YRBSS), preadolescent Latino boys are engaging in behaviors that put them at higher risk for sexually transmitted infections (STIs), including HIV, and substance use (YRBSS 2005). One of the key informants interviewed stated that these issues are becoming apparent in the clinical setting: “Behavioral concerns (among boys) become more apparent in the school age years because boys tend to have more behavioral and educational needs than girls. Also, middle-school is becoming more like high-school these days in that many teenage issues are

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apparent at younger ages such as 11, 12 and 13—risky behavior, sexual activity, alcohol and other drug use.” According to YRBSS data, 11.1 percent of Latino boys reported their first sexual intercourse prior to thirteen, more than double their white counterparts. This early initiation is accompanied by increased risk because few boys reported consistent condom use or none at all. In addition, Latino boys report higher rates of smoking a whole cigarette and drinking alcohol prior to the age of thirteen, with 16.5 percent reporting marijuana use before age thirteen. In great part, easy access to these substances by youth in urban poor communities contributes to the increases (YRBSS 2005). Alcohol and tobacco merchants are often negligent in the enforcement of the age of purchase laws, or they ignore the fact that of-age youth are purchasing these substances for them (IOM 2007; National Research Council and Institute of Medicine, 2004). The aggressive targeted marketing of the alcohol and tobacco industries seems to be contributing to the increased and early use among Latino boys and girls. Ever seeking new markets, these industries know the importance of reaching sectors of untapped markets at an early age so as to develop a long-term consumer base. The fact that Latino youth still have slightly lower rates of alcohol and tobacco use than their white counterparts makes them “attractive,” as does the growth rate of this population (IOM 2007; National Research Council and Institute of Medicine 2004). Mental Health

Data overwhelmingly suggest that the mental health service needs of Latino boys go unmet. The availability of and access to mental health services is limited in urban poor communities, particularly for uninsured Latinos. As such, Latinos have the highest rate of unmet need among preschool-aged children (Hazen et al. 2004). According to a key informant who is a pediatrician in Harlem, New York, “Poverty has every sort of significant impact on their health outcomes . . . a lot of the mothers that we see are depressed and alone. So if you combine all of these factors then behavioral and mental health [are] very important to address because these boys are being raised with mothers that [are] under stress themselves and often [experience] a high-incidence of domestic violence. The school-system is very poorly run in these neighborhoods—kids [problems] are not identified early by schools and special services within the school.” A prospective cohort study based in central and southern California recruited participants from seven community clinics. The majority of the participants were boys, 20 percent of whom were Latino boys. The study determined that in comparison to white families, Latino families were less likely to seek

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professional advice or help regarding their children’s problems (McMiller & Weisz 1996). A study of children ages six to twelve years who were discharged from a California hospital with a principal diagnosis of mental illness found that non-Latino boys were overrepresented among the patients and Latino boys underrepresented (Chabra, Chavez, and Harris 1999). In spite of the need, Latino children are less likely to receive mental-health services. The structural contributors appear to be a lack of available services, services that are not linguistically or culturally responsive, and inadequate outreach to Latino families and caretakers. The latter appears due to the limited or lack of information available to parents/caregivers of existing services, and/or general misunderstandings of symptoms/behaviors by parents, and providers who misdiagnose the problem and fail to follow up (Leal 2005). When discussing the immigrant experience—the primary focal point is usually the adult immigrant entering the United States. But the reality for many children of these immigrants—whether they stay behind or come to the United States—is much more complicated. For those children who have lived in conflict-ridden countries and witnessed genocide, civil war, extreme poverty, and/or violence perpetrated by governmental authorities, such trauma is compounded by the difficult and complex experience of immigration to the United States. Although these experiences and corresponding effects are not exclusive to young boys, it may be more difficult for them to express their feelings surrounding separation and trauma or to find an appropriate outlet to process their past experiences. Other concerns arise for those who stay behind. What are the effects on a child who remains in the home country to be cared for by someone other than the primary caregiver—no matter how loving or nurturing this other caregiver may be? And how is this attenuated when the child is sent to the United States to live with parental figures that have become less familiar over time? While there is insufficient research to respond, there is a great likelihood that adjustment within a family that has experienced long separation is compounded by the child’s entry to a culturally and socially distinct community and school system. The accompanying stress of separation and reunion place an added burden on Latino children of immigrants (National Research Council and Institute of Medicine 1999). Disparities: Epidemiological, Social, and Structural Considerations The School Years

The school years lay the foundation for a child’s understanding of his relation to and importance in his community and the world at large. He begins to shape

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the vision of his future outside of the home and apart from the protection of the primary caregiver. A child’s health status and quality of life are intimately tied to this environment and the ability to receive safe, stable, and appropriate stimuli to facilitate learning and growth, play and exercise. During the school years Latino boys, ages six to eighteen years, are more likely to experience higher rates of injury and trauma, developmental delays, and behavioral disturbances (Schmid 2001). Schmid’s review of the literature over a ten-year period revealed a number of factors that likely contribute to Latino boys’ frustration and difficulty in navigating the school system. This is often based on the fact that Latino students are more segregated than any other ethnic or racial group; low English proficiency (Spanish dominant) students are more segregated in classes and attend schools with overwhelmingly minority student populations than English proficient students; and Latino boys are more likely than Latino girls to be put into remedial courses and to take an adversarial stance toward teachers. Too often, the schools’ response to “problem” boys is to place them in special education, which results in the disproportionate overrepresentation of Latino and African American boys in these classes. These placements create situations that compromise their development and create frustration (Harvard Civil Rights Project 2001). Nancy Nevarez of the Academy for Educational Development concludes that “the predominance of Latino and African American boys placed in Special Education, primarily for reasons of discipline, makes them unmotivated and dispirited, and few of them earn a high school diploma” (Froschl and Sprung 2005). Such circumstances may explain the excessive dropout rates among Latino boys. In 2000, 21.1 percent of sixteen- to nineteen-year-old Latinos were high school dropouts (U.S. Census Bureau 2003). This rate was three times greater than that of their non-Latino counterparts (6.9 percent). In addition to a frustrating school environment, poverty and the economic needs of the family often contribute to leaving school early. Thirty-eight percent of Latino students, compared with 22 percent of whites, dropped out for economic reasons (Froschl and Sprung 2005). Given the relationship between high school graduation and a student’s life prospects and potential income, graduation rates are clearly important but have not received the needed attention. As boys age out of infancy—a period that can be considered a relatively “nongendered” life stage—and transition into the school-aged years, a trend emerges where they experience higher injury rates than their female peers in the United States (Laflamme and Diderechsen 2000; Mallonee 2003). Though some may attribute this trend in injuries to gender alone (i.e., “boys will be

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Marilyn Aguirre-Molina and Gabriela Betancourt

boys”), this does not explain the disproportionately high rates among Latino boys or take into account the context within which these injuries occur. Within the school environment, children under the age of fourteen are at greatest risk for injury. Those within the ten- to fourteen-year age group account for 46 percent of school-based injuries nationwide, with boys at a higher risk of injury than girls. There is also evidence that a great deal of the injury is due to poor playground equipment and inadequate maintenance, and limited supervision during playtime (National SAFE Kids Campaign 2004). According to a report from the surgeon general, serious violent crimes against youth between the ages of twelve and eighteen are 50 percent greater when in school than outside of the school environment. Within school, the highest victimization rate is found among boys between the ages of twelve and fourteen (U.S. Surgeon General 2001). Clearly, Latino boys fall within this group. Injury, Risks, and Exposure in the Home and Community

In this discussion, injury is defined as unintentional or accidental and not as a direct result of neglect or violence. It is generally associated with hazardous conditions in the home (e.g., faulty wiring, lack of window guards, unprotected heating vents/radiators) which are the direct responsibility of housing and other municipal authorities to maintain. The school, as well as public areas in urban neighborhoods (abandoned lots, unkempt playgrounds, faulty playground equipment, etc.), are all sources of unintentional injury. The excess rates of injury can be explained by the fact that many Latino boys live in poor households that are located in impoverished communities; the very same communities that are neglected by public sector authorities responsible for enforcing safety standards and conditions (Anderson et al. 1998; Simon et al. 2006). One pediatrician we interviewed stated, “We have millions of examples of why living in a poor community makes it harder to avoid injury and violence related problems—from area overcrowding to the lack of safe play areas. These impact not just the risk of getting injured, but the child’s overall wellbeing.” Latino boys living in rural communities are similarly overrepresented in the rates of unintentional injuries. Latino children living in or close to farm or rural areas—as is the case of many recent immigrant families working in the agricultural labor force—have a 70 percent higher industry-related fatality rate when compared to non-Latinos (Schwartz and Flores 2002). As is the case in urban environments, this is attributable to surroundings that are filled with risks and unsafe conditions that go unmonitored by housing and workforce authorities who are not held accountable.

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To fully comprehend the threats to child health, one must examine the physical environment of the child (as an individual), of children (as a group or community), and of Latino boys in particular (as a gendered construct), scrutinizing the socio/structural components affecting and producing an environment and corresponding exposures. For example, environmental exposures in the home, such as lead poisoning, are increasingly due to poor housing conditions and peeling lead-based paint. These high risk environments are due to landlords’ lack of adherence to housing policies and to housing authorities’ neglect. Poor families may be the most vulnerable to these situations—particularly immigrant families who are new to the United States. Many are not aware of housing regulations and their rights as tenants, or they may fear retaliation if they complain about the housing conditions (Early et al. 2006; Shapiro and Stout 2002; Sandel and Wright 2006). As one pediatrician interviewed put it, “[Living in a poor community] impacts their likelihood of getting asthma, because if they are playing in dirty alleys and city streets and breathing in all of the car fumes, they are more likely to have asthma problems than if they have a big, beautiful park that is not polluted and that they can run around in. . . . poverty in and of itself plays a major role . . . it is hard to imagine the amount of stress these families are under because both parents are trying to work two jobs so that there’s enough money to put food on the table, and stress in the house impacts the parent’s ability to parent.” Pollutants include asbestos or pesticides brought into the home by adults or caregivers, and they compromise the health of everyone in the home. Immigrant families, particularly if undocumented, and/or migrant workers are disproportionately vulnerable, as they often work as manual laborers in construction and agriculture where there are large outputs of particulate matters and toxins. Standards governing the education of all workers on the safe removal of matter before entering the home are often ignored and violated by employers (Froschl and Sprung 2005; Laflamme and Diderechsen 2000). Children are particularly prone to this type of exposure—toddlers exhibit hand-to-mouth behavior as part of their normal development and often play on the floor or lower levels where dust and other particulate matter settle. Children develop and grow rapidly and expend much more energy, and in doing so they take in more air for their body size than adults. Furthermore, depending on the economic situation of the family, young children—especially boys—may spend large amounts of time in or near their caregivers’ worksite. This is especially the case in rural areas where there are high concentrations of migrant workers employed in agriculture and working directly with pesticides and other industry toxins (Shalat et al. 2003).

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50

% gang members

40

30

20

10

0 1996

1998

1999

Hispanic/Latino

Caucasian/white

African American/black

Asian

Figure 4.1

2001 Other

Race/ethnicity of gang members.

Gang activity peaks in secondary school, but the most dramatic increases are occurring between the elementary and middle school years (U.S. Department of Justice 2005). Children are at highest risk as early as ten years of age and well into the high school years. The age of gang involvement is decreasing, as reported in a nationally representative sample of public school principals, 31 percent of whom reported that they were experiencing gang activity in their middle schools (U.S. Surgeon General 2001). Several of the key informants supported this finding. One stated that “a few years back there was actually a gang-related incidence among eighth-graders. It was striking that eighth-graders are already in gangs and beating each other up—gang membership seems to be getting younger and younger.” Latino young people clearly have the highest rate of gang involvement of any other group in the country. As demonstrated in figure 4.1, the trend is increasing. Ninety-four percent of gang members are male, 50 percent are under the age of eighteen, and 47 percent are Latino (Egley 2000). Despite the overrepresentation of Latino youth involved in gang activity, limited research has been undertaken with a Latino focus (U.S. Surgeon General 2001). The existing data in the uniform crime reporting systems (UCRs) does not capture Latino youth specific data, nor has it been captured via other national data collection systems. Therefore, there is reliance on local level data (such as regional and/or city). Summary and Conclusions

Within the context of family poverty, poor neighborhoods, and inadequate schools, young Latino boys enter and attempt to navigate the schools and their

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social and community environments. Therefore, it should not come as a surprise that as Latino boys age through the school years, the prevalence of absenteeism and school disengagement rises (Narro Garcia 2001). Current sociostructural factors (education, housing, and employment opportunities and cost of living) in the United States pose significant barriers to the attainment of Latino children’s optimum health, learning, and the successful achievement of developmental milestones. The health conditions identified and discussed here can be viewed as both the direct and indirect result of social, structural, and systemic factors ranging from poverty and lack of access to health care, poor housing conditions, and inadequate educational opportunities. However, the other side of the coin also exists: chronic health conditions are one of the many factors contributing to persistent poverty. If one is in poor health or disabled, it is difficult to attend school, be attentive in class, obtain employment, or maintain job performance. It can be argued that poverty exacerbates these conditions (Anderson and Armstead 1995; Hayward et al. 2000; Geronimus 2000). One of the key informants directly linked the social, economic, and structural environment to children’s health and well-being: “They live in overcrowded housing. . . . Because of poverty a lot of them have to eat junk food, [and] they have a sedentary type of life—parents are scared of letting the kids play [outside]. There is a lack of safe play areas to go to, [and] there is a lack of quality after-school programs.” The challenge to addressing disparities experienced by Latino boys is how to best use existing knowledge about the effects of structural factors on debilitated communities. This could contribute to creating efficacious policies, programs, and interventions that reach the core of these problems. This type of analysis, and the policies that would stem from it, is likely the only realistic approach for progressively eliminating health disparities and attaining social equity. References Anderson, C. L., P. F. Agran, D. Winn, C. Tran. 1998. Demographic risk factors for injury among Hispanic and non-Hispanic white children: An ecologic analysis. Injury Prevention 4: 33–38. Anderson, N. B., and, C. A. Armstead. 1995. Toward understanding the association of socioeconomic status and health: A new challenge for the biopsychosocial approach. Psychosomatic Medicine 57 (3): 213–225. Chabra, A., G. Chavez, and E. Harris. 1999. Mental illness in elementary school aged children. Western Journal of Medicine 170:28–34. Child Trends DataBank. 2009. http://www.childtrendsdatabank.org/status.cfm. Courtenay, W. 2003. Key determinants of health and the well-being of men and boys. International Journal of Men’s Health 2 (1): 1–27. Diaz, T., T. Sturm, T. Matte, M. Bindra, K. Lawler, S. Findley, and C. Maylahn. 2000. Medication use among children with asthma in East Harlem. Pediatrics 105: 1188–1193.

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Early, J., S. W. Davis, S. A. Quandt, P. Rao, B. Snively. 2006. Housing characteristics of farmworker families in North Carolina. Journal Immigrant Health and Minority Health 8 (2): 173–84. Egley, A. 2000. National youth gang survey trends (1996–2000). Fact sheet. Washington, DC: U.S. Department of Justice Office of Juvenile Justice and Delinquency Prevention. Flores, G., M. Abreu, and S. C. Tomany-Korman. 2006. A community-based study of risk factors for and consequences of being an uninsured Latino child. Pediatrics 118: 730–740. Froschl, M., and B. Sprung. 2005. Raising and educating healthy boys—A report on the growing crisis of boys’ education. New York: Educational Equity Center of the Academy for Educational Development. Fry, R. 2005. The high schools Hispanic students attend: Size and other key characteristics. Washington, DC: Pew Hispanic Center. Fuentes-Afflick E. 2006. Obesity among Latino preschoolers: Do children outgrow the “Epidemiological Paradox.” Archives of Pediatric and Adolescent Medicine 160: 656–767. Geronimus, A. 2000. To mitigate, resist, or undo: Addressing structural influences on the health of urban populations. American Journal of Public Health 90 (6): 867–872. Harvard Civil Rights Project. 2001. Conference on Minority Special Education, Cambridge, MA, November. Hayward, M. D., T. Miles, E. Crimmins, Y. Yang. 2000. The significance of socioeconomic status in explaining the racial gap in chronic health conditions. American Sociological Review 65 (6): 910–930. Hazen, A. L., R. L. Hough, J. A. Landsverk, and P.A. Wood. 2004. Use of mental health services by youths in public sectors of care. Mental Health Services Research 6 (4): 213–226. Hedley, A., C. Ogden, M. Carroll, L. Curtin, and K. Flegal. 2004. Prevalence of overweight and obesity among U.S. children, adolescents and adults. Journal of the American Medical Association 291 (23): 2847–2850. Institute of Medicine (IOM). 2007. Ending the tobacco problem: A blueprint for the nation. Washington, DC: National Academies Press. Karr, C., F. Rivera, P. Cummings. 2005. Severe injury among Hispanic and non-Hispanic white children in Washington state. Public Health Reports 120 (1): 19–24. Krieger, N. 2003. Does racism harm health? Did child abuse exist before 1962? On explicit questions, critical science and current controversies: An ecosocial perspective. American Journal of Public Health 93 (2): 194–199. Laflamme, L., and F. Diderechsen. 2000. Social differences in traffic injury risks in childhood and youth: A literature review and a research agenda. Injury Prevention 6 (4): 293–298. Leal, C. 2005. Stigmatization of Hispanic children pre-adolescents and adolescents with mental illness: Exploration using a National Database. Issues in Mental Health 26: 1025–1041. Lipton, R., M. Drum, D. Burnet, B. Rich, A. Cooper, E. Baumann, and W. Hagopian. 2005. Obesity at the onset of diabetes in an ethnically diverse population of children: What does it mean for epidemiologists and clinicians? Pediatrics 115: 553–560. Lwebuga-Mukasa, J., and E. Dunn-Georgiu. 2000. The prevalence of asthma in children of elementary school age in western New York. Journal of Urban Health: Bulletin of the New York Academy of Medicine 77 (4): 745–761. Mallonee, S. 2003. Injuries among Hispanics in the United States: Implications for research. Journal of Transcultural Nursing 14: 217.

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Maternal and Child Health Bureau. 2003. The oral health of children: A portrait of states and the nation. The National Survey of Children’s Health. Rockville: U.S. Department of Health and Human Services. McMiller, W., and J. Weisz. 1996. Help seeking preceding mental health clinic intake among African-American, Latino and Caucasian youths. Journal of the American Academy of Child and Adolescent Psychiatry 35 (8): 1086–1094. Narro Garcia, C. 2001. The factors that place Latino children at risk of educational failure. In Effective programs for Latino students, ed., R. E. Slavin and M. Calderón. Philadelphia: Lawrence Erlbaum Associates. National Center for Children in Poverty. 2006. United States demographics of low-income children. New York: Columbia University. National Research Council and Institute of Medicine. 1999. Children of immigrants: Health, adjustment, and public assistance. Committee on the Health and Adjustment of Immigrant Children and Families, Donald J. Hernandez, editor. Board on Children Youth and Families. Washington, DC: National Academy Press. ———. 2004. Reducing underage drinking: A collective responsibility. Committee on Developing a Strategy to Reduce and Prevent Underage Drinking, Richard J. Bonnie and Mary Ellen O’Connell, editors. Board on Children, Youth, and Families, Division of Behavioral and Social Sciences and Education. Washington, DC: National Academies Press. National SAFE Kids Campaign (NSKC). 2004. School injury fact sheet. Washington, DC: NSKC. http://www.preventinjury.org/PDFs/SCHOOL_INJURY.pdf. Pressley, J., B. Barlow, T. Kendig, and R. Paneth-Pollack. 2007. Twenty-year trends in fatal injuries to very young children: The persistence of racial disparities. Pediatrics 119 (4): e875–e884. Sandel, M., and R. J. Wright. 2006. When home is where the stress is: Expanding the dimensions of housing that influence asthma morbidity. Archives of Diseases of Childhood 91: 942–948. Schempf, A. H., R. M. Politzer, and J. Wulu. 2003. Immunization coverage of vulnerable children: Comparison of health center and national rates. Medical Research and Review 60 (1): 85–100. Schmid, C. L. 2001. Educational achievement, language-minority students, and the new second generation. Sociology of Education. Supplement, Currents of Thought: Sociology of Education at the Dawn of the 21st Century, 71–87. Schwartz I., and G. Flores. 2002. Disparities in unintentional injuries among Latino Children. Paper presented at the 30th Annual Meeting of APHA, November. Shalat, S., K. Donnelly, N. Freeman, J. Calvin, S. Ramesh, M. Jimenez, K. Black, C. Coutinho, L. Needham, D. Barr, and J. Ramirez. 2003. Non-dietary ingestion of pesticides by children in an agricultural community on the US/Mexico border: Preliminary results. Journal of Exposure Analysis and Environmental Epidemiology 13 (1): 42–50. Shapiro, G., and J. Stout. 2002. Childhood asthma in the United States: Urban issues. Pediatric Pulmonology 33: 47–55. Simon, T. D., C. B. Emsermann, L. M. Dickinson, S. J. Hambidge. 2006. Lower rates of emergency department injury visits among Latino children in the USA: No association with health insurance. Injury Prevention 12 (4): 248–252. Smith, L., J. Hatcher-Rose, R. Wertheimer, and R. Kahn. 2005. Rethinking race/ethnicity, income, and childhood asthma: Racial/ethnic disparities concentrated among the very poor. Public Health Reports 120: 109–116. U.S. Census Bureau. 2003. Overview of race and Hispanic origin. Census 2000 brief. http://www.census.gov/prud/2002pubs/c2kbr01-1.pdf.

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———. 2004. The Hispanic population in the United States. Washington, DC: U.S. Census Bureau. U.S. Department of Health and Human Services. 2005. Centers for Disease Control. The burden of oral diseases. http://www.cdc.gov/oralhealth/publications/library/ burdenbook/chapter4.html. U.S. Department of Justice. 2005. Speech by R. Schofield at National Crime Prevention Conference, New Orleans, LA, October 10, 2005. U.S. Surgeon General. 2001. Youth violence: A report of the Surgeon General. http://www.surgeongeneral.gov/library/youthviolence/toc.html. Whitaker, R. C., and S. M. Orzol. 2006. Obesity among U.S. urban preschool childrenrelationships to race, ethnicity and socioeconomic status. Archives of Pediatric and Adolescent Medicine 160: 578–584. Youth Risk Behaviors Surveillance System (YRBSS). 2005. MMWR 55 (5): 1–108.

M. Antonia Biggs, Claire D. Brindis, Chapter 5

Lauren Ralph, and John Santelli

The Sexual and Reproductive Health of Young Latino Males Living in the United States

Latinos are the largest, fastest growing, and youngest ethnic group in the United States, and the primary factor responsible for this growth is high fertility. It is estimated that by 2025, 24 percent of U.S. youth will be Latino, up from 15 percent in 2000 (U.S. Census Bureau 2000). Reproductive health concerns include high rates of teen pregnancy, teen births, sexually transmitted infections (STIs), and HIV/AIDS. The reasons behind these reproductive health disparities can be better understood by looking at other social and structural factors in young Latinos lives. Overall, these comprise important public health issues facing the Latino community. Since 1990, U.S. teen pregnancy rates have decreased steadily, a trend driven mainly by decreases among African American and white teens. Latina teen pregnancy rates increased slightly in the early 1990s, then decreased overall by a smaller margin than other racial/ethnic groups between 1990 and 2002 (19 percent as compared to 40 percent and 34 percent among African American and white teens) (Guttmacher Institute 2006). Thus, Latina teen birth rates remain the highest among any major racial/ethnic group. Over half (51 percent) of Latinas in the United States will become pregnant at least once during their teenage years, and one in five sexually active Latino teen males will cause a pregnancy (National Campaign to Prevent Teen Pregnancy [NCPTP] 2006). The negative consequences of early, unintended pregnancy are well established. These include lessened educational and employment opportunities for family members, including fathers, and worse health outcomes for both mother and child that extend throughout the life course (NCPTP 2002). Beyond pregnancy, rates of STIs, including HIV, are substantially higher among Latinos. In 2004, 83

84

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one-quarter of new HIV/AIDS cases among adolescents ages thirteen to nineteen occurred among Latinos (Kaiser Family Foundation and Ford Foundation 2001). The growing number of Latinos living with HIV/AIDS has resulted in nearly a quarter of Latinos naming the disease as the most urgent health problem facing the nation (Kaiser Family Foundation and Ford Foundation 2006). Until recently, the importance of focusing on young men in the prevention of teen and unintended pregnancies has not been widely recognized; the number of policy initiatives and programs involving males in sexual and reproductive health care remain limited. Even fewer sexual/reproductive health programs and services are geared to serve Latino males in a culturally competent manner (Sonenstein 2000). Such programs are important, as males, particularly Latino males, are at higher risk of acquiring STIs because they tend to be younger when initiating sex and they have more sexual partners than their female counterparts (Kann et al. 2000). This lack of attention has a twofold effect: first, Latino men are left without the appropriate sexual/reproductive health care, education, and knowledge necessary to motivate changes in sexual behavior. Secondly, an absence of male involvement in decision making with regard to family planning hinders efforts to decrease unintended pregnancies and the spread of STIs among both Latino men and women. Research on the sexual and reproductive health of Latino males to inform clinical practice and public health programs is often lacking. The determinants and characteristics of sexual and reproductive health differ substantially across gender and ethnic/racial groups and subpopulations. Therefore, one must be cautious before generalizing existing research on mainstream populations and across Latino subpopulations (Kowaleski-Jones and Mott, 1998). Social and structural factors, including poverty, educational attainment, immigrant generation, place of birth, and geographic location, have been linked to sexual and reproductive health behaviors and outcomes, but the research examining this is limited. Poverty, often accompanied by diminished access to health care, social isolation, substandard living conditions, and psychosocial hardship, affects health and health care access over the life course. Poor levels of educational attainment make it difficult for many Latinos to rise out of poverty. They remain a small proportion of the college population (around 10 percent), in part due to an elevated high school dropout rate (Shin 2005; Laird et al. 2006). Over two-thirds (65 percent) of Latino students are the children of at least one immigrant parent and 18 percent are foreign-born themselves (Shin 2005). Immigration profoundly shapes the lives and experiences of Latino families living in the United States. Many Latino youth are growing up in environments

The Sexual and Reproductive Health of Young Latinos

85

and with cultural influences that are vastly different from those experienced by their parents. These circumstances can lead to an array of challenges in communicating with parents and conflicts surrounding social mores and behavior (Driscoll et al. 2004). Youth with foreign-born parents experience higher poverty rates, go less far in school, have more limited English skills, and are less likely to receive public assistance, including Medicaid, than low-income children whose parents were native-born. Many recent Latino immigrants, particularly those from Mexico, have moved to rural areas across the United States. Barriers to accessing reproductive health care services may be greater for those living in rural and remote areas where affordable and culturally competent health care services are often less accessible. Particularly for migrant farm-working families, inaccessible site locations impede enrollment in public health programs, and frequent movement across states increases barriers to health care given state residency requirements for Medicaid coverage (Rosenbaum and Shin 2005). The sum of these social and structural factors places Latino youth at a great disadvantage. It is critical to understand the diversity of Latino male youth as part of an analysis of the role of social and structural factors in the sexual and reproductive health of young Latinos. Diversity of Latino Male Youth and Relevance to Sexual Health Outcomes

Sexual behaviors among Latino youth vary by immigrant generation and national origin groups, as well as educational background and degrees of acculturation. According to data from the 2002 National Survey of Family Growth (NSFG), U.S.-born Latino youth were significantly more likely than their foreign-born counterparts to have used effective contraception during a recent sexual encounter. They were also less likely to have received STI treatment in the last year. However, place of birth was unrelated to whether young Latino men had ever had sex or used an effective birth control method at first sex (see table 5.1). Data from the National Longitudinal Study of Adolescent Health found that among Mexican-origin adolescents, U.S.-born youth with U.S.-born parents were more likely to have had sex (46 percent) than U.S.-born youth with foreign-born parents (39 percent) or foreign-born adolescents (39 percent). Patterns of sexual behavior followed a less linear generational pattern among Central and South American teens, and similar proportions of second- and third- generation Puerto Rican youth reported having had sex. Contraceptive use was also found to vary by generation status; 42 percent of foreign-born Mexican teens and 52 percent of second-generation Mexican

Table 5.1

Sexual Health and Behavior Characteristics of Latino Males and Females Age Fifteen to Twenty-Four, 20 02 Used effective

Social and structural factors

⬎15 at

contraception

Nonvirgins

first sex

at first sex

(%)

(%)

(%)

Male

Females

Males

Females

Males

Females

n ⴝ 450

n ⴝ 524

n ⴝ 339

n ⴝ 336

n ⴝ 339

n ⴝ 366

Family income 100% federal poverty level

77.3

65.3

57.1

61.5

65.6

36.9**

100% federal poverty level

76.5

66.7

49.0

58.2

66.3

54.6

Two parents

76.3

62.4

55.5*

61.9

67.3

41.6**

One parent

78.6

74.9

42.7

54.6

63.1

60.0

U.S.-born

77.2

62.2*

43**

55.4

68.6

60.5**

Foreign-born, 5 years in U.S.

77.6

72.2

78.7

73.1

62.4

19.8

Foreign-born, 5 years in U.S.

77.7

72.6

62.8

59.1

62.7

30.9

No degree, not currently enrolled in school

73.3**

86.8**

58.1

52.5

63.6

24.2**

High school diploma, bachelor’s degree, or currently enrolled in school

51.6

33.8

49.0

62.9

67.2

58.0

Less than high school

82.0*

68.0

58.1

65.0*

60.5

35.9

High school graduate

71.3

65.2

47.2

57.7

72.2

58.4

Some college

73.3

62.3

43.3

50.4

71.8

60.5

Urban

72.6*

60.1**

51.7

60.5

63.6

47.7

Suburban/rural

80.5

71.5

52.0

58.6

67.9

47.0

12 months of continuous coverage

69.1**

61.2**

46.6

58.5

67

52.3*

12 months coverage

86.5

73.7

56.9

61.2

65.2

40.2

Parental living situation

Nativity and years in the U.S.

Education level

Maternal education

Residence

Health insurance coverage

*p  .05 **p  .01

Used

Used

Used

effective

condom

Received

Received STI treatment

condom

contraception

at last

STI test in

in past

at first sex

at last sex

sex

past year

year

(%)

(%)

(%)

(%)

(%)

Males

Females

Males

Females

Males

Females

Males

Females

Males

Females

n ⴝ 339

n ⴝ 366

n ⴝ 339

n ⴝ 366

n ⴝ 339

n ⴝ 366

n ⴝ 339

n ⴝ 366

n ⴝ 339

n ⴝ 366

53.8

30**

77.9

46.2

51.6*

21.4

23.5

17.0

13.9*

4.1

63.8

47.9

81.3

58.8

65.7

30.9

27.3

20.1

6.2

7.0

60.2

34.9**

82.3

50

60.5

24.3

23.0

15.2

10.3

3.9*

60.6

52.8

74.8

61.3

61.4

32.7

33.4

26.8

5.5

65.9

53.0**

82.6*

53.6

67.7

30.8

22.6

21.1

47.1

15.5

84.3

59.9

53.7

16.3

35.9

18.6

21.1

12.1

54.0

26.2

65.6

50.0

46.4

25.0

28.6

11.8

7.9

3.4

52.4

20.6**

83.2

48.3

71.3

15.9

23.0

27.8

8.3

14.5

63.9

49.7

89.2

46.2

81.3

30.5

16.3

25.9

3.1

7.1

51.9**

33.5**

80.7

47.6

56.4

23.7

25.2

12.3**

10.8

3.6

69.3

43.9

74.4

57.6

59.3

28.9

28.5

20.2

9.7

9.1

69.0

51.4

84.8

61.4

71.6

30.9

25.1

29.7

4.0

6.7

52.4*

40.8

81.9

59.6

58.2

24.0

30.5

13**

14.1*

4.2

66.0

40.2

78.8

48.5

62.6

29.4

22.8

23.7

5.1

7.1

64.7

45*

77.9

54.6

62.2

28.5

29.1

19.9

7.4

8.1

56.0

34.2

82.3

52.1

59.3

24.8

23.0

17.4

10.3

2.5

6.5*

10.1

4.4**

88

Biggs, Brindis, Ralph, and Santelli

teens reported birth control use at first sex (Harris 1999). For Mexican-origin teens, it appears that the likelihood of both intercourse and contraceptive use may increase with generation status. High teen birth rates for Latinas are mainly due to high rates among youth of Mexican origin, who comprise approximately two-thirds of the U.S. Latino population (Hamilton et al. 2005). In 2000, Mexican- and Puerto Rican-origin women had the highest teen birth rates (95.4 and 82.9 per 1,000, respectively), followed by African American (79.2 per 1,000), white (32.6 per 1,000), and Cuban-origin (23.5 per 1,000) teens (Sutton et al. 2006). While no specific data on HIV/AIDS are available for Latino youth, it is evident that for Latinos of all ages, AIDS cases and HIV transmission patterns vary by place of birth, country of origin, and geographic location. Latinos born in the United States account for 41 percent of estimated AIDS cases among Latinos in 2005, followed by Latinos born in Puerto Rico (22 percent) and Mexico (22 percent) (Kaiser Family Foundation and Ford Foundation 2006). The majority of Latino AIDS cases are concentrated in New York, California, and Puerto Rico. Structural Factors and Their Relationship to the Sexual Health of Young Latino Men

The sexual and reproductive health of young men is predicted by a series of behaviors such as age at sexual initiation, current sexual activity, number of sexual partners, and use of condoms and other contraceptives. On many indicators of risky sexual behaviors, young Latino men fall somewhere between the percentages reported for African American and white males. At the same time, there is a great deal of variation in reproductive health outcomes within the Latino population based on social and structural factors, such as household poverty, personal and parental educational attainment, family environment, immigration status, and health care access. In this section, we describe the sexual health behaviors of young Latino men and present, wherever available, data on the relationship between social and structural factors and reproductive health outcomes. We draw upon published reports, as well as original multivariable analyses we conducted using the 2002 NSFG, a nationally representative dataset based on a random household survey of in-person interviews. The NSFG was conducted with 12,571 men and women ages fifteen to forty-four in 2002—of which 450 were Latino men ages fifteen to twenty-four. The majority (58 percent) of young Latino males were of Mexican origin. This was the first year in which males participated in the NSFG. Due to its large national framework, the NSFG represents one of the few surveys conducted in the United States that gathers information

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89

on a significant number of Latino individuals and their reproductive health. The multivariable analysis permits exploration into the influence of multiple factors on various sexual health behaviors, including age at first intercourse, condom use at first intercourse, and contraceptive use at most recent intercourse. In this section, teens refer to youth ages fifteen to nineteen and young men and women refer to youth ages fifteen to twenty-four. Age at First Sex and Contraceptive Use

Men’s age at initiation of sexual intercourse is an important predictor of later sexual behavior, as adolescents who initiate intercourse at younger ages are more likely than adolescents who delay first intercourse to have multiple sexual partners, be diagnosed with an STI, and experience pregnancy (Kaestle et al. 2005; O’Donnell et al. 2001; Santelli et al. 1998). The average age of first sex is sixteen and a half for Latino males, compared to fifteen and a half for African American and approximately seventeen years for white males (Martinez et al. 2006). Sexually experienced Latino and white young men (ages eighteen to twenty-four) report that their first sexual intercourse is “wanted” at similar and higher rates (63 percent and 64 percent, respectively) than African American young men (56 percent) (Abma et al. 2004). Their female counterparts, however, are less likely to report that their first sexual intercourse was wanted; only 26 percent of Latina, 27 percent of African American, and 38 percent of white young women report that they really wanted their first sex to happen when it did. The negative reproductive health outcomes among Latino young men may partially be attributable to low levels of contraceptive use among this population. The 2002 NSFG reveals that across all ethnic/racial groups, young Latinos are the least likely to use a contraceptive method at various points in their sexual history. For example, 34 percent of sexually experienced Latino young men reported that they used no contraceptive method at first sex, compared to 22 percent of white and 18 percent of African American young men. Even more salient to HIV/STI prevention is the use of condoms. Sexually active Latinos in the NSFG sample were less likely to use a condom (60 percent) at first sex than African American (81 percent) or white (68 percent) young men. Given that condom use at first intercourse has been shown to positively predict condom use at later sexual experiences (Shafii et al. 2004), this represents a pattern with implications for long-term negative effects. Pregnancy Desire

For many young Latinos, childbearing is viewed as a way to transition into adulthood, as an opportunity to achieve something meaningful in a context of

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limited opportunities. Latino youth are more likely than African American and white youth to want to become teen parents. In 2002, approximately 27 percent of never-married Latino males ages fifteen to nineteen reported that they would be “a little pleased” or “very pleased” if they got a female pregnant now, whereas 20 percent of African American and 10 percent of white male teens felt this way (Abma et al. 2004). Similar feelings are expressed by young women— 25 percent of Latina, 16 percent of African American, and 9 percent of white female teens reported that they would be a little or very pleased if they got pregnant now. The desire to become pregnant, along with lower levels of contraceptive use, has resulted in higher rates of teen pregnancy and birth in the Latino population. The Role of Education

Personal educational attainment and educational goals are related to sexual behavior among young Latinos. Latino men and women ages fifteen to twentyfour who had reached a higher level in school (still in school, high school diploma, or college degree) were significantly less likely to have had sex and were more likely to have used a condom at first sex than those who had dropped out of school (see table 5.1). These findings are consistent with the literature wherein high school dropout, lack of school engagement, and lower educational attainment have been linked with school-age pregnancy and birth, sexual risk-taking, decreased likelihood of using contraception consistently, and of becoming sexually active at younger ages (Irwin et al. 1999; Kirby 2002; Manlove 1998; Rosengard et al. 2005). The Impact of Poverty

At the same time, sexual health outcomes among Latino men are often compounded by certain structural factors such as poverty. In 2002, young Latino men living in poverty were significantly less likely to use a condom at last sex (52 percent) than those living above the federal poverty level (66 percent) (see table 5.1). Further, a higher proportion of low-income Latinos received STI treatment (14 percent) as compared to higher income Latinos (6 percent). The Role of Parents and Families

Parents play an important role in helping to determine reproductive health outcomes for their children. Their influence occurs on multiple levels, including their own personal educational attainment, the family environment they create, and how often they communicate with their children about sex and sexuality. Young Latino men whose mothers had less than a high school education are

The Sexual and Reproductive Health of Young Latinos

91

significantly more likely to have ever had sex (82 percent) than those whose mothers had a high school diploma (71 percent) or attended college (73 percent). In addition, young men whose mothers had more years of education were significantly more likely to have used a condom at first sex than those with less educated mothers. The exact mechanism by which maternal education influences reproductive outcomes is unclear. However, research demonstrates that having a mother with lower educational attainment is related to fewer negative attitudes toward pregnancy and a greater desire among adolescent males to get someone pregnant (Cooksey et al. 1996; Irwin et al. 1999; Rosengard et al. 2005). Family structure has also shown to be associated with reproductive health outcomes. Latino men who reported their sexual debut before age fifteen were significantly more likely to have lived in single-parent than in two-parent homes during early adolescence. Young Latino men living with both parents were also less likely (though not significantly) to have ever had sex, more likely to have used an effective contraceptive method at first and last sex, and less likely to have received an STI test, most likely because they had less risky behaviors. In terms of parental communication, Latino male teens (62 percent) are the least likely to discuss sexual health information with their parents, when compared to white (71 percent) and African American (75 percent) male teens and Latina teens (65 percent). Over half of Latino teen males spoke with their parents about STIs, while discussions about birth control methods, how to say no to sex, and how to use a condom were less frequent (Abma et al. 2004). The Role of Health Care Access

Latinos face a number of barriers impeding their access to needed reproductive health care. Latinos have the highest uninsured rate among all racial or ethnic groups, often lack transportation, and experience cultural and language barriers. These occur in addition to the usual barriers that teens face in accessing care, including concerns regarding confidentiality, cost, and lack of teen sensitive services (Flores et al. 2006; Kaiser Family Foundation 2000). One study of Latino seventh-, ninth-, and eleventh-graders estimated that 20 percent had nowhere to go for medical attention (Rew et al. 1999). This inadequate access for needed health care services results in less frequent use of birth control methods and inadequate screening and treatment for STIs and HIV/AIDS. According to the 2002 NSFG sample, young Latinas with continuous health insurance coverage were significantly more likely than those without continuous health care coverage to use an effective contraceptive or condom at first sex (see table 5.1). Young Latino men and women with continuous

92

Biggs, Brindis, Ralph, and Santelli

health insurance coverage were also significantly less likely to have ever had sex than those without health insurance coverage. Among sexually active young male NSFG respondents, 26 percent of Latinos, 38 percent of African American, and 19 percent of white men had been tested for an STI in the last year, and 9 percent of Latinos, 5 percent of African American, and 4 percent of white young men were treated for an STI in the last year. In addition, Latinos are more likely than whites to delay care after an HIV diagnosis (Kaiser Family Foundation and Ford Foundation 2006). Predicting the Sexual Health of Young Latino Men

Given the important relationships between personal and demographic characteristics and key sexual behaviors (age at first intercourse, condom use at first intercourse, and contraceptive use at most recent intercourse), we explored data from Latino youth (fifteen to twenty-four years) in the 2002 NSFG using multivariable regression models. Predicting Age of First Sex

A number of factors were found to be significantly associated with age at first sex for Latino males in the United States. Paternal education was found to be an important predictive factor. As compared to Latino males whose father had a high school diploma only, males whose father completed at least some college had one-half the odds of initiating first sex at a younger age, defined as age fifteen or younger (odds ratio [OR)]  0.47) (see table 5.2). Place of birth was also found to be significantly associated with an early sexual debut for Latino males; U.S.-born males were over twice as likely (OR  2.3) as foreign-born individuals to report an early age at first intercourse. A similar relationship was observed for young Latinas. Previous research conducted among the general adolescent and young adult population has found that poverty level and family structure are significantly associated with age at first intercourse (Santelli et al. 2000). However, these did not significantly predict young Latinos’ sexual health outcomes. The lack of significant results may be due to the small sample of Latino males in the NSFG population, making it difficult to detect differences based on socioeconomic status. Latino males living in urban settings were found to have almost three times the odds of reporting condom use at first sex than males living in rural settings. A very different set of factors emerged as significant predictors of condom use for Latina women (see table 5.2). Significant predictors for condom use at first sex among Latinas included living in a single-parent family, higher educational attainment, greater family income, and being U.S.-born.

100% federal poverty level

not examined

2.34*

1.63

*Odds ratios (ORs) with statistically significant findings (p  0.05).

Continuous health care coverage in last year

Health care coverage

U.S.-born

Place of birth

Urban

Place of residence

0.78

0.47*

Some college

Family income

0.79

Less than high school

Father’s education

0.9 1.31

Some college

0.99

1.34

Less than high school

Mother’s education

Currently in school and/or a high school graduate

Education

Not living with both parents in same household

Family structure

Males ( N ⴝ 339)

not examined

1.72*

0.47

0.91

0.65

0.71

1.78

0.73

0.37*

1.4

Females ( N ⴝ 366)

ⱕ15 at first intercourse

not examined

1.52

2.94*

0.73

0.85

0.49*

1.02

0.78

1.02

0.81

Males ( N ⴝ 339)

not examined

2.82*

0.88

0.62*

1.41

0.75

1.12

1.28

2.34*

1.86*

Females ( N ⴝ 366)

Used condom at first intercourse

0.65

1.27

1.44

0.8

1.76

1.25

1.81

1.11

1.33

0.66

Males ( N ⴝ 339)

0.99

0.71

1.6

0.69

1.81*

1.52

1.03

0.72

1.66

1.7

Females ( N ⴝ 366)

Used effective contraception at last intercourse

Predicted Reproductive Health Outcomes for Latino Males and Females Age Fifteen to Twenty-Four, 20 02 (Odds Ratios)

Social and structural factors

Table 5.2

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NSFG analyses revealed that few of these structural characteristics predicted effective contraceptive use at most recent intercourse for Latino male youth. For Latinas, having a father who had completed at least some college significantly increased the odds (OR1.8) of using an effective method at most recent intercourse, as compared to Latina women whose father was a high school graduate. None of these factors significantly predict contraceptive use at most recent intercourse for Latino males. The small sample size of sexually experienced Latino youth in the NSFG may have limited our ability to detect significant predictors. It is also possible that this is a difficult variable to predict using standard demographic predictors available in national surveys. Policy Recommendations for Improving the Reproductive Health of Young Latino Men

Over the past decade, a growing body of research has established that the sexual behavior characteristics and outcomes of Latino youth in the United States differ substantially from that of youth of other racial and ethnic groups. However, limited research has examined these indicators separately for Latino males and females. Most important, educational attainment is a lead structural indicator of changes in reproductive behaviors of Latinos males, with more education being associated with delays in the age of sexual activity onset. These analyses demonstrate that some of the traditional factors associated with sexual behavior for the adolescent population, including advanced parental education and urban residence, are significant predictors of sexual behaviors among Latino males, such as using a condom at first intercourse and delaying first intercourse until older. However, these factors do not predict sexual behavior at most recent intercourse, suggesting that for Latino youth (and males in particular), other factors are involved in their contraceptive behavior as they age and gain sexual experience. Further, with the exception of place of birth, the factors that predict sexual behavior are different for young Latino men and women. These differences should be considered when developing outreach strategies, clinical service programs, and policies that are aimed to promote the reproductive health of Latino youth. Strategies directed at impacting a wide variety of social and economic structural factors also need to be considered when working toward improving the reproductive health outcomes of young Latino men. Based on a review of the literature and analyses, we have identified five policy recommendations geared at meeting the sexual and reproductive health needs of young Latino men. First, we recommend expanding the development and evaluation of culturally relevant prevention programs for young Latino

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males. Reproductive health programs, including sexuality education that provide young Latino men with life planning and general life skills (i.e., opportunities for educational and career advancement), combined with reproductive health knowledge and skills in developmentally appropriate ways can help to reduce the risk of STIs and teen fatherhood. Replication and adaptation of effective programs in Latino communities is needed. Secondly, there is a need to increase Latino men’s access to health care services, including family planning/reproductive health care services. Through outreach and prevention education programs, Latino youth need to be informed of health services and programs available to them. Young men are eligible for family planning services through Medicaid waivers in eight out of the twentysix states with such waivers, including New York and California, yet they are a small minority of the clients served in these states (Guttmacher Institute 2006). Eligibility requirements can be expanded to include males and teens in states with family planning Medicaid waivers and new states can be encouraged and helped to apply for waivers that include males and teens. Medicaid coverage could be extended to undocumented and uninsured persons as well as migrant workers. Medicaid clients could be allowed to use services across state lines by developing a traveling Medicaid card, thereby increasing health care access particularly among migrant farm-working families (Rosenbaum and Shin 2005). There is a need to develop strategies to reduce barriers to care related to cost, transportation, stigma, and embarrassment associated with accessing family planning/reproductive health services, confidentiality, cultural competency, and limited language proficiency. Finally, reproductive health care services could be expanded to include male-oriented exams, contraceptive counseling, and STI testing. Our third policy recommendation is to develop and provide youth with male-friendly, youth-friendly, and culturally and linguistically competent health care services. To achieve this, written materials should be available in appropriate languages, sensitive to cultural beliefs, and at appropriate reading levels. Input from young Latino males in the development and distribution of these materials can help to increase the effectiveness of these materials. Culturally competent services should respect and acknowledge cultural norms and values and understand the role of families in shaping youths’ lives. A more male-friendly health care setting could be achieved by including maleoriented themes in the waiting room and using male Latino peer providers in the clinic. Finally, a “best practices” model could be developed from health care settings that have been successful at serving young Latino males—for example, the Young Men’s Clinic of the Columbia and New York Presbyterian

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Hospital and the University of California’s New Generation Health Center in San Francisco. The fourth policy recommendation to ensure the optimal reproductive health of Latino young men is to emphasize that they stay in school and go on to college. Several steps need to be taken to achieve this goal. For example, national and local initiatives to promote Latino youths’ academic success and to prevent school dropout, truancy, and suspension, and to strengthen students’ commitment to school, could be developed. Such programs should involve parents, students, and community-based organizations. The education of one generation will have a large impact on the next generation of teens. Efforts should be targeted at schools with particularly high Latino populations and high dropout rates and tailored to specific community and cultural contexts. Programs should address factors including linguistic access to education, youths’ financial obstacles, teacher and administration support for Latino youths’ academic success, and parental involvement; efforts should also involve evaluation and replication of effective programs (Brewster and Bowen 2004; Hernandez and Nesman 2004; Jurkovic et al. 2004). Our final recommendation is to provide expanded funding for basic and applied health research. Sexual behaviors and health outcomes vary among subgroups of Latino males based on factors such as country of origin, generational status, and socioeconomic status. Further research focusing on sexual health predictors and HIV/STI and early pregnancy prevention is needed for subgroups of young Latino males. Studies should increase their focus on differences among Latino subgroups based on country of origin, generation status, acculturation, same-sex behavior, and other factors. National data pertaining to Latino youth in the United States are currently limited by insufficient sample sizes and insufficient focus on diversity of youth surveyed; future large-scale data collection efforts involving Latino youth should aim to obtain large representative samples and ensure relevant diversity, so as to have sufficient statistical power to examine in detail factors affecting sexual health outcomes for Latino subpopulations. Lastly, existing programs and services serving Latino male youth should be systematically evaluated to identify, replicate, and adapt successful efforts. References Abma, J. C., G. M. Martinez, W. D. Mosher, and B. S. Dawson. 2004. Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2002. National Center for Health Statistics. Vital Health Statistics 23 (24), http://www.cdc.gov/nchs/ data/series/sr_23/sr23_024.pdf. Brewster, A. B., and G. L. Bowen. 2004. Teacher support and the school engagement of Latino middle and high school students at risk of school failure. Child and Adolescent Social Work Journal 21 (1): 47–67.

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Cooksey, E. C., R. R. Rindfuss, and D. K. Guilkey. 1996. The initiation of adolescent sexual and contraceptive behavior during changing times. Journal of Health and Social Behavior 37 (1): 59–74. Driscoll, A. K., C. D. Brindis, M. A. Biggs, and L. T. Valderrama. 2004. A future with promise: A chartbook on Latino adolescent reproductive health. San Francisco: University of California, San Francisco, Center for Reproductive Health Research and Policy, Department of Obstetrics, Gynecology and Reproductive Sciences and the Institute for Health Policy Studies. Flores, G., M. Abreu, and S. C. Tomany-Korman. 2006. Why are Latinos the most uninsured racial/ethnic group of US children? A community-based study of risk factors for and consequences of being an uninsured Latino child. Pediatrics 118 (3): 730–740. Guttmacher Institute. 2006. US teenage pregnancy statistics national and state trends and trends by race and ethnicity. http://www.guttmacher.org/pubs/2006/09/12/USTPstats .pdf. ———. 2008. State policies in brief: State Medicaid family planning eligibility expansions. http://www.guttmacher.org/statecenter/spibs/spib_SMFPE.pdf. Hamilton, B. E., J. A. Martin, S. J. Ventura, P. D. Sutton, and F. Menacker. 2005. Births: Preliminary data for 2004. National Center for Health Statistics. National Vital Statistics Reports 54 (8): 1–17. Harris, K. M. 1999. The Health Status and Risk Behaviors of Adolescents in Immigrant Families. In Children of immigrants: Health, adjustment, and public assistance, ed D. J. Hernandez. Washington, DC: National Academy Press. Hernandez, M., and T. M. Nesman. 2004. Issues and strategies for studying Latino student dropout at the local level. Journal of Child and Family Studies 13 (4): 453–468. Irwin, D. E., J. C. Thomas, C. E. Spitters, P. A. Leone, J. D. Stratton, D. H. Martin, J. M. Zenilman, J. R. Schwebke, and E. W. Hook. 1999. Self-reported sexual activity and condom use among symptomatic clients attending STD clinics. Sexually Transmitted Diseases 26 (5): 286–290. Jurkovic, G. J., G. Kuperminc, J. Perilla, A. Murphy, G. Ibañez, and S. Casey. 2004. Ecological and ethical perspectives on filial responsibility: Implications for primary prevention with Latino immigrant adolescents. Journal of Primary Prevention 25 (1): 81–104. Kaestle, C., C. Halpern, W. Miller, and C. Ford. 2005. Young age at first sexual intercourse and sexually transmitted infections in adolescents. American Journal of Epidemiology 161 (8): 774–780. Kaiser Family Foundation and Ford Foundation. 2006. HIV/AIDS policy fact sheet: Latinos and HIV/AIDS. http://www.kff.org. ———. 2001. Fact sheet: The HIV/AIDS epidemic in the United States: AIDS at 20. http://www.kff.org. ———. 2000. Medicaid and the uninsured: Health insurance coverage and access to care among Latinos. http://www.kff.org. Kann, L., S. A. Kinchen, B. I. Williams, J. G. Ross, R. Lowry, J. A. Grunbaum, L. J. Kolbe, and state and local YRBSS Coordinators. 2000. Youth risk behavior surveillance: United States, 1999. Morbidity and Mortality Weekly Report 49 (SS-5): 1–94. Kirby, D. 2002. The impact of schools and school programs upon adolescent sexual behavior. Journal of Sex Research 39 (1): 27–33. Kowaleski-Jones, L., and F. L. Mott. 1998. Sex, contraception and childbearing among high-risk youth: Do different factors influence males and females? Family Planning Perspectives 30 (4): 163–169.

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Laird, J., S. Lew, M. DeBell, and C. Chapman. 2006. Dropout rates in the United States: 2002 and 2003 (NCES 2006-062). Washington, DC: U.S. Department of Education, National Center for Education Statistics. http://nces.ed.gov/pubs2006/2006062.pdf. Manlove, J. 1998. The influence of high school dropout and school disengagement on the risk of school-age pregnancy. Journal of Research on Adolescence 8 (2): 187–220. Martinez, G. M., A. Chandra, J. C. Abma, J. Jones, and W. D. Mosher. 2006. Fertility, contraception, and fatherhood: Data on men and women from Cycle 6 of the 2002 National Survey of Family Growth. Vital and Health Statistics 23 (26). http://www.cdc.gov/ nchs/data/series/sr_23/sr23_026.pdf. National Campaign to Prevent Teen Pregnancy (NCPTP). 2006. Fact sheet: Teen sexual activity, pregnancy and childbearing among Latinos in the United States. http://www.teenpregnancy.org/religion/latino_fact_sheet_2006.pdf. National Campaign to Prevent Teen Pregnancy (NCPTP). 2002. Not just another single issue: Teen pregnancy prevention’s link to other critical social issues. http://www .teenpregnancy.org/resources/data/pdf/notjust.pdf. National Survey of Family Growth (NSFG). 2002. http://www.cdc.gov/nchs/nsfg.htm. O’Donnell, L., C. O’Donnell, and A. Stueve. 2001. Early sexual initiation and subsequent sex related risks among urban minority youth: The reach for Health Study. Family Planning Perspectives 33 (6): 268–275. Rew, L., M. Resnick, and T. Beuhring. 1999. Usual sources, patterns of utilization, and foregone health care among Hispanic adolescents. Journal of Adolescent Health 25: 407–413. Rosenbaum, S., and P. Shin. 2005. Migrant and seasonal farmworkers: Health insurance coverage and access to care. Kaiser Commission on Medicaid and the Uninsured. http://www.kff.org/uninsured/upload/Migrant-and-Seasonal-Farmworkers-Health -Insurance-Coverage-and-Access-to-Care-Report.pdf. Rosengard, C., M. G. Phipps, N. E. Adler, and J. M. Ellen. 2005. Psychosocial correlates of adolescent males’ pregnancy intention. Pediatrics 116 (3): 414–419. Santelli, J., N. Brener, R. Lowry, A. Bhatt, and L. Zabin. 1998. Multiple sexual partners among U.S. adolescents and young adults. Family Planning Perspectives 30 (6): 271–275. Santelli, J., R. Lowry, N. Brener, and L. Robin. 2000. The association of sexual behaviors with socioeconomic status, family structure, and race/ethnicity among US adolescents. American Journal of Public Health 90: 1582–1588. Shafii, T., K. Stovel, R. Davis, K. Holmes. 2004. Is condom use habit forming? Condom use at sexual debut and subsequent condom use. Sexually Transmitted Diseases 31 (6): 366–372. Shin, H. 2005. School enrollment in the United States: Social and economic characteristics of students: October 2003. Current Population Reports. http://www.census.gov/ prod/2005pubs/p20–554.pdf. Sonenstein, F. L., ed. 2000. Young men’s sexual and reproductive health: Toward a national strategy. Washington, DC: Urban Institute. Sutton, P. D., and T. J. Mathews. 2006. Birth and fertility rates by Hispanic origin subgroups: United States, 1990 and 2000. National Center for Health Statistics. Vital Health Statistics 21 (57), http://www.cdc.gov/nchs/data/series/sr_21/sr21_057.pdf. U.S. Census Bureau. 2004. The foreign-born population in the United States: 2003. Current Population Reports. http://www.census.gov/prod/2004pubs/p20-551.pdf. ———. 2000. Projections of the total resident population by 5-year age groups, race, and Hispanic origin with special age categories: Middle series, 1999 to 2000. Washington, DC: Population Division, U.S. Census Bureau, 2000.

Chapter 6

Andres Gil and William Vega

Alcohol, Tobacco, and Other Drugs

Few areas of Latino health are as profoundly affected by changes in human behavior as drug abuse (Volkow 2006). Drug use is socially acquired behavior. Societies and the subcultures that compose them vary widely in their degree of toleration or outright condemnation of those who consume or become addicted to illicit drugs (Vega et al. 2002). Examining the differences between subgroups of Latinos with different personal and extra-personal characteristics provides insights about factors that protect against or promote illicit drug use (Vega and Gil 1998). In keeping with the goal of this book, this chapter places special emphasis on the impact of structural factors on the development of illicit drug use among Latino males. As noted in the conference announcement for the 2007 College of Problems of Drug Dependence, “There is accumulating evidence that the antecedents, consequences, and mechanisms of drug abuse and dependence are not identical in males and females and sex/gender may be an important variable in treatment and prevention outcomes.” Research about the health gradient has documented how social inequality reduces personal resistance to many health problems and social pathologies. Recent research has shown that subordination to inferior social status and discrimination are both linked to various forms of organic anomalies and disease, including immune system dysfunction and cardiovascular disease. Michael Marmot, one of the foremost investigators of inequality and disease, has noted, “It is not the social position in the hierarchy per se that is the culprit, but what position in the hierarchy means for what one can do in a given society: the degree of autonomy and social participation” (Marmot 2004, 2005, 2006). Other researchers (Williams and Jackson 2005; Kawachi, Daniels, and Robinson 2005; 99

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Krieger, Chen, and Ebel 1997) have concluded that it is time to move our aim from individual risk factors, which typifies the medical model logic of focusing on individuals, and instead shift our focus to the effects of the social structure and unequal distribution of wealth on all-cause morbidity and mortality and public policies that can alter the status quo. This chapter will address both individual and structural risk factors with the explicit assumption that structural factors can create a propensity toward experiencing risk factors that systematically produce inferior health for the least affluent sectors of the population (Link and Phelan 1995). The chapter proceeds by presenting four levels of information: (1) a review of factors that have been identified as affecting Latino drug use; (2) variations in intraethnic and interethnic prevalence levels of drug use and related factors; (3) trajectories of drug progression during the years from childhood to early adulthood; and (4) an analysis of longitudinal trajectories of Latino male drug use taking into account various structural indicators. We will use a well-known national data set collected by the U.S. Public Health Service and a large longitudinal data set collected by the authors that was designed to address many questions pertinent to the theme of this chapter. What factors increase drug use among Latinos? The key assumption is that structural factors, such as poverty and low educational achievement, act selectively to produce general vulnerability to drug use precisely because they increase exposure to certain types of risk factors and decrease the availability of protective factors. This general vulnerability is expressed through interactions between an individual and his or her environment. Using the well-known construct of “segmented assimilation,” it refers directly to the social structure of urban areas and is reflected in neighborhood quality of life and the educational and economic opportunity structures afforded therein to residents (Portes and Zhou 1993; Vega and Gil 1999). For example, ethnic enclaves provide a subsociety for the residents of a neighborhood to meet their daily needs. Too often, neighborhoods characterized by poverty are more disorganized or even chaotic and provide avenues for illegal activities, and subcultures that support them, to thrive. The conditions in neighborhoods with high concentrations of poor people are more likely to produce chronic social stress and expose residents to traumatic experiences (Williams and Jackson 2005). There is more delinquency and crime and higher percentages of single-parent households in poverty. A Brief Overview of the Latino Health Paradox and Drug Use

Much attention has been given to the Latino health paradox. The basic proposition is rooted in findings from various health studies that Latino immigrants,

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despite backgrounds of poverty in their nations of origin and continued experiences of poverty or near poverty conditions in the United States, are nevertheless much healthier than would be anticipated considering their social position. While critics have alleged that there are reasons to doubt the paradox for some diseases, based on reexamination of data used to support the validity of past research, there has been absolute consistency in showing that Latino immigrants have exceptionally low rates of illicit drug use and addiction compared to U.S.born Latino or U.S. non-Hispanic white males (Grant et al. 2004; Warner et al. 2006). In other words, the paradox holds for illicit drug use and dependence. Numerous studies of both adolescents and adults have confirmed this, including national population studies conducted in the Latin American nations of origin of immigrants coming to the United States (Alegría et al. 2007; Grant et al. 2004; Medina-Mora et al. 2005; Turner and Gil 2002; Vega et al. 1998). There are multiple findings from the research literature that have been cited as responsible for increasing the likelihood of Latino males using illicit drugs or progressing to addiction. Below we highlight only a few important points due to space limitations. Age of arrival and the location of settlement impact immigrant drug use. Young males who arrive in the United States as children have a heightened probability of using illicit drugs compared to those who arrive as adults. Latino males are much more likely to use illicit drugs and become drug dependent if they live in urban areas compared to males living in rural areas—regardless of whether they are foreign-born or U.S.-born (Vega et al. 1998). There is clear evidence of an incremental movement toward greater use of illicit drugs across three generations after immigration, presumably as assimilation increases (Alegría et al. 2007). Latinos who report in interviews that their parents had behavioral problems are more likely to use drugs (Vega and Sribney 2003). These behavior problems include depression, alcohol, and drug problems and were much more likely to occur in the homes of U.S.-born Latino parents than among foreign-born parents. Assimilation markers used in drug research and in this chapter have included age of arrival for immigrants, years of residence in the United States for immigrants, nativity, and a dominant use of either or both Spanish or English languages. We refer to these as “markers” of assimilation because there is no a priori rationale to assign them causal significance. These markers may be indicating that social network composition of immigrants and U.S.-born is shifting across generations, and over time. This may have implications for drug use and drug dependence with prolonged exposure to Englishspeaking people through school, media, and social experiences. Therefore, if low-socioeconomic-status males immigrate into the United States during early

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adulthood, they are unlikely to experience the same degree of social assimilation as those arriving as children. And while social network affiliations and level of assimilation go hand in hand, it is very likely that both exert shared and unique influences on Latino adolescents in the context of segmented assimilation. Assimilation is not solely a cultural or language change experience. It also influences lifestyle and worldview, including attitudes and beliefs about a sense of self in the social world. We have many decades of educational reports demonstrating that Latino males in urban poverty settings are very vulnerable to poor academic performance and have high rates of early school termination. Many of these factors are commonly mentioned as cofactors for adolescent drug use and drug progression, but they are also outcomes of stratified inequality. Assimilation also takes a toll on family stability, as families are more prone to fragmentation and divorce in the second and third generations after immigration. Gender role expectations change, patterns of social interaction in family and friend networks are modified, and marital disruption increases. By the third generation, the likelihood that a Latino male will be in a single-parent household doubles to nearly 40 percent compared to the immigrant generation. Family economic stresses and changes in family composition increase the propensity toward adolescent drug use among Latino males (Gil, Vega, and Biafora 1997). Increased assimilation creates differential acculturation between children and parents in various areas of social life, and increasing assimilation of U.S.born Latino parents increases the probability of their own substance abuse and mental health problems. Both of these situations can trigger family stress, conflicts, and diminished parenting effectiveness in communication and problem solving with children (Dumka, Roosa, and Jackson 1997; Martinez 2006; Santisteban et al. 2002). The immigration process also fragments families and undermines the emotional content and support of adult family members with their children due to impediments in family reunification (Mitrani, Santisteban, and Muir 2004). It has also been reported that across generations Latino families are likely to change parenting styles toward more permissive styles associated with greater substance use in children. However, it needs to be stressed that these patterns are not unique; they reflect normative tendencies in American society, and, overall, young Latino males have rates of drug use that are slightly lower than those of non-Hispanic white adolescents. However, this difference is entirely attributable to the lower rates for immigrant males. U.S.born Latinos are reporting drug-use levels that are often equal to or even higher than non-Hispanic whites for various substances in national surveys and large regional studies (Vega, Chen, Williams, forthcoming).

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Life Stress and Drug Use in Latino Males

Latino males that experience a higher frequency (e.g., quantity and duration of exposure) of risk factors, including life stressors, during childhood and adolescence are far more likely to start using drugs and to progress to harder drugs than others who do not have these negative experiences (Lloyd and Taylor 2006; Turner and Lloyd, 2003; Vega and Gil 1998). These risk factors include behavior problems, depression, suicidal ideation, and conflicts with parents and teachers, bad grades, and friends who approve of drug use or actually use drugs. Late childhood initiation into tobacco and/or alcohol use is a clear danger signal (Vega and Gil 2005). Although foreign-born adolescents report more total risk factors than U.S.-born adolescents, the latter are more reactive to these risk factors than are immigrant boys, suggesting they have fewer personal and family coping resources available (Vega et al. 1993). Traumatic events such as domestic and street violence experienced by Latino boys have an independent and potentially an even stronger impact on drug use than do everyday life stressors and directly contribute to differences in drug-use initiation and progression observed in national studies, specifically in higher rates among U.S.-born Latinos (Turner, Lloyd, and Taylor 2006). Synopsis of What We Know

This overview is merely illustrative of research that has been conducted with Latino male drug users. For a comprehensive review of Latino substance use, see “Scientific Opportunities in Hispanic Drug Abuse Research” (Amaro and Iguchi 2006). And for an overview of the psychosocial issues that have a direct bearing on Latino child and adolescent development, see “Hispanics and the Future of America” (National Research Council 2006). Though wide in scope and often rich in detail, the total body of Latino drug-use research literature is inconsistent in coverage. Research that examines the role of socioeconomic status or neighborhood composition is rare. This type of investigation is needed because most of the risk factors and risk-related processes previously mentioned, such as problematic families’ affiliation with drug-using peers and bad neighborhood conditions, are usually interrelated. Drug abuse is not specific to any socioeconomic class in U.S. society, in part because the nation has one of the highest consumption levels in the world. However, drug addiction among Latinos, serious delinquency, and incarceration are disproportionately lowersocioeconomic-status phenomena. It is axiomatic in social science that education and income will structure opportunities for both positive and negative lifestyles. How does the Hispanic paradox, as it pertains to drug use, fit into this picture? The protective effects of

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the paradox are primarily attributable to spending one’s childhood and adolescence in a Latin American country, which may minimize pre-adult socialization to social networks and peers in which drug use is common and accepted. However, we currently have no viable method to conserve and deploy these protective effects among males in the second and subsequent generations post immigration. Whereas poverty may not substantially increase the risk of drug addiction for the average Latino immigrant male who arrived in the United States at twenty years of age, poverty will certainly increase the risk for a twenty-year-old U.S.-born Latino male. We will explore in this chapter how this may occur. A second very important limitation of the wide literature on factors affecting drug use among Latino males is the snapshot nature of almost all of the research available. We have very few long-range observational studies on cohorts of children followed for decades to determine how early life factors such as poverty and different types of neighborhood exposures affect longrange trajectories of drug initiation, progression, and addiction. Obtaining relevant information has become more urgent as today three-quarters of the approximately 41 million Latinos in the United States are either immigrants or children of immigrants, so the impact of inadequate educational preparation, poverty, and segmented assimilation on Latino males is enormous, as documented in increased incarceration rates, drug rehabilitation, and maintenance programs. National Data Trends

Below is a brief overview of drug-use patterns in U.S. ethnic groups during adolescence derived from two national data sets (the Nation Survey on Drug Use and Health [NSDUH] and the Monitoring the Future Surveys [MTF]). Findings from the MTF, which consist of surveys of school youth indicate that nonLatino whites have the highest prevalence rates for alcohol and most illicit drugs and that Latinos follow closely, with African Americans reporting the lowest rates (Johnston et al. 2006). For example, among twelfth-grade students the thirty-day prevalence of alcohol use in 2005 was 52.3 percent among whites, followed by Latinos (43.3 percent) and blacks (29.0 percent). Similarly, in 2005, the annual prevalence of marijuana use was 36.6 percent for whites, 29.6 percent for Latinos, 26.3 percent for blacks, and the annual any illicit drug prevalence was 41.6 percent, 34.5 percent, and 29.0 percent respectively for each of these three groups. Heroin use appears to be a major exception, with higher rates among Latinos (1.3 percent annual rate in 2005), followed by blacks (0.8 percent) and whites (0.7 percent) (Johnson et al. 2006).

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Findings from the NSDUH (previously called the National Household Survey), differ somewhat from the MTF surveys in that results from the NSDUH tend to indicate similar rates among non-Latino whites and Latinos. For example, there have been very similar rates of illicit drug use among Latinos and non-Latino whites ages twelve to seventeen years old (31.2 percent and 30.8 percent respectively for lifetime use). The rates for African Americans were also similar (30.4 percent); although for past-year and past-month use, African Americans reported lower prevalence rates. Among persons aged eighteen to twenty-five years old, non-Latino whites are the highest (55.0 percent lifetime illicit drug use), followed by 42.9 percent for Latinos and 39.9 percent for African Americans. Among Latinos the rates of illicit drug use for lifetime, past-year, and past-month use were very similar between males and females aged twelve to seventeen years old. For example, lifetime use was 31.7 percent and 31.2 percent for males and females respectively in 2003, and past-year use was 21.3 percent and 21.8 percent respectively. For those aged eighteen to twenty-five years, rates among Latino males and females are also very similar, with 44.4 percent and 41.5 percent lifetime use respectively for males and females (SAMHSA 2003). Findings from the NSDUH for alcohol use indicates highest use among non-Latino whites, followed by Latinos and then African Americans, with lifetime rates of 20.5 percent, 16.2 percent and 10.1 percent respectively for those aged twelve to seventeen years (SAMHSA 2003). Among those aged eighteen to twenty-five years old, the findings are similar to the younger age group in terms of differences among the three ethnic groups, although the rates are much higher, 68 percent for non-Latino whites, 52.1 percent for Latinos, and 47.2 percent for African Americans. Substance Use among Latino Males: Analytical Approach

The analyses of the longitudinal data presented below progresses from the examination of substance-use patterns to the study of the longitudinal impact of structural factors on substance-use disorders. A technical appendix is included at the end of the chapter for readers interested in methods information. The analyses follow a developmental approach, examining substance-use patterns through three developmental periods, early adolescence (mean age  11.07), middle adolescence (mean age  14.02), and early adulthood (mean age  20.1, with a range of 19.0 to 23.0 years old), and concluding with longitudinal analyses of the influence of early- and mid-adolescence structural factors on early adulthood DSM-IV substance disorders. Many national data sets do not distinguish between Latinos born in the United States and those who are foreign-born. And, where those distinctions are

26.0 15.5 20.6 14.7 1.9 2.3 0.0 15.1 53.7

21.9 9.6 15.6 14.7 2.1 2.6 0.2 12.2 44.7

African

9.2 4.6 10.5 11.3 1.7 0.8 0.0 3.8 29.2

240 82.9 51.7 4.6 0.8 2.5 0.4 5.4 6.7

American

26.8 5.6 18.0 17.1 2.4 4.0 0.4 16.3 48.6

51 92.8 66.1 23.5 3.2 35.9 1.6 36.7 44.6

Latinos

U.S.-born

26.2 13.1 12.0 15.6 2.6 3.1 0.5 13.5 46.9

192 88.5 55.7 17.2 5.2 24.5 1.0 29.7 35.9

Latinos

Foreign-born

Note Data weighted to conform to population race/ethnicity and gender by socioeconomic status; gender comparisons are among Latinos only. a Foreign-born Latinos different from U.S.-born Latinos. b Foreign-born Latinos different from African Americans. c Foreign-born Latinos different from non-Latino whites. d U.S.-born Latinos different from African Americans. e U.S.-born Latinos different from non-Latino whites. f Other drugs consists of inhalants, tranquilizers, sedatives, amphetamines and stimulants, and analgesics. g Other drug abuse/dependence consists of inhalants, cocaine, hallucinogens, heroin, sedatives, tranquilizers, stimulants, and analgesics. * p  .05 **p  .01 ***p  .001.

259 93.4 66.3 22.9 3.9 37.2 2.7 43.6 47.9

whites

Non-Latino

942 89.6 60.4 17.2 3.2 25.4 1.5 29.2 34.1

All a

Males age 19–21

Drug Abuse by Substance, DSM-IV Disorders, Ethnicity, and Gender (Percent)

Substance use Alcohold, e Marijuanab, d, e Cocaine (powder)b, c, e Crack cocainec Hallucinogensb, c, d, e Heroinf Other drugsa, c, d, e Any except marijuana/Cocaineb, c, d, e DSM-IV substance disorders Alcohol abusec, e Alcohol dependenceb, c, f Marijuana abuseb, d, e Marijuana dependencee Cocaine abuse Cocaine dependencee Heroin abuse/dependence Other drug abuse/Dependencec, e, g Any drug abuse/dependencec, e

Table 6.1

26.5*** 8.8 15.4** 16.5** 2.5 3.6 0.5 15.1* 47.9***

11.5 8.5 9.0 9.9 1.6 3.1 0.2 10.3 31.2

445 86.5 51.9 18.7 2.2 21.1 1.3 30.3 35.1

Females

Latinos

443 91.0* 61.6** 20.8 4.1 30.9*** 1.4 33.6 40.9*

Males

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made, U.S.-born Latinos report higher rates of illicit drug use, as well as substance disorders (Turner and Gil 2002). Our examination of substance-use patterns and the impact of structural factors follow a cohort of Latinos and contrasts U.S.- and foreign-born Latino males. It is important to point out the uniqueness of the longitudinal data being utilized in terms of the foreign-born or immigrant group. These are individuals who immigrated to the United States prior to the age of twelve; therefore, by the time they reached early adulthood they had been in the United States for half of their lifetime or more. This provides a unique opportunity to examine drug-use trajectories as the sample matures and assimilates, but also should be distinguished from contrasts of immigrant and U.S.-born Latino adults in which the immigrants have arrived in the United States as adults. Prevalence of Substance Use and DSM-IV Substance Disorders

Table 6.1 presents prevalence rates for substance use and DSM-IV substance disorders among non-Latino white, African American, and U.S.- and foreign-born Latinos, as well as gender differences within Latinos. As shown, non-Latino whites and U.S.-born Latinos reported the highest rates for all substances, and African Americans reported the lowest prevalence. These findings are very similar to those reported by the Monitoring the Future Surveys. For all substances, except cocaine, U.S.-born Latinos reported higher rates than their foreign-born counterparts. These differences exist despite the fact that the foreign-born group have been in the United States since age twelve or earlier. In terms of statistically significant differences, U.S.-born Latinos score significantly higher than African Americans on almost all substances. Similarly, foreign-born Latinos scored significantly lower than African Americans with most substances. Prevalence rates for DSM-IV disorders are highest among non-Latino whites, followed by U.S.-born Latinos, foreign-born Latinos, and African Americans. There is one notable exception, heroin abuse/dependence, for which rates are highest between the two Latino groups. The rates of these substance disorders are similar among the U.S.- and foreign-born Latinos, with some exceptions in which rates are higher among the immigrant group (i.e., marijuana abuse and dependence, other drug abuse/dependence, and having at least one substance disorder). Most statistically significant differences were found in the comparison of U.S.-born Latinos and African Americans. In terms of gender differences for Latinos, males reported higher rates than females, and most differences are statistically significant. The analyses for table 6.1 illustrated ethnic differences as well as gender differences among Latinos in substance use and DSM-IV substance disorders

108

Andres Gil and William Vega Table 6.2 Developmental Transitions of Prevalence of Substance Use among Latino Males (Percent) U.S.-born

Foreign-born

Alcohol Lifetime T1

44.7***

32.2

Lifetime T3

80.6***

66.9

Lifetime T4

92.9

88.5

Past year T1

22.8

20.3

Past year T3

52.2**

37.4

Past year T4

69.8

66.7

Marijuana Lifetime T1

3.1*

Lifetime T3

22.7**

12.5

.6

Lifetime T4

66.2*

55.7

Past year T1

.9

Past year T3

13.2

8.5

Past year T4

45.8*

34.9

Lifetime T1

7.2

5.7

Lifetime T3

20.9

19.8

Lifetime T4

45.8

38.5

.6

Other Drugsa

Past year T1

3.2*

.5

Past year T3

6.8

6.8

Past year T4

30.1

24.5

Note T1  early adolescence, mean age 11.07 years; T3  mid-adolescence, mean age 14.02 years; T4  early adulthood, mean age 20.01 years. a

Other drugs consists of inhalants, cocaine, hallucinogens, heroin, sedatives, tranquilizers, stimulants, and analgesics. p  .05 **p  .01 ***p  .001.

during early adulthood. The next series of analyses focus on the developmental transition of substance use among U.S.-born and foreign-born Latino males. Table 6.2 presents the transition of lifetime and past-year alcohol, marijuana, and other drug use from early adolescence (T1) to mid-adolescence (T3) and early adulthood (T4). As would be expected, there is a clear developmental transition toward greater use. For example, at early adolescence 44.7 percent of U.S.-born Latinos and 32.2 percent of foreign-born Latinos had used alcohol in their lifetimes, and the prevalence had increased to 92.9 percent and 88.5 percent

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respectively, at T4. Findings are similar for marijuana, with low use at early adolescence for the U.S.-born (3.1 percent) and minimal use for the foreignborn (0.6 percent), and increasing to 66.2 percent and 55.7 percent respectively by early adulthood (T4). Through the developmental periods from early adolescence to young adulthood, from ages eleven to twelve years old to nineteen to twenty-three years old, the U.S.-born Latino males reported higher prevalence rates of substance use; however, over time the difference between the two groups narrowed. For example, during early adolescence the prevalence for lifetime alcohol use was 12.5 percent higher for U.S.-born, but by early adulthood this had been reduced to 4.7 percent. For marijuana use, the U.S.-born had rates that were 80.6 percent higher during early adolescence, and only 16.0 percent higher during early adulthood. For other drugs the difference narrowed from 20.8 percent to 16.0 percent. Additional analyses (not shown) illustrated transitions into combined or polydrug use. Again, there is a clear developmental transition toward greater drug use, with the majority of U.S.- and foreign-born males not using any substance at T1 (58.2 percent and 69.8 percent respectively), and a majority being users by early adulthood (T4). Similarly, the prevalence of the use of two or more drugs increased from 7.2 percent to 27.6 percent and 68.1 percent from T1 to T4 for the U.S.-born. This prevalence increased from 4.1 percent to 20.9 percent and 58.3 percent for the foreign-born. Thus, essentially, the majority of Latino males were not drug users during early adolescence, and by early adulthood the majority had used two or more substances. Generally, the group of foreign-born males reported lower rates of polydrug use than the U.S.-born. The next set of analyses, table 6.3, examines the impact of structural factors on DSM-IV substance disorders. These results include longitudinal analyses (T1 and T3 structural and family factors), and T4 (early adulthood) substance disorders. The findings are presented in terms of odds ratios for the presence of each substance disorder. The results indicate multiple significant effects of the structural factors on substance disorders. We highlight some of the most important. Living in neighborhoods with high concentration of poverty and high levels of family poverty during early adolescence (T1) was related to marijuana abuse (odds ratios of 1.8 and 1.9 respectively) as well as to cocaine dependence (odds ratios  2.4). There were strong relationships between school performance factors and substance disorders. While low grades (GPA) during early adolescence were not related to any of the drug disorders, low grades during mid-adolescence (T3) were related to marijuana dependence, cocaine abuse and dependence, and other drug abuse/dependence. High scores on conduct (failing conduct

1.4

1.9*

1.1

1.1

1.9*

High conduct T1

High conduct T3

0.98

0.80

0.81

Mother less than high school

Father less than high school

Primary caretaker less than high school

1.2

1.1

1.7*

2.7***

One-parent house T3

No father before age 12

No father from 13 to 18

Low-bonding mother

Low-bonding father

*p  .05 **p  .01 ***p  .001

0.93

0.94

One-parent house T1

Family factors

0.74

Early family economic hardship

Family economic factors

High school dropout

1.5

1.4

0.87

1.5

1.3

1.0

1.8*

1.6

1.6

1.7

1.4

2.0*

1.4

.92

1.2

Low GPA T3

.66

1.5

Low GPA T1

School records

1.3

1.4

Family poverty

dependence

abuse

Neighborhood poverty

Alcohol

Alcohol

1.4

1.8*

1.4

0.99

1.6*

1.1

1.1

0.97

1.3

1.1

1.4

1.5

1.4

.71

.95

1.9*

1.8*

abuse

Marijuana

2.0*

0.97

1.1

1.3

1.4

1.0

1.8*

1.7

1.2

1.8*

3.8***

2.0**

2.0**

2.0*

1.1

1.1

1.0

dependence

Marijuana

2.3*

2.2*

0.70

0.65

1.4

1.0

1.5

2.0*

1.6

1.9*

6.6***

2.0*

2.0*

2.3*

1.5

1.7

1.7

abuse

Cocaine

5.2**

1.3

1.8

1.3

1.0

1.0

1.3

2.2*

1.5

1.0

7.3***

3.2*

3.2*

2.0*

1.0

2.4*

2.4*

dependence

Cocaine

Odds Ratios for DSM-IV Substance Disorders Predicted by Structural Factors among Males

Early adolescence census factors

Table 6.3 Other

2.7**

1.9*

1.8*

1.5

1.7*

1.1

1.7*

1.9*

1.6

1.2

4.1***

1.7*

1.5

1.9*

1.4

1.7

1.6*

dependence

abuse/

Any

2.2**

2.1**

1.8**

1.4

2.0**

1.3

1.6*

1.4

1.3

1.4

3.1***

1.7*

1.7*

1.3

1.2

1.6*

1.4

dependence

abuse/

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111

grades of D and F) during T1 and T3 were also related to many of the substance disorders, including having two or more disorders by early adulthood (odds ratio  1.7). Not surprising, being a high school dropout was related to all disorders, except marijuana abuse, and the odds ratios were very high, ranging from 7.3 for cocaine dependence to 1.9 for alcohol abuse and dependence. Finally, among the family factors, living in a one-parent household was predictive of substance disorder from mid-adolescence only, a period in which illicit drug use begins its developmental ascent. Lack of father presence either during early or mid-adolescence appears to have a negative impact on drug use among these Latino males, and while low bonding with the mother also has negative impacts, low bonding with the father is predictive of more substance disorders, including relatively high odds ratios for all statistically significant disorders, including cocaine dependence (5.2), alcohol abuse, and other drug abuse/dependence (2.7). The final set of analyses (table 6.4) examines the relationship between the structural factors used in the prior analyses and DSM-IV substance disorders separately for U.S.-born and foreign-born Latinos. Based on the results for the entire sample of Latino males (table 6.3), some of the nonsignificant factors were excluded, and to address the complexity of too many analyses and reduced statistical power, some of the DSM-IV disorders were combined into abuse/dependence. The top half of the table presents analyses for the U.S.-born and the bottom for the foreign-born. Growing-up in neighborhoods with high rates of families in poverty predicts substance-use disorders for both groups, although the impact seems stronger for the foreign-born. On the other hand, early economic hardship for the family (early adolescence and mid-adolescence) is a consistently stronger predictor of substance-use disorders among the U.S.-born. Early conduct problems in school are also more consistent predictors of substance disorders for the U.S.-born group. Being a high school dropout is strongly related for both groups, although in terms of alcohol abuse and dependence, it only has an impact for the U.S.-born group. In terms of family effects, one important difference is the lack of effect of father’s education among the U.S.-born compared to the immigrants. U.S.-born adolescents whose father did not have a high school education were less likely to have two or more drug abuse/dependence disorders (odds  0.38). On the other hand, having a father with less than a high school education was strongly related to all disorders, except alcohol use, for the foreign-born group. There were also some important differences with regard to parent bonding, with low bonding with the mother and father being more consistently related to substance disorders for the U.S.-born group, although

1.0

2.3*

High conduct T1

High school dropout

0.47

Father less than high school

1.1

1.2

1.5

2.2*

One-parent house T3

No father from 13 to 18

Low-bonding mother

Low-bonding father

Family factors

0.84

Early family economic hardship

Family economic factors

1.2

1.8*

0.88

1.8

2.1

4.4*

0.34

2.2*

3.4*

1.2

2.1*

1.3

abuse

Low GPA T3

School records

Family poverty

Alcohol dependence

Alcohol

Cocaine

2.2*

1.4

1.2

2.0*

0.67

2.4**

3.5***

1.8*

1.2

1.4

3.2*

2.5*

0.67

1.0

1.5

2.3*

6.8***

4.2**

2.1*

1.9*

abuse/dependence

Marijuana

3.7**

2.1*

1.5

1.7

0.76

1.8

4.0***

1.9*

1.7

1.7*

abuse/dependence

Other

2.8**

1.9*

1.9*

2.7**

0.38*

1.8*

3.5***

1.6

1.4

1.7*

abuse/dependence

2+ Drug

Odds Ratios for DSM-IV Substance Disorders Predicted by Structural Factors among Latino Males by Nativity

Early adolescence census factors

U.S.-born

Table 6.4

1.2

1.4

High conduct T1

High school dropout

1.3

Father less than high school

0.95

2.1*

3.4**

No father from 13 to 18

Low-bonding mother

Low-bonding father

*p  .05 **p  .01 ***p  .001

0.76

One-parent house T3

Family factors

0.65

Early family economic hardship

Family economic factors

1.6

1.0

Low GPA T3

School records

Family poverty

Early adolescence census factors

Foreign-born

0.81

1.4

1.1

1.1

2.9*

1.6

1.1

1.9*

0.5

2.1*

1.6

1.5

1.4

1.3

3.6***

1.1

3.2**

2.2*

1.5

1.6

4.7*

0.83

2.0*

1.4

3.0*

0.61

9.6***

1.6

2.3*

2.7*

1.7

1.6

2.2*

1.6

4.3**

0.71

4.3***

1.2

2.2*

1.7*

1.6

3.4**

1.6

1.4

3.8***

1.1

2.7**

1.9*

1.6

1.5

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Andres Gil and William Vega

there were several specific drugs for which bonding was significant for the foreign-born (i.e., two or more abuse/dependence for mother bonding, alcohol abuse for both mother and father bonding, and cocaine abuse/dependence for father bonding). Finally, we conclude with a brief examination of the impact of neighborhood poverty on the effects of assimilation, as measured by language-based indicators, on substance disorders. As described earlier, the sample for these analyses consists of a longitudinal cohort of Latino adolescents that entered middle school in 1990 and were about eleven years old. Thus, even those that were immigrants in this cohort have resided in the United States through at least part of grade school, and all of middle and high school. Therefore, languagebased indicators of assimilation produce a distribution that is bilingual— intermediate or high acculturation, using mostly English. The measure used for these analyses contain two assimilation subgroups: bicultural-intermediate and high assimilation. In analyses (not shown) there is no relationship between level of assimilation and DSM-IV substance disorders during early adulthood, with the prevalence for intermediate and high assimilation males being very similar (prevalence rates were only slightly higher among the high assimilation group). However, as predicted by the segmented assimilation model, among those who grew up in high density poverty neighborhoods there is a clear difference in the impact of assimilation on substance disorders, with prevalence rates being much higher for the more assimilated. For example, those who were high assimilation had rates of alcohol abuse/disorder that were 47 percent higher, 53 percent higher for marijuana abuse/dependence, 43 percent higher for other drug/ dependence, and 41 percent higher for two or more drug disorders. Conclusion

Drug use among Latino youth is disturbingly high, and current trends are indicative of systematic intergenerational increases (Gil, Wagner, and Tubman 2004; Johnston et al. 2006; SAMHSA 2003; Turner and Gil 2002). Latino males in the United States are a young population and are disproportionately concentrated in the age group (twelve to twenty-five years) of first use of an illicit drug and progression to drug dependence (Delva et al. 2005; Vega et al. 2002). The high prevalence rate of substance use among U.S.-born Latinos is of concern given longstanding demographic trends in high school dropout rates and high proportions of families headed by women with children living in poverty (Delva et al. 2005). The long-standing pattern of low educational attainment is reinforced by the unequal distribution of resources for public education and the rapid growth

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of private schools that has persisted despite legal efforts across the nation to equalize financial support across affluent and low-income school districts. National efforts to increase accountability for school performance by invoking punitive measures and providing incentives for excellence and innovation have not reduced either the very large quality gaps in public education or differentials in per capita student financing (Carroll et al. 2005; Darling-Hammond 2002). The result is that with current trends, nearly 90 percent of Latino males will not be college graduates, and nearly 40 percent will not be high school graduates. Thus Latinos will not benefit, as a population, from the large gains in lifetime income and social mobility commensurate with educational attainment. A very strong case can be made that educational failure is the single most important predisposing determinant and public policy problem to overcome in order to reduce drug use and progression to drug dependence in the second and third generations of Latino males. Economically marginal families who are burdened by low educational attainment and who work in multiple jobs yet are poorly paid will have more difficulties managing their children. Latino boys reared in low-resource families that emphasize high control over behavior but which are also characterized by low cohesiveness, coercive parenting practices, and minimal emotional support are especially vulnerable. This vulnerability peaks for second- and third-generation Latino males residing in low-resource, disorganized urban neighborhoods where parents struggle to maintain authority over their adolescent children. In these areas, drug sales and drug use are rampant and often accompanied by high exposure to domestic abuse, as well as witnessing or being victimized by interpersonal violence in homes, schools, and other public places (Sampson 2003). These experiences are traumatizing and linked to depression and drug abuse for Latino males (Turner et al. 2006). Neighborhood development and environmental intervention studies are needed to address the question of how to most effectively increase educational and employment opportunities for Latino youth and families, as well as fostering safer neighborhoods and public spaces. Of priority interest for future research is how changing these structural conditions and physical environments most effectively reduce drug use by modifying the social processes that are proximate risk and protective factors in childhood and adolescence. Key indicators of changing social determinants are family residential stability, increased educational completion rates, reduction in street crime and domestic violence, improved neighborhood physical environments, and expanded local opportunities for developing the effective social role performance of Latino males—especially in the years immediately preceding early adulthood.

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In summary, research recommendations and intervention efforts targeting Latino males should acknowledge that the increasing vulnerability of Latinos to drug addiction is not solely a problem of individuals, their biochemistry, or their genetic destiny. Vulnerability to drug abuse is a population problem in a nation with the highest rates of drug dependence in the developed world. It is first and foremost a product of economic marginality and/or inadequate social incorporation of subpopulations that routinely experience structured inequality. That structured inequality emerges and is sustained by differences in power and wealth in society; thus, it is an imbedded and socially created problem, susceptible primarily to political solutions, including the effectiveness of local constituencies to organize the resources and human capital in their neighborhoods to create changes that will ultimately reduce drug addiction. Merely expanding the number of available drug treatment options is an incomplete solution. Needed is increased opportunity for human development at a neighborhood level. Based on these assumptions, our research and policy recommendations include investigations of the following: • Segmented assimilation effects on drug-use patterns in neighborhoods, especially local differences in macro and micro economic development that directly influences ethnic enclave vitality and social resource availability through employment opportunities, social networks, and neighborhood political, cultural, and organizational development. • The impact of sweeping school-based innovations on high school completion rates—and, in turn, the consequences for adolescent drug initiation, abuse, and dependence, and the successful adult role transitions of Latino males. • The effects of economic strains and assimilation on Latino families and their ability to provide effective parenting, their own successful efforts in coping with parenting responsibilities under these conditions, and the potential benefits of parenting interventions to improve their ability to adequately supervise male children, sustain a nurturing family environment, and advocate for their children in the schools and for other human services. Final Comment

Among both U.S.-born and immigrant Latino boys, strong family ties are the first line of defense and provide a buffering, or protective barrier, against emotional distress and drug use. Disruptions in family structure, chronic strains occasioned by unsteady employment and very low wages, and the absence of strong family networks and effective parenting increases drug use. Latino boys,

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especially in late childhood, have cultural expectations about family support that act as a protective bunker against pernicious pro-drug social environments. Conversely, in the instance of chaotic families, inadequate emotional support can facilitate adolescent drug experimentation and association in peer networks that increase access and social reinforcement to use drugs. The increased levels of drug dependence that we have witnessed in the second and third generation of Latino males post arrival of Latino immigrant families attests to the disorganizing power of structural forces as they are experienced within lowincome communities in the United States. Broad changes in public policy aimed at distributive justice—including social incorporation of low-income immigrants, reform of education systems, and revitalization of decaying inner-city neighborhoods—are needed to stem the tide of population-level drug addiction in the United States. Though it is seemingly expensive to execute such policies, the long-range benefits realized via improved health for communities, including reduction of drug use and associated health and criminal justice problems among Latino males, would ultimately prove to be cost effective by improving individual and family economic productivity, and by reducing the financial impact and social burdens of disease and social deviance for American society. These recommendations are not intended to minimize the importance of developing substance abuse interventions that are effective with Latino populations. However, solely focusing on such efforts is unlikely to prove sufficient for addressing the larger population-level problem.

Appendix: Technical Methods Samples

Below is an overview of the longitudinal data set and the variables used in the analyses. For a detailed description of the data set, see Gil, Vega, and Turner (2002); Turner and Gil (2002); and Vega and Gil (2005). The longitudinal data derive from a study that has followed a cohort of youth from entrance into middle school through the transition into early adulthood. The first phase of the study began in 1990, when all of the public middle schools in Miami-Dade County, South Florida, and subsequently all the high schools, agreed to participate in the study. The first wave of data contained 7,386 students, 6,760 males, and 626 females. Questionnaires were administered annually between 1990 and 1993 beginning in middle school (grades 6 and 7) and finishing when participating students completed middle school (grades 8 and 9). Completed questionnaires

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were obtained from 7,386 students at wave 1, 6,646 at wave 2, and 5,924 at wave 3. Analyses provided assurance that wave 1 participants were highly representative of the population from which they were drawn and that this was also true for waves 2 and 3 (Vega and Gil 1998). The sample for the study was representative of south Florida’s diverse population, consisting of 63.6 percent Latino, 14.0 percent African American, 13.3 percent European American, and 6 percent Haitian and Caribbean black. Further details regarding the sampling and study procedures for the first phase can be found elsewhere (Gil et al. 2002; Vega and Gil 1998). The second phase of the study began in 1998, during which a fourth wave of data was collected. Within the confines of ethnicity criteria, all female participants from the first phase of the study (n  410) and a random sample of 1,273 male participants from the first phase were selected for follow-up. The success rate among the original sample of males and females was 76.4 percent. Those interviewed were compared with the total sample drawn from the original study population on twenty-eight early adolescent behaviors and family characteristics of possible relevance to mental health or substance abuse risk (analyses not shown). No statistically significant differences were observed. Comparisons were also made with respect to school drop out. Among those interviewed, 20.5 percent reported that they had dropped out of high school. This corresponds closely with rates reported by the school board on the same student cohort of 21.1 percent for males and 15.2 percent for females (Turner and Gil 2002). The sample for the analyses conducted for this chapter consisted of the cohort of youth followed from the first wave of the study during middle school (1990–91, mean age 11.07 years old) until wave 4 (1998–2000, mean age 20.1 years old). The size of the sample for this study was 1,208, with 339 U.S.-born Latinos, 229 foreign-born Latinos, 298 African Americans, and 346 European Americans. For most of the analyses, the sample consists of Latino males (n  443) and females (n  445). Measures Substance Use

The analyses utilize prevalence rates of substance use as well as DSM-IV substance disorders. In terms of prevalence rates, analyses include measures of lifetime and past-year use of alcohol, marijuana, cocaine, hallucinogens, as well as a combination of other drugs that include barbiturates, tranquilizers, and inhalants. For DSM-IV substance-use disorders, variables include alcohol abuse and dependence, marijuana abuse and dependence, cocaine abuse and

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dependence, and combined measures of other drug abuse/dependence that includes inhalants, cocaine, hallucinogens, heroin, sedatives, tranquilizers, stimulants, and analgesics. For the estimation of DSM-IV diagnoses, the instrument used was the Michigan Composite International Diagnostic Interview (CIDI), which has been employed as part of the National Comorbidity Study (Kessler et al. 1994). Evidence for the validity of the Michigan CIDI diagnostic estimates have been reported for most DSM disorders, including the addictive disorders utilized in this chapter (Nelson et al. 1996; Warner et al. 1995). In addition to the measures of substance use and DSM-IV substance disorders, a composite variable indicating combined substance use was created. This measure indicates mutually exclusive categories of abstinence, use of alcohol only, marijuana only, other drugs other than alcohol and marijuana only, alcohol and marijuana only, alcohol and other drug except marijuana, marijuana and other drug except alcohol, and the combination of alcohol, marijuana, and at least one other drug. Structural Factors

Structural factors were obtained from four sources: 1990 U.S. Census data, official school records, self-reports from the youth, and parent interviews. U.S. Census data from 1990 was used because it coincides from the first wave of the longitudinal data, when participants started middle school (mean age  11.07 years). Two measures of poverty were used: overall neighborhood poverty and proportion of families in poverty. From the school records, grade point average (GPA) and scores on conduct for early and mid-adolescence were used, as well as a measure of high school dropout by the end of high school. Family Economic Factors

These measures derive from parent and youth interviews. The measures derived from the parent interviews include family economic hardship, level of education of each parent and of the primary caretaker, family structure, and presence of the father at different developmental periods. From the youth interviews there are two measures: bonding with the mother and bonding with the father. References Alegría, M., N. Mulvaney-Day, M. Torres, A. Polo, Z. Cao, and G. Canino. 2007. Prevalence of psychiatric disorders across Latino subgroups in the United States. American Journal of Public Health 97: 68–75. Amaro, H., and M. Y. Iguchi. 2006. Scientific opportunities in Hispanic drug abuse research. Drug and Alcohol Dependence Special Issue, supp. 1, vol. 84: S1–S3.

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Carroll, S. J., C. Krop, J. Arkes, P. A. Morrison, and A. Flanagan. 2005. California’s K–12 public schools: How are they doing? Santa Monica: Rand Corp. Darling-Hammond, L. 2002. Access to quality teaching: An analysis of inequality in California’s public schools. Document wws-rr002–1002. Los Angeles: UCLA’s Institute for Democracy, Education, and Access. Delva, J., J. P. Wallace, P. M. O’Malley, J. G. Bachman, L. D. Johnston, and J. E. Schulenberg. 2005. The epidemiology of alcohol, marijuana, and cocaine use among Mexican American, Puerto Rican, Cuban American, and other Latin American eightgrade students in the United States: 1991–2002. American Journal of Public Health 95 (4): 696–702. Dumka, L. E., M. W. Roosa, and K. M. Jackson. 1997. Risk, conflict, mothers’ parenting, and children’s adjustment in low-income, Mexican immigrant, and Mexican American families. Journal of Marriage and the Family 59 (2): 309–323. Gil, A. G., W. A. Vega, and F. Biafora. 1997. Temporal influences of family structure and family risk factors on drug-use initiation in a multiethnic sample of adolescent boys. Journal of Youth and Adolescence 23: 373–393. Gil, A. G., W. A. Vega, and R. J. Turner. 2002. Early and mid-adolescence risk factors for later substance abuse by African Americans and European Americans. Public Health Reports 117: S15–S29. Gil, A. G., E. F. Wagner, and J. G. Tubman. 2004. Young adult consequences of early adolescent substance use: Substance use and psychiatric disorders in a multiethnic sample of males. American Journal of Public Health 94 (9): 1603–1609. Grant, B. F., F. S. Stinson, D. S. Hasin, D. A. Dawson, S. P. Chou, and K. Anderson. 2004. Immigration and lifetime prevalence of DSM-IV psychiatric disorders among Mexican Americans and non-Hispanic whites in the United States. Archives of General Psychiatry 61: 1226–1233. Johnston, L. D., P. M. O’Malley, J. G. Bachman, and J. E. Schulenberg. 2006. Monitoring the future national survey on drug use, 1975–2005. Vol. 1, Secondary school children. Publication 06–5883. Bethesda: National Institute on Drug Abuse. Kawachi, I., N. Daniels, and D. E. Robinson. 2005. Health disparities by race and class: Why both matter. Health Affairs 24: 343–352. Kessler, R. C., K. A. McGonagle, S. Zhao, and C. B. Nelson. 1994. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry 51: 8–19. Krieger, N., J. T. Chen, and G. Ebel. 1997. Can we monitor socioeconomic inequalities in health? A survey of U.S. Health Department’s data collection and reporting practices. Public Health Reports 112: 481–491. Link, B., and J. Phelan. 1995. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior (extra issue): 80–94. Lloyd, D. A., and D. A. Taylor. 2006. Lifetime cumulative adversity, mental health and the risk of becoming a smoker. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine 10: 95–112. Marmot, M. G. 2006. Status syndrome: A challenge to medicine. JAMA 295:1304–1307. ———. 2005. Role of socialization in explaining in health. Social Science and Medicine 60 (9): 2129–2133. ———. 2004. The status syndrome: How social standing affects our health and longevity. New York: Henry Holt. Martinez, C. R. 2006. Effects of differential family acculturation on Latino adolescent substance use. Family Relations 55: 306–317.

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Medina-Mora, M. E., G. Borges, C. Lara, C. Benjet, J. Blanco, C. Fleiz, J. Villatoro, E. Rojas, and J. Zambrano. 2005. Prevalence, service use, and demographic correlates of 12month DSM-IV psychiatric disorders in Mexico: Results from the Mexican National Comorbidity Survey. Psychological Medicine 35: 1–11. Mitrani, V. B., D. A. Santisteban, and J. A. Muir. 2004. Addressing immigration-related separations in Hispanic families with a behavior-problem adolescent. American Journal of Orthopsychiatry 74: 219–229. National Research Council. 2006. Hispanics and the Future of America: Panel on Hispanics in the United States. Ed. M. Tienda and F. Mitchell. Committee on Population, Division of Behavioral and Social Sciences and Education. Washington, DC: National Academies Press. Nelson, C. B., R. J. A. Little, A. C. Heath, and R. C. Kessler. 1996. Patterns of DSM-II-R alcohol dependence symptom progression in a general population survey. Psychological Medicine 26: 449–460. Portes, A., and M. Zhou. 1993. The new second generation: Segmented assimilation and its variants. Annals of the American Academy of Political and Social Science 530: 74–96. Substance Abuse and Mental Health Services Administration (SAMHSA). 2003. National Survey on Dug Use and Health, 2002, 2003, and 2006. Rockville, MD: Office of Applied Studies. Sampson, R. J. 2003. The neighborhood context of well-being. Perspectives in Biology and Medicine 46: S53–S64. Santisteban, D. A., J. A. Muir-Malcolm, V. B. Mitrani, and J. Szapocznik. 2002. Integrating the study of ethnic culture and family psychology in intervention science. In Family psychology: Science-based interventions, ed. H. A. Liddle, D. A. Santisteban, R. F. Levant, and J. H. Bray, 331–351. Washington, DC: American Psychological Association. Turner, R. J., and A. G. Gil. 2002. Psychiatric and substance use disorders in South Florida: Racial/ethnic and gender contrasts in a young adult cohort. Archives of General Psychiatry 59: 43–50. Turner, R. J., and D. A. Lloyd. 2003. Cumulative adversity and drug dependence in young adults: Racial/ethnic contrasts. Addiction 98: 305–315. Turner, R. J., D. A. Lloyd, J. Taylor. 2006. Stress burden, drug dependence, and the nativity paradox among U.S. Hispanics. Drug and Alcohol Dependence 83: 79–89. Vega, W. A., S. Aguilar-Gaxiola, L. Andrade, R. Bijl, et al. 2002. Prevalence and age of onset for drug use in seven international sites: Results from the International Consortium of Psychiatric Epidemiology. Drug and Alcohol Dependence 68: 285–297. Vega, W. A., E. Alderete, B. Kolody, and S. Aguilar-Gaxiola. 1998. Illicit drug use among Mexicans and Mexican Americans in California: Effects of gender and acculturation. Addiction 93: 1839–1850. Vega, W. A., K. Chen, and J. Williams. Forthcoming. Smoking, drugs, and other behavioral health problems among multiethnic adolescents in the NHSDA. Addictive Behaviors. Vega, W. A., and A. G. Gil. 2005. Revisiting drug progression: Long range affects of early tobacco use. Addiction 100 (9): 1358–1369. ———. 1999. A model for explaining drug use behavior among Hispanic adolescents. Drug and Society 14: 57–74. ———. 1998. Drug use and ethnicity in early adolescence. New York: Plenum Press. Vega, W. A., and W. Sribney. 2003. Parental risk factors and social assimilation in alcohol dependence of Mexican Americans. Journal of Studies on Alcohol 64: 167–175.

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Vega, W. A., R. S. Zimmerman, G. J. Warheit, E. Apospori, and A. Gil. 1993. Risk factors for early adolescent drug use in four ethnic and racial groups. American Journal of Public Health 83: 185–189. Volkow, N. D. 2006. Hispanic drug abuse research: Challenges and opportunities. Drug and Alcohol Dependence 84S: S4–S7. Warner, L. A., A. Valdez, W. A. Vega, M. de la Rosa, R. J. Turner, and G. Canino. 2006. Hispanic drug abuse in an evolving cultural context: An agenda for research. Drug and Alcohol Dependence 84S: S8–S16. Warner, L. A., R. C. Kessler, M. Hughes, J. C. Anthony, and C. B. Nelson. 1995. Prevalence and correlates of drug use and dependence in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry 52: 219–229. Williams, D. R., and P. B. Jackson. 2005. Social sources of racial disparities in health. Health Affairs 24: 325–334.

Valentine V. Villa, Nancy Harada, Chapter 7

and Anh-Luu Huynh-Hohnbaum

The Causes and Consequences of Poor Health among Latino Vietnam Veterans Parallels for Latino Veterans of the War in Iraq

Latinos have a long-standing tradition of military service in the United States. Nearly half a million Latinos served in World War II (Leal 1999). During the Vietnam War, a disproportionate number of Latinos were among the ranks of those that enlisted and/or were drafted (Mariscal 1999). In Iraq, Latinos represent 9 percent of those serving (over 130,000 individuals), and 12 percent of those that have been killed in combat (U.S. Department of Defense 2006). Of the more than 870,000 Military Ready Reserve members, more than 71,500 are Latino (U.S. Department of Defense 2003). It is estimated that an additional 37,000 noncitizens (most of whom are Latino) currently serve in the U.S. military (Barone 2003). Moreover, the Latino population has garnered a disproportionate number of Medals of Honor, the nation’s highest award for valor (U.S. Department of Defense 2003). Cleary, there is a history of Latino’s having fought and died for the United States of America. However, there is somewhat less of a history of research and discourse on the impact that military service and war have had on the lives of those Latinos that have served in the military, particularly the impact on health. Research which examines the aspects of the Vietnam War experience that impact the health of Latino veterans can be utilized to improve the health of this cohort of veterans, as well as subsequent eras of veterans that may have similar war experiences, such as veterans of the war in Iraq. Latinos and Military Service

Latino representation in the military has consistently been disproportionately higher than their representation in the U.S. population. Reports based on 123

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aggregate numbers, however, often underrepresent Latino military participation. For example, it has been argued that Hispanics are underrepresented in the military because the Hispanic population represents 12 percent of the U.S. population and only 9 percent of the military population (Foreign Policy 2004). The problem with the use of aggregate population numbers is that the 12 percent benchmark used to make this argument also includes the population under eighteen years of age, those that are thirty-five to sixty-four, and those sixty-five and over. These populations do not typically participate in the active duty portion of the military. To obtain a more accurate estimate of Latino representation in the military, one would calculate the percentage of Latinos age eighteen to thirty-five (the age range of individual most likely to serve in active duty) in the total U.S. population and compare that with the percentage participating in the military. Doing so reveals that the Hispanic population age eighteen to thirty-five represents approximately 4 percent of the total U.S. population (U.S. Census Bureau 2004) and 9 percent of the active duty military (U.S. Department of Defense 2002). Latinos are therefore disproportionately overrepresented in the military. Furthermore, examination of military participation rates by race since 1990 finds that while there has been a decline in the overall participation rates of African Americans and whites, there has been a steady increase in participation rates among Latinos (U.S. Department of Defense 2003). Why are young Latinos joining the military? Part of the answer has to do with structural factors, most notably poverty. The California Health Interview Survey, which includes a statewide probability sample of 55,000 households, finds that among the 1,990 Latino adolescents surveyed, the most salient predictor of an individual’s planning to join the military after high school was poverty. This relationship persisted, with parental education, parents’ marital status, and parental involvement being constant (CHIS 2001). Another factor associated with Latino’s growing participation is the aggressive recruitment of the Department of Defense (DOD). Despite their overrepresentation in the military and the trend toward increased participation over the last decade, the DOD has made recruitment of Latinos into the military one of its national priorities. For example, reports issued by the DOD October 2002 and September 2003 discuss the importance of utilizing events that recognize Hispanic Heritage Month to recruit Latinos/ Hispanics into the military. The audiences for these events were Latino middle school, high school, and college students. During these events, summit meetings were also held that included representatives from various branches of the military for the purpose of exploring ways to improve efforts to increase Latino/Hispanic representation in the military. These efforts are an outgrowth or by-product of a set of DOD Hispanic initiatives originally

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issued in 2000 that have the objective of increasing the number of Latinos in the military (U.S. Department of Defense 2003). Impact of Military Service on Vietnam Veterans

The impact of military service on the health of the Latino population, in particular Latinos who served in Vietnam, has been significant. Perret (1990) argues that when examining the health and well-being of veterans it is necessary to disaggregate the veteran population by war cohort because of the difference in military service of the wars. Health research that looks at health by war cohort have for the most part examined the health status of Vietnam veterans disaggregating the population into those who were exposed to combat and/or served in Vietnam versus all others (Boyle, Decoufle, and O’Brien 1989; Breslin et al. 1988). In general, these studies find that veterans who served in Vietnam report significantly worse physical and mental health across a variety of indicators, including sense of well-being, functioning, psychiatric disorders, and mental disorders when compared to those who did not serve in Vietnam. Moreover, studies that have compared health status across war cohorts find that combat exposure and violence is related to the development of psychiatric disorders (Breslau and Davis 1987; Card 1983; Elder and Clipp 1989), with Vietnam-era veterans and Korean-era veterans tending to fare worse in terms of mental health and sense of well-being when compared to World War II veterans (Fontana and Rosenheck 1994). There is also evidence from epidemiological studies that confirm a relationship between combat psychological trauma, posttraumatic stress disorder (PTSD), and physical disease (Pitman 2006). Beckham et al. (1998) found that Vietnam veterans with combat-related PTSD report more current and chronic health problems than combat veterans without PTSD. They also found that PTSD severity is associated with greater cardiovascular morbidity and more health complaints. For example, Vietnam veterans are more likely to have abnormal electrocardiographs and elevated white blood cell counts (Boscarino et al. 1999a, 1999b) when compared to other eras of veterans. Studies that disaggregate the population by race/ethnicity, while fewer in number, find that among Vietnam-era veterans Latinos are more likely than non-Hispanic white veterans to report having PTSD and other co-morbidities. Specifically, Ortega and Rosenheck (2001) utilizing data from the National Vietnam Veterans Readjustment Survey found that Puerto Rican Vietnam veterans had greater risk for asthma, urinary tract infections, and PTSD even after adjusting for age, education, and household income. In the same study, Mexican American Vietnam-era veterans had higher adjusted risk for

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psychiatric disorders as well as alcohol abuse and dependence. They also found that after adjusting for premilitary and military risk factors for PTSD, Mexican American veterans and Puerto Rican veterans still had significantly higher probabilities of PTSD than white veterans, with Puerto Ricans having more severe forms of PTSD (Ortega and Rosenheck 2000). Evidence of ethnic and war cohort differences in health were also found by the current authors. Specifically, Villa et al. (2002) examined health status across multiple war cohorts and multiple race ethnicities utilizing data from the Veteran Identity Program (VIP). The VIP quantitative study included a survey of 3,227 male veterans residing in California and southern Nevada. They found that Vietnam-era veterans are disadvantaged relative to all other war-era veterans for the majority of indicators of physical functioning—that is, activities of daily living (ADL) and instrumental activities of daily living (IADL). This disadvantage persisted when socioeconomic status, disease prevalence, and mental health status were held constant. Their analysis further found that Latino and African American Vietnam veterans reported worse health than white veterans with all social and economic indicators held constant. These findings suggest that there is something unique about the Vietnam experience as well as the experience of being a member of an ethnic/minority population, which predisposes this population of veterans to poor health and more difficulties in functioning relative to other veterans. Evidence from the VIP Focus Group Study

The above research lends support to the argument put forth by Boyle, Decoufle, and O’Brien (1989) that the experience of being a Vietnam-era veteran is different from other eras of veterans. They argue that the Vietnam era had unique characteristics that set it apart from other modern-day wars, including the guerilla mode of warfare, lack of clear military objectives, limited offensive action, constant threat of terrorism, and an antiwar sentiment in the United States. Somewhat lacking in the research to date, however, is articulation of the impact these unique characteristics of the Vietnam War have had on the health of veterans. Distinguishing the pathways through which military service during the war has impacted health requires that we examine not only how the properties of the war impact health, but also how environmental, structural (e.g., discrimination, racism), and social factors (e.g., society’s response to Vietnam veterans) associated with military service may play a role in determining health. Indeed, it has been argued that if we are to more fully understand the health of any population, military or civilian, research efforts will have to examine the factors, including medical, structural, environmental,

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psychological, and social that are related to ill health (Harada et al. 2002; Hyams et al. 1996; Spiro et al. 1999). Utilizing the VIP focus group data, we explored the impact that military service in Vietnam (environmental), race/ethnicity within the context of military service (structural), and the veteran experience (social) have had on the health and functional status of Latino Vietnam veterans. A total of seventy-nine Vietnam-era veterans participated in the focus groups, including African American (n  19); Latino (n  23), Asian/Pacific Islander (n  12); and nonHispanic white (n  19). While the focus of this analysis is the pathways through which the military experience during the Vietnam War impacted the health of Latino veterans, we will compare the experience of Latinos with that of other minority groups (Asians and African Americans) and non-Hispanic whites because this is a multiethnic/racial sample. The Role of Environment and Properties of War

One of the main themes that arose from the VIP focus group data was how serving in Vietnam impacted health and mental health status. The majority of veterans felt that their health was impacted in a negative way either through exposure to Agent Orange, other toxic chemicals, or the psychological trauma associated with the guerilla mode of warfare. Whites and Latinos consistently referred to how fighting in combat affected both their mental and physical state. Referring to the Vietnam War as being in the “jungle,” veterans shared how fighting there was different and how it gave them a unique perspective. This was consistent particularly among Latinos, African Americans, and nonHispanic whites. Several veterans described the overwhelming presence of alcohol and drugs. Some felt that the use of drugs was often a coping mechanism to deal with the ongoing war. Latinos, more so than other ethnic groups, talked about having drug addictions and/or suffering from alcoholism because of the trauma of combat. Some veterans discussed their belief that such addictions are responsible for the high divorce rate among veterans, others explained that the accessibility of alcohol and drugs had long-term effects on their health. This finding was consistent across all ethnic groups. Many of the veterans felt that upon their return home the government did a poor job of preparing them to reenter civilian life, and many veterans felt lost and confused. The transition was extremely stressful and the effects were long lasting, affecting their ability to work and to sustain employment. A large majority of the veterans, in particular Latinos and whites, more so than African Americans or Asian Americans, expressed having PTSD or PTSD symptoms and difficulty functioning. Common affective complaints included restlessness, suicidal thoughts,

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irritability, and depression. Somatic complaints were headaches, digestive issues, and dizziness. It was different over there in Vietnam. I was out there in the jungle so long; it didn’t bother me to kill. That’s the way life was. You adjust to the way things happen. It [the Vietnam War] kind of destroyed me . . . I just take life second by second. Just live for the next second. (Latino veteran) Post-traumatic stress disorder or combat fatigue or whatever you want to call it, has occurred war after war. They know that you send a nineteen-year-old kid to a combat situation, you’re going to have a problem with that person later. Instead of debriefing and have something set up for him to go through after release from the service, they [wait] until thirty years later when all hell has broke loose and his life is a wreck, then they say “OK, let’s do something about this. Let’s calm the PTSD down” . . . . For them not to have something prepared, a debriefing, I think it’s atrocious. I think it’s demeaning. I think it’s indecent. (African American veteran) For thirty years I went through hell. I didn’t know why until 1 1/2 years ago. I came to find out that I had PTSD. I thought the nightmares, the sweats, the hell that I went through . . . that everybody else was going through it. I think we got screwed. When I got back from Vietnam, I could barely do anything. I came back to my folks’ home and I went into what was still my bedroom at the time. I opened the door and I went in and I closed the door and I did not come out for years. I wasn’t able to cope with my memories from the nightmares or the anger or the frustration. (non-Hispanic white veteran) I found out he [fellow soldier] was dead . . . I grabbed his head and put it to myself. When I think of his face, that emotional feeling that I have ’til now it is just a sickening feeling. I cry. (Asian American veteran)

The Role of Racism and Discrimination

The veterans in all of the racial/ethnic groups shared that there was a certain degree of racial/ethnic discrimination and prejudice present while serving in Vietnam. There was conflict between racial/ethnic groups, and most of the conflict was majority against minority. While they still experienced some, the Asian American veterans expressed the least amount of discrimination. The African Americans and Latinos reported experiencing the most discrimination. While some expected there to be some discrimination, for a few veterans, the degree was much more than they expected. A large majority of the veterans

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shared witnessing some form of discrimination, whether or not they were the victims. Both nonminority and minority veterans felt that Latinos and African Americans were the targets of most of the discrimination, that they were treated differently than whites and were expected to do the worst duty assignments. The majority of Latino and African American veterans reported stress and feelings of depression related to discrimination. I didn’t know what prejudice was until I went into the military . . . that’s where it really was. (Latino veteran) I grew up in a segregated community . . . so it’s nothing new to me to experience racism or prejudice in the military. I thought that was just the way life was . . . except the blacks were behind us and they were getting it even worse. I saw a lot of conflicts between blacks and whites. White officers really doing a number on blacks. (Latino veteran) There was so much prejudice . . . I was assigned to a higher headquarters and I was the only black assigned there. I was treated like, gosh, like . . . I never . . . I’m originally from Louisiana and things weren’t as bad over there like I had it in the service and when I came out I had a bleeding ulcer. (African American veteran) There was a lot of prejudice over there [Vietnam]. You would find the most with the blacks, Hispanics, and maybe Native Indian. They were given a lot of chores and a lot of duties that nobody in their right mind would want to take. If you weren’t Christian and you weren’t white, you had a bad time. (Non-Hispanic white veteran)

The Role of Society

The main disadvantage expressed by all ethnic groups was the treatment by society upon their return. Many felt that they were not recognized for their service. Veterans, particularly Latino, African American, and white/nonHispanics, were frustrated with their mistreatment. Vietnam War veterans across racial/ethnic groups reported that they were treated differently than veterans from other wars. Most felt they were treated poorly in comparison to previous war cohorts. The majority of veterans stated that they were ordered not to wear their uniforms in public because of the public backlash toward Vietnam veterans. Most veterans, in particular Latino and non-Hispanic whites, shared that it was not just the treatment from society that was bad, but from other veteran cohorts as well, namely World War II. The veterans across racial/ethnic groups felt an overwhelming sense of disrespect from society and the government. Many felt that the media had a lot to do with the negative portrayal of

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Vietnam veterans. The majority of veterans across racial/ ethnic groups felt that the treatment by society compounded or fueled their feelings of depression, PTSD, and other health conditions. A few African American and white veterans urged society to extricate their feelings about the war and its politics with their feelings about the veterans themselves. It was pretty hard adjusting to society because we were baby killers and women and children killers. It was hard to even meet women because everybody had long hair then. When you had short hair, you’re an outcast right away. They knew [you had been in the military]. (Latino veteran) I spent almost four years there, and then the treatment was like there wasn’t anybody there when we got out. It was sort of a sad situation. Even still to this day it sort of makes me ticked off and mad about it. Nothing’s really changed. (Latino veteran) I was proud to serve my country and everything and being a veteran. But, being in Vietnam, I’ve been using drugs for thirty-two years. I’ve been to prison six times. I’ve never had a job since I left Vietnam in 1966. (African American veteran) They [public] were demonstrating when you come home, like we were called baby killers . . . so we tried our best to meld back into society or hide in society when we came back. I took my uniform off and I never seen it again. (African American veteran) My father served in World War II . . . he got medals. They fought bravely. I come from that background where I grew up listening to all that stuff . . . When it was my turn to go in, it was just the total opposite. So you’re like thrown to the dogs. The anger is still there, obviously, because you feel like you want to do something and [you’re] looked at as a traitor. You’re damned if you do and you’re damned if you don’t. I don’t know what you expect to get from people . . . I love my country. I have anger because of how they [society] treated us. (non-Hispanic white veteran) When we came back, we were the enemy. We were the [expletive] enemy. We were okay to be sent like lambs to the slaughter . . . then you go and try to access some of this [health benefits]. They [the VA] look at you like, you don’t deserve this. You’re not sick. How many years did it take for Agent Orange after Vietnam for the government to finally acknowledge there was damage? You know what it was? It was a monetary thing. It had nothing to do with helping people. I’m the guy who’s living with posttraumatic stress syndrome. (non-Hispanic white veteran)

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The Pathways to Poor Health

The findings suggest that there are properties unique to the Vietnam War that have negatively impacted the health of Vietnam veterans. Environmental hazards, as well as properties of war (i.e., the mode of warfare), have impacted both the mental and physical health of Vietnam veterans. It seems clear that the mode of guerilla warfare is particularly responsible for the relatively high levels and consistent reporting of psychological trauma, PTSD, depression, substance abuse, and physical health complaints by these veterans. Latinos, African Americans, and non-Hispanic whites report equal levels of health complaints associated with service in Vietnam, with Latinos and non-Hispanic whites more likely to report having PTSD. Our findings relative to the high levels of PTSD found among Latinos may account for some of the higher levels of health problems and difficulties in functioning found among Latinos in the quantitative VIP study conducted by Villa et al. (2002). This is consistent with the Zatzick et al. (1997) findings that Vietnam veterans with PTSD were more likely to report physical limitations and higher levels of functional impairment than those without PTSD. These data also find that while all racial/ethnic groups report having witnessed discrimination, African Americans and Latinos were more often the victims of discrimination and more likely to report the negative impact it had on their mental and physical health. This parallels studies on the civilian population, which find that discrimination and racism experienced by minority populations in the United States is linked to a host of health issues, including hypertension, cardiovascular disease, elevated blood pressure, low birth weights, psychological distress, major depression, anxiety, low self-rated health, and reports of multiple chronic conditions (Williams 2004). Moreover, the VIP data are also consistent with data on the civilian population that find that discrimination increases the likelihood of unhealthy behaviors, such as impaired sleep patterns, decreased physical activity, increased substance abuse, and overeating, all of which are risk factors for increased morbidity and mortality (Williams 2005). Ethnic minority populations often employ these risk behaviors as a way of coping with the chronic stress associated with racism and discrimination. Finally, the data suggest that the social experience of being a Vietnam veteran has had a negative and lasting impact on health and mental health. All ethnic groups had difficulty with society’s treatment when they returned home from Vietnam. Latinos and non-Hispanic whites in particular report that it exacerbated their feelings of depression, PTSD, and other mental health problems that they were already experiencing. It also is evident that it was the

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experience of coming back home, specifically the mistreatment and the level of disrespect experienced by all of the veterans, that seemed to have the most negative impact on their health. These findings mirror those of Hoge et al. (2004), who report that public indifference or antagonism toward veterans can produce feelings of alienation, distrust, and symptoms of PTSD, as well as other psychiatric problems. Parallels for Veterans of the War in Iraq

The data presented are particularly disconcerting when one considers the similarities between the Vietnam War and the wars of the twenty-first century, in particular the wars in Iraq and Afghanistan. The war in Iraq, otherwise known as Operation Iraqi Freedom (OIF), and the war in Afghanistan, referred to as Operation Enduring Freedom (OEF), represent the longest period of sustained combat exposure the United States has been involved in since the Vietnam War (Grieger et al. 2006). Like Vietnam, the wars in Iraq and Afghanistan are highly politicized, having diminishing support from the American public and international community, lacking in a clear military objective, and employing a guerilla mode of warfare with a nonreadily identifiable enemy. According to Grieger et al. (2006), the OIF and OEF conflicts differ from other wars of the twentieth century in the nature of deployed forces (e.g., they comprise an all-volunteer force with heavy reliance on reserve forces who experience longer and multiple deployments); the nature of exposure (e.g., increased exposure to explosive devices, mortar fire, car bombs, and suicide bombs); as well as the nature of injuries (e.g., advancement in body armor and treatments have reduced the number of deaths, meaning soldiers who would have died in previous conflicts now survive, but with serious debilitating and disabling injuries). The nature of combat is somewhat different than wars of the twentieth century. Early in the conflict, advancement of forces was swift and U.S. forces initially were greeted by citizens of Iraq and Afghanistan as liberators. Now with more sophisticated and frequent insurgent activity, there is an increasing distrust of U.S. presence in those countries, a continuously rising U.S. death toll, and declining popular support for the war (Grieger et al. 2006). As of November 16, 2004, over 10,726 U.S. military soldiers (all races) had suffered war injuries (U.S. Department of Defense 2004). While the proportion of soldiers of all races that have died (10 percent) is much lower than the percentage for other wars, as many soldiers have been injured in combat in Iraq as in the Revolutionary War, the War of 1812, and the first five years of the Vietnam conflict (Gawande 2004). In terms of outcomes, like Vietnam-era veterans, veterans of the war in Iraq have significant levels of PTSD and other mental health issues. According to

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Hoge et al. (2006), 19 percent of service members returning from Iraq and 11.3 percent of service members returning from Afghanistan report having mental health problems. Another study (Hoge et al. 2004) further found that 12 percent to 19 percent of soldiers returning from Iraq screened positive for PTSD, and an additional 7.1 percent to 15.2 percent met criteria for depression. Additionally, the same study found that among troops returning from Afghanistan (where combat is somewhat less intense), 6.2 percent to 11.5 percent screened positive for PTSD, with an additional 6.9 percent to 14.2 percent meeting the criteria for depression. One of the explanations for these relatively high levels of PTSD and depression is the relatively high exposure to traumatic stress while in combat, particularly on the part of soldiers in Iraq (Ramaswamy et al. 2005). Hoge et al. (2004) reports that among the three thousand veterans surveyed upon return from Iraq, nearly 90 percent of Army and 95 percent of Marines reported being attacked or ambushed; 86 percent of Army and 97 percent of Marines reported receiving incoming artillery, rocket, or mortar fire; 93 percent of Army and 97 percent of Marines reported being shot at; 95 percent of Army and 94 percent of Marines reported seeing dead bodies; 96 percent of Army and 87 percent of Marines reported knowing someone seriously injured or killed; and 48 percent of Army and 65 percent of Marines reported being responsible for the death of an enemy combatant. This war is unique in terms of health outcomes in that soldiers are more likely to survive wounds that would have been fatal in previous wars. Accordingly, Gawande (2004) reports that the nature of injuries in Iraq is different from other conflicts. He adds that blast injuries from suicide bombs and land mines have increased substantially since the war began and are difficult to manage, often involving penetrating, blunt, and burn injuries. Another dismaying finding is the increase in the number of blinding incidences in this war. Furthermore, Gawande (2004) argues, while Kevlar vests have proved to be dramatically effective in preventing torso injuries, surgeons in Iraq are finding that IEDs are causing blast injuries that extend upward under the armor and produce unprecedented numbers of mangled extremity injuries, including loss of limbs, arms, and parts of the face. These kinds of injuries have the potential to adversely impact young veteran’s health and functioning, as well as limit their social and economic opportunities over their life course. Policy and Program Recommendations

The impact of military service on the health and mental health of Latino veterans has been substantial. One of the most disturbing findings in the earlier data is the prevalence of PTSD among these two cohorts of veterans. Research has

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amply demonstrated the impact PTSD has on health as well as sense of wellbeing, social relationships, and earnings/income. PTSD is associated with higher levels of chronicity, disrupted social relationships, marital dissolution, domestic violence, diminished sense of well-being, lower earnings, unemployment, poverty, and more days of worked missed (Escobar et al. 1983; Savoca and Rosenheck 2000; Zatzick et al. 1997). The Latino population currently has some of the lowest educational and income levels of the total U.S. population (U.S. Census Bureau 2003). Untreated PTSD among Latino veterans can only exacerbate educational and economic disparities. According to Ramaswamy et al. (2005), the Veterans Administration medical centers provide a network of specialized PTSD programs that offer veterans education, evaluation, and treatment conducted by mental health professionals from a variety of disciplines. It is imperative that at the point of discharge veterans are informed of these programs and their right to access them immediately. In addition, because we know that PTSD symptoms can worsen over time and further compromise physical health, it is critical that the DOD follow up with veterans after discharge at regular intervals to assess if health and mental health conditions have improved or worsened and to assess if the veterans have accessed services. This kind of proactive intervention can improve health and mental health early on, thereby fostering the ability to pursue educational and economic opportunities that will improve access to resources which protect health over the life course. Absent intervention now, Latino veterans with PTSD and other health issues that impact their ability to work, function, and acquire wealth may find themselves returning to the poverty they were hoping to escape by joining the military. The health of our veteran population is not only the result of military service or properties of war but also of the environmental, structural, and social factors associated with military service. While mode of warfare is certainly responsible for many of the health issues facing Latino veterans, there are other characteristics of the war experience that have had a detrimental impact on health, including environmental hazards, racism/discrimination, and maltreatment toward veterans on the part of U.S society. These factors have exacerbated health and mental health problems among Latinos and in many instances have been the cause of them. It is important for us to recognize this in light of the large numbers of veterans now serving in Iraq and Afghanistan who are and will soon be returning home to the United States. The U.S. government and the military should take an active role in developing policies and procedures that address environmental hazards and structural and social inequalities associated with military service. Policies and procedures developed now by the

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U.S. government and the military that address these factors can go a long way in improving health, mental health, and ultimately economic outcomes among Latino veterans. For example, environmental hazards—chemical toxins, dirty bombs, suicide bombers, and car bombs—associated with military duty overseas should be more carefully assessed before deployment so that soldiers can be protected in advance and potential hazards can be anticipated and hopefully avoided. The U.S. military should provide proper gear, supplies, and armor to protect soldiers in advance of deployment. Doing so would enable soldiers to avoid injuries that could hold serious consequences for their health and functioning, as well as their ability to pursue economic opportunities. For those veterans who have already survived injuries that carry long-term debilitating consequences, the Veterans Administration must outreach to these veterans specifically in the areas of medical and occupational rehabilitation, as well as opportunities related to education. Structural factors, in particular racism and discrimination that occur within the context of military service, need to be addressed by the U.S. government. As such, the military’s adherence to antidiscrimination laws and civil rights laws should be strictly enforced with clear consequences and sanctions for noncompliance. Long-term negative effects of racism and discrimination on health as well as functioning is clear. Racism and discrimination diminish health as well as one’s ability to amass social and economic resources that protect and bolster health. Similarly, efforts to recruit Latinos into the military should be matched by an equal amount of effort on the part of the federal government to recruit Latinos into college and other educational opportunities. As such, affirmative action laws should be upheld and civil rights and antidiscrimination laws in education and employment enforced. Doing so will make the choice to serve in the military a real choice rather than a choice made because of the absence of other viable educational and economic opportunities. Finally, society must learn to separate the soldier from the politics and the war. For many young Latinos, military service is perceived as the only pathway out of poverty and economic disparity. The promises of educational and occupational benefits upon discharge are factors that pull young Latinos into the military (Gifford 2005), as are family traditions of military service and the recognition and pride associated with serving one’s country. Therefore, it is imperative that we as a society recognize the contribution and sacrifice of these young people, regardless of our feeling about the war. There is certainly ample evidence of the horrific toll that society’s lack of respect, support, and recognition has on the physical and mental health of veterans.

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Conclusion

Latinos clearly have accepted the call to arms. They have a long and impressive history of military service that is laudable, and they have paid the price for military service. This has been a high price: disproportionately high levels of PTSD, mental health issues, and difficulty functioning. Our most recent veterans have also experienced high levels of combat-related injuries that have rendered them blind and disabled. And a disproportionate number of Latinos have paid the ultimate price. For this sacrifice, it is incumbent that the U.S. government initiate outreach services and programs that respond to the specific physical and mental health issues Latino veterans experience, thereby improving the health and well-being of this population. Note The VIP research for this study was supported by a grant from the Veterans Administration, Health Research and Development Division, grant ECV97–028. We would like to thank all of the veterans that participated in the VIP focus groups for their dedication to this project and for sharing their experience and insights. We would also like to offer our sincere thanks and appreciation to all of the men and women who have served in the U.S. military. They have our deepest admiration and respect. References Barone, M. 2003. Making new amigos. U.S. News & World Report 134 (2): 26. Beckham, J. C., S. D. Moore, M. Feldman, E. Hertzberg, A. C. Kirby, and J. A. Fairbank. 1998. Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder. American Journal of Psychiatry 155 (11): 1565–1569. Boscarino, J. A., and J. Chang. 1999a. Electrocardiogram abnormalities among men with stress-related psychiatric disorders: Implications for coronary heart disease and clinical research. Annals of Behavioral Medicine 21 (3): 227–234. ———. 1999b. Higher abnormal leukocyte and lymphocyte counts 20 years after exposure to severe stress: Research and clinical implications. Psychosomatic Medicine 61 (3): 378–386. Boyle, C. A., P. Decoufle, and T. R. O’Brien. 1989. Long-term health consequences of military service in Vietnam. Epidemiologic Reviews 11: 1–27. Breslau, N., and G. C. Davis. 1987. Posttraumatic stress disorder: The etiologic specificity of wartime stressors. American Journal of Psychiatry 144: 578–583. Breslin P., K. Kang Han, Y. Lee, V. Burt, and B. M. Shepard. 1988. Proportionate mortality study of U.S. Army and U.S. Marine Corps veterans of the Vietnam War. Journal of Occupational Medicine 30 (5): 412–419. Card, J. 1983. Lives after Vietnam. Lexington: Heath. California Health Interview Survey (CHIS). 2001. Adolescent Data File. University of California Center for Health Policy Research, Los Angeles. Elder, G. H., and E. C. Clipp. 1989. Combat experience and emotional health: Impairment and resilience in later life. Journal of Personality 57 (2): 311–341.

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Escobar, J., E. Randolph, G. Puente, F. Spiwak, J. Asmen, et al. 1983. Post-traumatic stress disorder in Hispanic Vietnam veterans clinical phenomenology and sociocultural characteristics. Journal of Nervous and Mental Disease 171 (10): 585–596. Fontana, A., and R. Rosenheck. 1994. Traumatic war stressors and psychiatric symptoms among World War II, Korean, and Vietnam War veterans. Psychology and Aging 9 (1): 27–33. Foreign Policy. 2004. Minority report. Foreign Policy (September/October): 17. Gawande, A. 2004. Causalities of war: Military care for the wounded from Iraq and Afghanistan. New England Journal of Medicine 351 (24): 2471–2475. Gifford, B. 2005. Combat casualties and race: What can we learn from the 2003–2004 Iraq Conflict? Armed Forces and Society 31 (2): 201–225. Grieger, T. A., S. J. Cozza, R. J. Ursano, C. Hoge, P. E. Martinez, C. C. Engle, and H. J. Waine. 2006. Posttraumatic stress disorder and depression in battle-injured soldiers. American Journal of Psychiatry 163 (10): 1777–1783. Harada, N. D., J. Damron-Rodriguez, V. M. Villa, D. Washington, S. Dhanani, H. P. Shon, M. Chattopadhyay, H. Fishbein, M. Lee, and T. Makinodan. 2002. Veteran identity and race/ethnicity: Influences on VA outpatient care utilization. Medical Care 40 (1): 117–128. Hoge, C. W., J. L. Auchterlonie, and C. S. Miliken. 2006. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association 95 (9): 1023–1032. Hoge, C. W., C. A. Castro, S. C. Messer, D. McGurk, D. I. Cotting, and R. L. Koffman. 2004. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 351 (1): 13–22. Hyams, K. C., F. S. Wignall, and R. Roswell. 1996. War syndromes and their evaluation: From the U.S. Civil War to the Persian Gulf War. Annals of Internal Medicine 125: 398–405. Leal, D. L. 1999. It’s not just a job: Military service and Latino political participation. Political Behavior 21 (2): 153–174. Mariscal, G. 1999. Aztlan and Viet Nam Chicano and Chicana Experiences of the War. Berkeley: University of California Press. Ortega, A. N., and R. Rosenheck. 2001. Mental and physical health and acculturation among Hispanic Vietnam veterans. Military Medicine 166 (10): 894–897. ———. 2000. Posttraumatic stress disorder among Hispanic Vietnam veterans. American Journal of Psychiatry 157 (4): 615–619. Perret, G. 1990. A Country Made by War. New York: Vintage Books. Pitman, R. K. 2006. Combat effects on mental health: The more things change, the more they remain the same. Archives of General Psychology 63: 127–128. Ramaswamy, S., V. Madaan, F. Qadri, C. J. Heaney, T. C. North, P. R. Padala, S. P. Sattar, and F. Petty. 2005. A primary care perspective of posttraumatic stress disorder for the Department of Veterans Affairs. Primary Care Companion Journal of Clinical Psychiatry 7: 180–187. Savoca, E., and R. Rosenheck. 2000. The civilian labor market experiences of Vietnam-era veterans: The influence of psychiatric disorders. Journal of Mental Health Policy and Economics 3: 199–200. Spiro, A., P. P. Schnurr, and C. M. Aldwin. 1999. A life-span perspective on the effects of military service. Journal of Geriatric Psychiatry 30 (1): 91–128.

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U.S. Census Bureau. 2004. Current Population Survey. Annual Social and Economic Supplement. Ethnicity and Ancestry Statistics Branch, Population Division. Washington, DC: U.S. Census Bureau. ———. 2003. The Hispanic Population in the United States: March 2002. Washington, DC: U.S. Census Bureau. U.S. Department of Defense. 2006. Active Duty Military Deaths—Race, Ethnicity. Washington, DC: U.S. Department of Defense. ———. 2004. Official Guard and Reserve Manpower Strengths and Statistics. Washington, DC: U.S. Department of Defense. ———. 2003. Department of Defense wants more Hispanics in civilian workforce, military ranks. Washington, DC: U.S. Department of Defense. ———. 2002. Department of Defense to mark 2002 Hispanic Heritage Month. Washington, DC: U.S. Department of Defense. Villa, V. M., N. Harada, D. Washington, and J. Damron-Rodriquez. 2002. Health and functioning among four war eras of U.S. veterans: Examining the impact of war cohort membership, socioeconomic status, mental health and disease prevalence. Military Medicine 167 (9): 783–789. Williams, D. R. 2005. The health of U.S. racial and ethnic populations. Journal of Gerontology: Social Sciences 60 (suppl. 2): S53–62. ———. 2004. Racism and health. In Closing the Gap, ed. Kenneth. E. Whitfield, 69–80. Washington, DC: Gerontological Society of America. Zatzick, D. F., C. R. Marmar, D. S. Weiss, W. S. Browner, T. J. Metzler, J. M. Golding, A. Stewart, W. E. Schlenger, and K. B. Wells. 1997. Posttraumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam veterans. American Journal of Psychiatry 154 (12): 1690–1695.

Sandra P. Arévalo, Laia Bécares, Chapter 8

and Hortensia Amaro

Health of Incarcerated Latino Men

Disparities in health status and health care between Latinos and other race/ ethnic groups in the United States have been broadly documented in the scientific literature (IOM 2003). However, national data sources and reports on health disparities have excluded institutionalized populations such as those who are incarcerated (CDC 2004; APHA 2004; AHRQ 2005). It is axiomatic in criminology that people of low socioeconomic status are more likely to be prosecuted for crimes than are rich ones, and that minority group arrestees are at a significant disadvantage in every stage of judicial processing within the criminal justice system. Therefore, structural factors operate to increase both risk of Latino males experiencing both poor health and the greater likelihood of incarceration in facilities where disease is rampant, medical care is commonly delayed and substandard, and violence is routine. By the end of 2005, a total of 2,320,359 individuals were incarcerated in U.S. correctional facilities, with Latinos comprising 20.2 percent of prisoners in federal and state correctional facilities and 15 percent of inmates in local jails (Harrison and Beck 2006b). At the same time, the penal system has been remiss in systematically documenting the health status and access to adequate health care of incarcerated individuals. There is no national health data system for accurately documenting the health status and health care needs of incarcerated individuals in federal or state prisons or local jails. Currently, national estimates of health conditions of incarcerated populations are derived from calculations based on data sets from noninstitutionalized populations. Given the disproportionate incarceration rates of minority populations, especially males (Harrison and Beck 2006a), the need to improve data on the health 139

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status of incarcerated individuals and address differences among various race/ ethnic groups is a significant but neglected part of the health disparities picture in the United States. Moreover, accurate disease rates among the different soon-to-bereleased Latino subgroups inform us about illnesses that can affect the community to which the inmate returns and enable us to predict and procure preventive and treatment services, easing the community burden suffered at time of reentry. Incarceration Rates in the United States

Latino incarceration rates have soared dramatically, doubling in numbers since the 1980s. From 1974 to 2001, Latino men experienced a fourfold increase in the representation of incarcerated individuals, from 4.0 percent to 16.5 percent, as compared to a threefold increase for black men and three-fourths of an increase for white men (Bonczar 2003). Policies such as “three strikes and you are out,” mandatory minimum sentences, and the deinstitutionalization of the mentally ill have contributed to the creation of an incarcerated population that is mostly urban, of racial/ethnic minority background, and with a high prevalence of various health problems. These processes, together with the War on Drugs and the disinvestment of human services in low-income, minority communities, have transformed mass incarceration into yet another social determinant of health, increasing the existing racial/ethnic disparities in health (Freudenberg 2001). Racial/Ethnic Health Comparisons among Incarcerated Populations

Estimates on racial/ethnic health comparisons among incarcerated individuals derived from a national survey of nonincarcerated populations indicate some areas of health disparities affecting Latinos. For example, whereas lower prevalence rates of asthma, diabetes, regular drug use, and drug use in the month prior to incarceration have been reported among Latino male inmates as compared to their black and white counterparts (National Commission on Correctional Health Care 2002b), Latino male inmates have been estimated to have higher rates of heart disease and some sexually transmitted infections, as compared to both white and black male inmates (National Commission on Correctional Health Care 2002b). In the case of infectious diseases such as HIV and hepatitis B, rates of seroprevalence among Latino inmates are significantly higher than those of white inmates (Macalino et al. 2004). Among state prisoners, Latino inmates were about twice as likely as non-Latino inmates to be HIV-positive (Maruschak 2005). Estimates of the mental health of incarcerated populations have also been derived from surveys of nonincarcerated populations using the National Comorbidity Survey (NCS). Such estimates indicate that Latino male prisoners

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have higher rates of depression than black inmates and higher rates of posttraumatic stress disorder and antisocial personality disorder than both white and black inmates (National Commission on Correctional Health Care 2002b). In addition, Latino prisoners’ health status has been found to worsen at higher rates between incarceration and release, as compared to non-Latino prisoners. A 1991 study on the differences in health status of prisoners between intake and release found that Latino prisoners were 5.5 times more likely than nonLatino prisoners to report poorer health at time of release (Wallace et al. 1991). Limitations of Correctional Health Data

Despite a well-documented disproportionate disease burden amongst the incarcerated population, whose rates of disease are four to ten times greater than those of nonincarcerated individuals (Urban Institute 2002), there is no national data registry designed to track disease prevalence among incarcerated individuals (Binswanger et al. 2005). Data collection has thus been left to independent researchers or to the individual Departments of Corrections. Regrettably, the data collection capabilities of state Departments of Corrections have been reported to be somewhat limited (National Commission on Correctional Health Care 2002a). A 2002 survey of forty-one Departments of Corrections on their data collection activities found that fewer than 50 percent of the departments surveyed reported collecting data on prevalence of chronic diseases; 40 percent collected data on the medication needs of inmates; and approximately 50 percent reported collecting data on mental health diagnoses (National Commission on Correctional Health Care 2002a). Moreover, rates of disease differ depending on the location of the study and on the demographic distribution of the population and thus are not easily comparable. Because of the lack of a national system for collecting data on the health of incarcerated individuals, there has been a reliance on estimates of health conditions that have been derived from surveys of nonincarcerated populations, such as the U.S. National Comorbidity Survey (NCS) or the National Health and Nutrition Examination Survey (NHANES), among others. The current lack of national datasets tracking the health status of incarcerated populations signifies that we do not know the exact distribution of disease among incarcerated populations, nor can we make correct comparisons among racial/ethnic groups. Estimates for Health and Disease Indices among Incarcerated Latino Men

Findings reported in this section come from two national data sets: the 2002 Survey of Inmates in Local Jails (SILJ) and the 1997 Survey of Inmates in State

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and Federal Correctional Facilities (SISFCF). SILJ facilities are operated by local authorities and hold juvenile and adult individuals before or after adjudication; individuals held in SILJ usually serve sentences of one year or less. In contrast, SISFCF facilities are operated by a state or the federal government, and they hold only those persons who have been sentenced to one year or more of incarceration. Details on sample design for both surveys can be found in the U.S. Department of Justice (2002). Data for the SILJ and the SISFCF were collected through personal interviews and included information on current offense and sentence, criminal history, family background and personal characteristics, history of drug and alcohol use and participation in substance abuse treatment programs, gun possession and use, as well as prison activities and programs and services. Data for the SILJ 2002 were collected from January through April 2000; data for the SISFCF 1997 were collected from June through October 1997. A total of 14,285 interviews were completed for the state survey (SILJ) and 4,041 for the federal survey (SISFCF). The sample used in this chapter consisted of 4,663 respondents from the SILJ: 2,094 (44.9 percent) blacks (B); 1,750 (37.5 percent) whites (W); 641 (13.7 percent) Mexican Americans (MA); and 178 (3.8 percent) Puerto Ricans and Caribbeans (PRC). And 13,495 respondents from the SISFCF: 6,427 (47.6 percent) blacks; 4,878 (36.1 percent) whites; 1,683 (12.5 percent) Mexican Americans; and 507 (3.8 percent) Puerto Ricans and Caribbeans. Variables selected for the analyses were sociodemographic measures, criminal history, drug use, physical and mental health conditions, and physical and mental health services received since admission. All statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) software, version 14. Pearson Chi-square tests were conducted for categorical variables, one-way ANOVAs (α  0.05) for continuous variables, and UNIANOVAs (α  0.05) when controlling for age were conducted in order to test for differences in the two separate databases among black, white, and Latino inmates. When F-tests were significant, mean comparisons were performed using the Tukey’s HSD (honestly significant difference) comparison of means test (α  0.05). Sociodemographic Characteristics

Questions on ethnicity included a yes/no question “Are you Spanish, Latino, or Hispanic origin?,” followed by a multiple-choice question to select the categories that best describe their origin or descent, the options to this question were Mexican American, Chicano, Mexican, Cuban, Puerto Rican or other

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143

Caribbean, Central or South American Spanish, Other Spanish, Don’t Know, and Refused. Four groups were selected for these analyses: the Mexican American (MA) group consisted of those who answered yes to the Latino/ Hispanic/Spanish question and subsequently selected only Mexican American, Chicano, or Mexican as their origin. The Puerto Rican and Caribbean (PRC) group consisted of those who answered yes to the Latino/Hispanic/ Spanish question and subsequently selected only Puerto Rican and Caribbean as their origin. Blacks (B) were selected from those who answered no to the Latino/Hispanic/Spanish question and selected only black or African American as their race. Whites (W) were selected from those who answered no to the Latino/Hispanic/Spanish question and selected only white as their race. Comparisons by race/ethnicity showed significant differences in demographic characteristics in both the SILJ and SISFCF samples. Whereas W were the oldest group in local jails (mean age  32.3 years compared to B, MA, and PRC’s mean age: 30.2, 29.2, and 29.0 years, respectively), in state and federal prisons, PRC were the oldest group (mean age  42.4 years compared to B, W, and MA’s mean age: 35.8, 38.3, and 39.1 years, respectively). MA were more likely to be married in both local jails and state and federal prisons, and in both samples, MA had the lowest education level, with an average grade prior to incarceration of 9.6 in the SILJ and 9.3 in the SISFCF, compared to 11.1, 11.2, and 10.5 for B, W, and PRC, respectively, in the SILJ, and 11.0, 11.2, 10.2 for B, W, and PRC, respectively, in the SISFCF. In both samples, B were more likely to have children (SILJ: 55.0 percent; SISFCF: 61.0 percent), compared to W, MA, and PRC (SILJ: 46.7 percent, 50.5 percent, and 54.8 percent respectively; SISFCF: 50.6 percent, 54.6 percent, and 54.8 percent respectively). Criminal History

Latinos (MA  38.2 percent; PRC  40.4 percent) and blacks (35.2 percent) compared to whites (47.4 percent) in local jails were more likely to be awaiting arraignment, trial, conviction, or sentencing; to being held for parole/probation violations; or to be awaiting transfer to a state or federal prison to serve their sentences than to be convicted and serving sentences. Over half of MA inmates in SILJ had been convicted for violent offenses (57.1 percent), whereas 44 percent of B had been convicted for property offenses (44.4 percent) and 66.7 percent of PRC had been convicted for drug offenses. Among inmates in federal and state prisons, violent offenses were reported by all racial/ethnic groups as the main reason for conviction.

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Ever 90.0 80.0

Daily/almost daily during month prior to incarceration

82.8 76.7

75.8

70.0 60.2

57.5

percentage

60.0 50.0

30.0

40.1

37.8

40.0

38.2 31.2

21.6 23.1

20.0

25.3

23.6 12.0

8.4

10.0

7.7

5.0

9.0

14.7

11.3 5.5

2.3

10.7

2.2

B

W

MA

Figure 8.1

PRC

B

heroin/opiates

crack/cocaine

marijuana

0.0

W

MA

PRC

B

W

MA

PRC

Drug use among inmates in local jails.

Drug Use

Included history of drug use in lifetime and in the month prior to incarceration, as well as frequency of use in the month prior to incarceration and lifetime participation in a program for alcohol and/or drug treatment. Figures 8.1 and 8.2 present data on drug use for men incarcerated in local jails and state and federal prisons, respectively. Percentages presented in the figures are unadjusted for age, but the p values described below reflect age-adjusted values. Significant differences were found among the local jail sample on marijuana, crack/ cocaine, and heroin/opiates (see fig. 8.1). Post-hoc comparisons controlling for age revealed significantly lower rates of lifetime drug use among MA compared to W for marijuana, crack/cocaine, heroin/opiates, depressants, stimulants, and hallucinogens, and significantly lower rates of lifetime use of marijuana compared to B. Similarly, PRC compared to W had significantly lower rates of lifetime drug use; after controlling for age these differences were statistically significant for marijuana, crack/cocaine, depressants, stimulants, and hallucinogens. PRC had also significantly lower rates of lifetime use of marijuana compared to B. Among Latino groups, PRC compared to MA had higher rates of

Health of Incarcerated Latino Men

Ever 80.0

145

Daily/almost daily during month prior to incarceration

76.3 76.1 67.9

70.0

70.6

60.0 49.3 49.3

percentage

50.0

51.5

43.7

40.0

33.9 29.9

29.3

26.2

30.0

21.9

23.9 16.3

20.0

11.6 12.2

26.5 18.1

16.6 15.6 10.0

10.0

4.7

6.1

B

W

Figure 8.2

MA

PRC

B

heroin/opiates

crack/cocaine

marijuana

0.0

W

MA

PRC

B

W

MA

PRC

Drug use among inmates in state and federal prisons.

lifetime drug use; after controlling for age these differences were statistically significant for marijuana and heroin/opiates use. After adjusting for age, post-hoc comparisons of daily or almost daily drug use in the month prior to incarceration also indicated significantly lower use among MA compared to W for marijuana, crack/cocaine, and heroin/opiates, and significantly lower rates compared to B for marijuana and cocaine/crack. PRC, on the other hand, only differed from W in daily or almost daily drug use of heroin/opiate. However, PRC had higher rates of daily and almost daily drug use of heroin/opiates and stimulants compared to B. Among Latino groups, PRC had significantly higher rates of marijuana use, cocaine/crack use, and heroin/opiate use than MA when adjusting for age. Further analysis showed no significant race/ethnic differences regarding ever being in a substance abuse treatment program among those reporting daily and almost daily use of any drug. In the state and federal prisons sample, PRC had the highest rates compared to all other groups for lifetime crack/cocaine and heroin/opiate use after

Sexually transmitted infection

Tuberculosis

3,130

Received treatment for health problem after admissionh

Sexually transmitted infectionk

Hepatitis 38

99

403

4,663

Received medical services since admissiong

j

4,663

Received physical and mental health check at admissionf

Asthmai

4,663

784

Received mental health services in year prior to incarceration and/or admissione

HIVd

2,866

197 413

Hepatitis

c

3,130

Asthma

4,663

Total ( N )

43.8

41.4

40.1

72.8

76.4

86.6

12.5

1.3

3.3

4.3

60.4

9.4

67.3

Black (%)

6.7

32.6

29.8

71.1

67.2

88.3

23.6

0.5

1.2

13.6

37.4

8.6

69.8

White (%)

80.0

38.5

45.7

71.8

69.1

88.8

7.3

3.7

4.6

12.5

50.0

5.5

59.8

American (%)

Mexican

50.0

54.5

40.0

81.7

89.3

90.4

16.9

12.0

5.8

17.9

73.3

11.2

64.6

Other Caribbean (%)

Puerto Rican/

Physical and Mental Health Conditions Reported and Services Received among Inmates in Local Jails

Report at least one physical health condition since admissionb

Table 8.1

0.014

n.s.

n.s.

n.s.

0.000

n.s.

0.000

0.000

0.000

0.001

0.005

0.007

0.001

p value a

824

77 50.5

58.1 54.9

45.5 50.0

53.3 57.6

87.5

Among those tested for AIDS since admission.

n.s.

n.s.

Among those who reported a sexually transmitted infection since admission.

Among those who reported a mental health condition in the year prior to incarceration/admission.

m

Among those who tested positive for tuberculosis at admission.

l

k

Among those who reported hepatitis since admission.

j

Among those who reported any physical health condition since admission.

Among those who reported asthma since admission.

i

h

Includes report having a medical examination, a skin test for tuberculosis, or a blood test since the time of admission.

g

Includes getting checked for illness/injury/intoxication, being asked about medical history, being asked about thoughts of or attempts at suicide at time of admission.

f

Mental health conditions included taking medications, hospitalization, receiving counseling/therapy, or any other services for mental health problems in the year prior to incarceration/admission.

e

d

Among those tested for tuberculosis since admission.

c

Physical health conditions included cancer, paralysis, high blood pressure, stroke/brain injury, heart problems, kidney problems, arthritis/rheumatism, asthma, cirrhosis.

b

Percentages reflect rates unadjusted for age, but the p values reflect age-adjusted values.

a

n.s.  not significant

Note

Had mental health condition in last year and received services since admissionm

Received tuberculosis medicinel

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adjusting for age. Among Latino groups, post-hoc analyses showed higher rates of lifetime use of heroin/opiates among PRC compared to MA. Similarly, PRC had the highest rates of daily and almost daily use of crack/cocaine, these rates were significantly higher than W and MA. PRC had also the highest rates of daily and almost daily use of heroin/opiates, rates significantly higher than those for W, B, and MA. Among those reporting daily and almost daily use of any drug, PRC (74.1 percent) and MA (59.4 percent) compared to W (76.3 percent) and B (72.6 percent) reported ever being in a program for alcohol or drug treatment. After controlling for age, overall differences were significant at p  0.0001 level. MA were significantly less likely to have participated in a substance abuse treatment program compared to W and PRC. Physical and Mental Health Conditions

The physical and mental health conditions survey consisted of twenty-one questions on physical health conditions experienced since admission (e.g., cancer, paralysis, high blood pressure, etc.) in the SILJ. The physical health data from the SISFCF included two questions on injuries received since admission, one question concerning colds/viruses/flu since admission, plus seven blank items to report on any medical condition experienced since admission. There were also five items on mental health services received in the year prior to incarceration for the SILJ, as well as four items on lifetime mental health services received for the SISFCF. Tables 8.1 and 8.2 show data on physical and mental health conditions and use of services since admission among men in local jails and state and federal prisons, respectively. MA in local jails were less likely to report any medical problems or physical conditions since their admission even after controlling for age (see table 8.1). PRC had the highest rates of reporting asthma, hepatitis, sexually transmitted infections (STIs) and of being positive for TB and HIV. When compared to W, Latino groups reported higher rates of being positive for TB (for PRC and MA) and positive for HIV (for PRC and MA). PRC were more likely to report hepatitis than W and more likely to report an HIV-positive test than B. MA were less likely to report having received mental health services in the year prior to their incarceration. A similar pattern was shown among inmates in federal and state prisons (see table 8.2). MA had the lowest rates of reported medical problems or physical conditions but the highest rates of testing positive for TB. In local jails, PRC were more likely to test positive for HIV when compared to W and B and more likely to have a positive TB test than W. MA and PRC were less likely than W to report lifetime mental health services when controlling for age.

13,495

Received medical services since admissiong

361

1,575 69.1

88.3

85.5

98.0

88.0

20.3

1.8

12.6

47.8

Black (%)

Mexican

54.5

93.9

80.4

98.3

89.3

12.6

0.7

17.5

38.2

American (%)

Puerto Rican/

70.0

92.2

83.3

98.0

87.6

22.5

4.3

15.2

50.7

Other Caribbean (%)

n.s.

0.000

0.000

n.s.

0.032

0.000

0.000

0.000

0.000

p value a

Among those who reported any physical health condition since admission.

h

Includes report having a medical examination, a skin test for tuberculosis, or a blood test since the time of admission.

g

Includes getting checked for illness/injured/intoxication, being asked about medical history, being asked about thoughts of or attempts at suicide at time of admission.

f

Mental health conditions included taking medications, hospitalization, receiving counseling/therapy, or any other services for mental health problems in the year prior to incarceration/admission.

Among those tested for AIDS since admission.

d

e

67.4

82.1

87.2

98.4

89.7

34.8

0.7

8.0

53.7

White (%)

Physical health conditions included cancer, paralysis, high blood pressure, stroke/brain injury, heart problems, kidney problems, arthritis/rheumatism, asthma, cirrhosis.

Among those tested for tuberculosis since admission.

c

b

Percentages reflect rates unadjusted for age, but the p values reflect age-adjusted values.

a

n.s.  not significant

Note

Had mental health condition in last year and received services since admission

Received tuberculosis medicine

798

13,495

Received treatment for health problem after admissionh

13,495

Received physical and mental health check at admissionf

1,575

Tested positive for HIV since admissiond

Obtained mental health services in lifetimee

1,575

Tested positive for tuberculosis since admissionc

13,495

Total ( N )

Physical and Mental Health Conditions Reported and Services Received among Inmates in Federal and State Prisons

Reported at least one physical health condition since admissionb

Table 8.2

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Physical and Mental Health Services Received

The survey of physical and mental health services received consisted of an item assessing physical and mental health check-ups provided at the moment of admission (including three survey questions on whether or not the inmate was checked for illness/injuries/intoxication at admission, asked about medical history at admission, and asked about thoughts/attempts of suicide at admission). One item assessed medical services received since admission (including three survey questions about whether the following services were received since admission: a medical examination, a skin test for TB, and a blood test). There was also one item assessing medical attention received for those who reported a medical condition since admission; one item on receiving medicine to treat TB for those who reported a positive TB test since admission; and one item assessing mental health services received since admission for those who reported receiving any mental health services before admission. Among local jail inmates who reported a medical condition since admission, there were no significant race/ethnic differences in seeing a health care provider for their health-related problem (see table 8.1). On the other hand, racial/ethnic differences in seeing a health care provider were found among state and federal inmates with a health condition since admission. MA who reported a medical problem since admission were less likely than W to have seen a health care provider. Further, among inmates who reported a positive TB test since admission, MA and PRC compared to W were significantly more likely to receive medicine to treat it. Conclusions Latino Subgroup’s Differences

Previous studies on the health of prisoners have reported data on Latinos but have not examined Latino subgroups. Our review shows that Puerto Rican and Other Caribbean males held in local jails reported higher use rates of marijuana and heroin and other opiates than all other racial/ethnic groups, and the highest frequency of use for all drugs in the month prior to incarceration. Puerto Ricans and Other Caribbeans in state and federal prisons reported the highest use rates of crack cocaine and heroin and other opiates, as well as the highest frequency of use for all drugs, except marijuana, in the month prior to incarceration. A possible explanation for the finding that Mexican Americans have lower drug use is that one-third of the Latino prisoners nationally are immigrants, and it has been shown that foreign-born Latinos are far less likely to become drug addicts or deal drugs than are their U.S.-born counterparts, including Mexican Americans (Caetano 1990; de la Rosa, Khalsa, and Rouse

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1990). Place of birth was not available in the data sets used in our analyses; therefore, we were unable to explore the effects of this variable on drug use. Puerto Ricans and Other Caribbeans reported not only high drug use but also the highest rates of HIV seroprevalence in both local jails and state and federal prisons. This is especially worrisome considering the majority of state prison and city or county jail systems had voluntary or on-request HIV testing, a process that underestimates the true HIV seroprevalence in this sample, since it is expected that a portion of HIV-infected inmates probably refused voluntary testing. Similarly, the data presented here suffer from an underreporting of drug use, as has been previously stated in studies among the same population (Lu, Taylor, and Riley 2001). In addition, Puerto Ricans and Other Caribbeans in local jails also reported the highest rates of asthma, hepatitis, STIs, and TB. At the same time, they reported the highest rate of physical and mental health check-ups at admission and medical services received since admission. In terms of Mexican American male prisoners, inmates held in state and federal facilities reported the highest rate of TB since incarceration. Concomitantly, they also reported the highest rate of receipt of TB medicine during that same time frame. Mexican Americans in state and federal prisons reported fewer health problems at incarceration and thus also reported the lowest rates of receipt of mental health services and seeing a health care person since admission. This pattern of lower need and lower receipt of health services was also reported by Mexican Americans in local jails. They had the fewest medical problems since admission and the lowest rate of mental health services received prior to incarceration. Health Services Needs

Recent studies on incarcerated populations have found a high prevalence of health complications at admission, very high rates of unhealthy behavior preincarceration, and prior limited access to health care (Conklin, Lincoln, and Tuthill 2000); our analyses yielded similar findings, indicating serious public health problems for the inmates as well as for the communities they are returning to. Rates of both physical and mental health illness found in our analyses are similar to those reported by other studies also using national samples (National Commission on Correctional Health Care 2002a, 2002b; Mumola 1999). Our findings showed that although reporting the highest rates of drug use, Puerto Rican and Other Caribbean inmates held in local jails were less likely to receive substance abuse treatment. Whereas white inmates reported high rates of receiving alcohol and other drug treatment upon incarceration, barely more than half of those Puerto Ricans and Other Caribbeans who needed such treatment reported getting it. This finding highlights the need for an examination of

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the referral processes and utilization of substance abuse treatment in this population. If adequate substance abuse treatment is not provided upon admission, addicted Latino males may be at risk for medically unsupervised withdrawal while incarcerated, which could be highly deleterious to their health and increase their vulnerability to relapse (DeVries and Shippenberg 2002; Lingford-Hughes and Nutt 2003). These differing patterns of medical conditions among Latino subgroups also point to the need for data to be analyzed separately. Accurate analysis on the behaviors of the different subgroups will paint a truthful picture of treatment and prevention needs for soon-to-be-released Latino inmates and the different communities they are reentering. The disproportionate percentage of HIV seroprevalence among the Puerto Rican and Other Caribbean subgroup indicates a great need to address this public health problem. Studies suggest that the social structure and social context of disproportionate rates of low socioeconomic status and mass incarceration in minority communities are associated with higher rates of STI/HIV in these communities that is beyond that explained by individual behavior (Adimora et al. 2001, 2003, 2004, 2006a, 2006b; Adimora and Schoenbach 2002, 2005). Data from other studies suggest that higher rates of STI/HIV among incarcerated men and recent releases are attributable to greater risky-sex and substance-use behavior in this population (Adimora et al. 2003, 2004; Galea and Vlahov 2002; Seal et al. 2003). Research also indicates that such risky behavior is more likely to happen with female partners immediately following release from prison as a way to “prove that prison hasn’t taken away their manhood” (Seal et al. 2003, 134). An Opportunity for Public Health Prevention and Treatment

Lamentably, incarceration provides for many inmates their first and only source of health care (Glaser and Greifinger 1993; Weinbaum, Lyerla, and Margolis 2003), making effective prevention, treatment, and discharge planning programs indispensable. The period of incarceration offers a unique opportunity for Latino men to access HIV-prevention services and other medical services that they might otherwise find difficult to obtain. Studies of European prisons have proven the effectiveness of harm reduction approaches, such as the provision of condoms, clean needles, and syringes. Nonetheless, these approaches are absent from most U.S. correctional facilities (Haggerty 2000). Regrettably, studies have shown that a very small percentage of incarceration facilities (5 percent of local jails and 10 percent of federal and state prisons) provide comprehensive HIV/AIDS education and prevention programs (Hammett, Harmon, and Maruschak 1999), and that the state of prevention, screening, and treatment programs and discharge planning of prisoners

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with chronic diseases in correctional facilities is largely inadequate (NCCHC, 2002a; Hornung et al. 2002). Another important reason to address the health of minority incarcerated populations is the fact that ethnic minorities released from prison are more likely than whites to migrate to urban areas (Hartwell 2001), which are already burdened with disproportionately high rates of poor health, substandard housing, unemployment, and drug use. The large numbers of incarcerated and released individuals provide a great opportunity to institute health care and social services, both pre- and post-release. During incarceration, public health interventions should tackle the high prevalence of medical conditions and mental health diagnoses found among prisoners with culturally competent screening, assessment, and treatment programs in all criminal justice settings. Community Reentry Planning

Equally important is the need to dedicate resources to the process of discharge planning. Continuity of treatment after release should be planned with community agencies, linking correctional settings and community providers (including housing and employment authorities) so that released prisoners do not encounter an interruption in their services. Studies have shown that programs offering pre- and post-release services incorporating health care, substance abuse treatment, housing and employment, and mental health treatment are successful in reducing the detrimental effects of incarceration among returnees and their communities (Conklin, Lincoln, and Flanigan 1998; Freudenberg 2001; Hammett, Roberts, and Kennedy 2001; Richie, Freudenberg, and Page 2001; Travis, Solomon, and Waul 2001). Failure to provide strong links to community agencies upon release could result in nonadherence to treatment, leading in turn to possible development of drug-resistant viral strains (in the case of HIV and TB, for example), that could be transmitted to others in the community (Hammett, Roberts, and Kennedy 2001). Since a great majority of incarcerated men will be released back into society, prison health care and prevention programs would not only reduce rates of disease and transmission from inmate to inmate but also impact the transmission of communicable diseases in the community after release (Flanigan et al., 1999; Gaiter and Doll 1996; Glaser and Greifinger 1993; Mast et al. 1998; Skolnick 1998; Weinbaum et al. 2003; Willmott and van Olphen 2005). Addressing Contextual Factors to Improve the Health of Latino Inmates

Economic hardships are felt by individuals and their families upon incarceration and after release. Upon release into the community, prisoners are faced

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with difficulties integrating back into society since federal, state, and local laws may prohibit ex-convicts from receiving public housing benefits (Urban Institute 2004). Latino men reentering their communities are faced with a series of structural barriers—including poverty, stigma and discrimination, homelessness or inadequate housing, unemployment or unstable employment, limited education and educational opportunities, exposure to violence, and barriers to appropriate health and social services—which limit their opportunities for economic mobility. These hurdles impact adversely on the health and well-being of the offender, the family of the offender, and the community to which the offender returns, exacerbating existent racial/ethnic health disparities. Correctional health services present an opportunity to provide a holistic approach to mental and physical health and substance use treatment and prevention, as opposed to the independent provision of services that are usually provided in the community (Freudenberg 2001; Glaser and Greifinger 1993). However, despite the Supreme Court affirmation of inmates’ constitutional right to medical care (Estelle v. Gamble [429 U.S. 97, 104–105 (1976)]), inmates’ right to access to proper medical care seems to be restricted due to the security and coercive nature of the correctional system, inadequate medical resources allocated to inmates, and refusal of community providers to care for inmates (because they are perceived as dangerous, unclean, and a prisoner rather than a patient) (Glaser and Greifinger 1993). Interventions within the correctional health care system incorporating vocational training and health care services, as well as linkages with community agencies, are vital to promoting successful reentry into communities and reducing and preventing the spread of disease among populations. Effective health care in correctional facilities provides an opportunity, often the only one, to positively impact the quality of life of inmates, their families, and their communities. References Adimora, A. A., and V. J. Schoenbach. 2005. Social context, sexual networks, and racial disparities in rates of sexually transmitted infections. Journal of Infectious Diseases 191 (suppl 1): S115–122. ———. 2002. Contextual factors and the black-white disparity in heterosexual HIV transmission. Epidemiology 13 (6): 707–712. Adimora, A. A., V. J. Schoenbach, I. A. Doherty. 2006. HIV and African Americans in the southern United States: Sexual networks and social context. Sexually Transmitted Diseases 33 (7 suppl): S39–45. Adimora, A. A., V. J. Schoenbach, F. E. Martinson, T. Coyne-Beasley, I. Doherty, T. R. Stancil, and R. E. Fullilove. 2006. Heterosexually transmitted HIV infection among African Americans in North Carolina. Journal of Acquired Immunodeficiency Syndrome 41 (5): 616–23.

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Adimora, A. A., V. J. Schoenbach, F. Martinson, K. H. Donaldson, T. R. Stancil, and R. E. Fullilove. 2004. Concurrent sexual partnerships among African Americans in the rural south. Annals of Epidemiology 14 (3): 155–160. Adimora, A. A., V. J. Schoenbach, F. E. Martinson, K. H. Donaldson, R. E. Fullilove, and S. O. Aral. 2001. Social context of sexual relationships among rural African Americans. Sexually Transmitted Diseases 28 (2): 69–76. Adimora, A. A., V. J. Schoenbach, F. E. Martinson, K. H. Donaldson, T. R. Stancil, and R. E. Fullilove. 2003. Concurrent partnerships among rural African Americans with recently reported heterosexually transmitted HIV infection. Journal of Acquired Immunodeficiency Syndrome 34 (4): 423–429. Agency for Healthcare Research and Quality (AHRQ). 2005. National healthcare disparities report. AHRQ Publication No. 06–0017. http://www.ahrq.gov/qual/nhdr05/nhdr05.htm. American Public Health Association (APHA). 2004. Racial/Ethnic Disparities. Fact sheets. http://www.apha.org/nphw/facts/RaceEth-PHW04_Facts.pdf. Binswanger, I. A., M. C. White, E. J. Perez-Stable, J. Goldenson, and J. Tulsky. 2005. Cancer screening among jail inmates: Frequency, knowledge, and willingness. American Journal of Public Health 95 (10): 1781–1785. Bonczar, T. P. 2003. Prevalence of Imprisonment in the U.S. Population, 1974–2001. Bureau of Justice, Special Report, August, NCJ 197976. Caetano, R. 1990. Hispanic drinking in the US: Thinking in new directions. British Journal of Addiction 85: 1231–1236. Centers for Disease Control and Prevention (CDC). 2004. Health disparities experienced by Hispanics—United States. Morbidity and Mortality Weekly Report 53 (40): 935–937. Conklin, T. J., T. Lincoln, and T. P. Flanigan. 1998. A public health model to connect correctional health care with communities. American Journal of Public Health 88: 1249–1251. Conklin, T. J., T. Lincoln, and R. W. Tuthill. 2000. Self-reported health and prior health behaviors of newly admitted correctional inmates. American Journal of Public Health 90: 1939–1941. de la Rosa, M. R., J. H. Khalsa, B. A. Rouse. 1990. Hispanics and illicit drug use: A review of recent findings. International Journal of the Addictions 25: 665–691. DeVries, T., and T. Shippenberg. 2002. Neural systems underlying opiate addiction. Journal of Neuroscience 22 (9): 3321–3325. Ditton, P. 1999. Mental health and treatment of inmates and probationers. Bureau of Justice Statistics Special Report. http://www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf. Flanigan, T. P., J. D. Rich, and A. Spaulding. 1999. HIV care among incarcerated persons: A missed opportunity. AIDS 13: 2475–2476. Freudenberg, N. 2001. Jails, prisons, and the health of urban populations: A review of the impact of the correctional system on community health. Journal of Urban Health 78 (2): 215–235. Gaiter, J., and L. S. Doll. 1996. Editorial: Improving HIV/AIDS prevention in prisons is good public health policy. American Journal of Public Health 86: 1201–1203. Galea, S., and D. Vlahov. 2002. Social determinants and the health of drug users: Socioeconomic status, homelessness and incarceration. Public Health Reports 117: S135–S145. Ginzberg, E. 1991. Access to health care for Hispanics. Journal of the American Medical Association 265: 238–241. Glaser, J., and R. Greifinger. 1993. Correctional health care: A public health opportunity. Annals of Internal Medicine 118: 139–145.

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Golembesk, C., and R. Fullilove. 2005. Criminal (in)justice in the city and its associated health consequences. American Journal of Public Health 95 (10): 1701–1706. Haggerty, M. 2000. Incarcerated populations and HIV. Community Research Initiative on AIDS (CRIA). http://www.thebody.com/cria/summer00/prison.html. Hammett, T. M., P. M. Harmon, and L. M. Maruschak. 1999. 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities. Washington, DC: National Institute of Justice. Hammett, T. M., P. M. Harmon, and W. Rhodes. 2002. The burden of infectious disease among inmates of and releases from US correctional facilities, 1997. American Journal of Public Health 92 (11): 1789–1794. Hammett, T. M., C. Roberts, and S. Kennedy. 2001. Health-related issues in prisoner reentry. Crime and Delinquency 47: 390–409. Harrison, P. M., and A. J. Beck. 2003. Prisoners in 2003. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. http://www.ojp.usdoj.gov/bjs/abstract/p03.htm. ———. 2006a. Prisoners in 2005. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. http://www.ojp.usdoj.gov/bjs/pubalp2.htm#Prisoners. ———. 2006b. Prisoner and jail inmates at midyear 2005. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. http://www.ojp.usdoj.gov/bjs/ pubalp2.htm#Prisoners. Hartwell, S. 2001. An examination of racial differences among mentally ill offenders in Massachusetts. Psychiatric Services 52: 234–236. Hornung, C. A., B. J. Anno, R. B. Greinfinger, and S. Gadre. 2002. Health care for soonto-be-released inmates: A survey of state prison systems. In The health status of soonto-be-released inmates: A report to Congress, 2: 1–11. Chicago: National Commission on Correctional Health Care. Inciardi, J. A. 1996. The therapeutic community: An effective model for correctionsbased drug abuse treatment. In Drug treatment behind bars: Prison-based strategies for change, ed. K. E. Early, 65–74. Westport, CT: Praeger Press. Institute of Medicine (IOM). 2003. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press. Khan, A. J., E. P. Simard, W. A. Bower, H. L. Wurtzel, M. Khristova, K. D. Wagner, K. E. Arnold, O. V. Nainan, M. LaMarre, and B. Bell. 2004. Ongoing transmission of hepatitis B virus infection among inmates at a state correctional facility. American Journal of Public Health 95 (10): 1793–1999. Krebs, C., and M. Simmons. 2002. Intraprison HIV transmission: An assessment of whether it occurs, how it occurs, and who is at risk. AIDS Education and Prevention 14 (suppl B): 54. Lingford-Hughes, A., and D. Nutt. 2003. Neurobiology of addiction and implications for treatment. British Journal of Psychiatry 182: 97–100. Lu, N., B. Taylor, and K. Riley. 2001. The validity of adult arrestee self-reports of crack cocaine use. American Journal of Drugs and Alcohol Abuse 27 (3): 399–419. Macalino, G., D. Vlahov, S. Sanford-Colby, S. Patel, K. Sabin, C. Salas, and J. Rich. 2004. Prevalence and incidence of HIV, hepatitis B virus, and hepatitis C virus infections among males in Rhode Island prisons. American Journal of Public Health 94 (7): 1218–1223. Maruschak, L. 2005. HIV in Prisons, 2003. NCJ 210344. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. http://www.ojp.usdoj.gov/bjs/pub/pdf/hivp03.pdf. Mast, E. E., I. T. Williams, M. J. Alter, and H. S. Margolis. 1998. Hepatitis B vaccination of adolescent and adult high-risk groups in the United States. Vaccine 16 (suppl): S27–29. Mumola, C. 1999. Substance abuse treatment, state and federal prisoners. 1997. Bureau of Justice Statistics Special Report NCJ 172871. Washington, DC: U.S. Department of Justice.

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National Commission on Correctional Health Care (NCCHC). 2002a. The health status of soon-to-be-released inmates. Vol. 1 of A report to Congress. http://www.ncchc.org/ pubs/pubs_stbr.vol1.html. ———. 2002b. The health status of soon-to-be-released inmates. Vol. 2 of A report to Congress. http://www.ncchc.org/pubs/pubs_stbr.vol2.html Pepper, B., and J. Massaro. 1992. Trans-institutionalization: Substance abuse and mental illness in the criminal justice system. TIE Lines 9 (2): 1–4. Reindollar, R. W. 1999. Hepatitis C and the correctional population. American Journal of Medicine 107 (6B): 100S–103S. Richie, B., N. Freudenberg, and J. Page. 2001. Reintegrating women leaving jail into urban communities: A description of a model program. Journal of Urban Health 78: 290–303. Robins, L. N., and D. A. Regier. 1991. Psychiatric Disorders in America. New York: Free Press. Seal, D. W., A. D. Margolis, J. Sosman, D. Kacanek, and D. Binson. 2003. HIV and STD risk behavior among 18- to 25-year-old men released from U.S. prisons: Provider perspectives. AIDS and Behavior 7 (2): 131–141. Skolnick, A. 1998. Look behind bars for key to control of STDs. Journal of the American Medical Association 279: 97–98. Snider, D., and M. Hutton. 1989. Tuberculosis in correctional institutions. Journal of the American Medical Association 261: 436–437. Travis, J., A. L. Solomon, and M. Waul. 2001. From prison to home: The dimensions and consequences of prisoner reentry. Washington, DC: Urban Institute. http://www .urban.org/pdfs/from_prison_to_home.pdf. Urban Institute. 2004. Taking stock: Housing, homelessness and prisoner reentry: Final report. http://www.urban.org/UploadedPDF/411096_taking_stock.pdf. ———. 2002. The public health dimensions of prisoner reentry: Addressing the health needs and risks of returning prisoners and their families. Meeting Summary: The National Reentry Roundtable Meeting, December 11–12, Los Angeles. U.S. Census Bureau. 2008. National population estimates—Characteristics. http://www .census.gov/popest/national/asrh/. U.S. Department of Justice. 2004. Correctional populations: Number of persons under correctional supervision. Bureau of Justice Statistics. http://www.ojp.usdoj.gov/bjs/ glance/tables/corr2tab.htm. ———. 2002. Survey of inmates in local jails. Computer file. Bureau of Justice Statistics. Ann Arbor, MI: Inter-university Consortium for Political and Social Research, 2006. ———. 1997. Survey of inmates in state and federal correctional facilities. Computer file. Bureau of Justice Statistics and U.S. Dept. of Justice, Federal Bureau of Prisons. Compiled by U.S. Dept. of Commerce, Bureau of the Census. Ann Arbor, MI: Interuniversity Consortium for Political and Social Research, 2000. Wallace, S., J. Klein-Saffran, G. Gaes, and K. Moritsugu. 1991. Health status of federal inmates: A comparison of admission and release medical records. Journal of Jail and Prison Health 10: 133–151. Weinbaum, C., R. Lyerla, and H. Margolis. 2003. Prevention and control of infections with hepatitis viruses in correctional settings. Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. http://www.cdc.gov/mmwr/PDF/rr/ rr5201.pdf. Willmott, D., and J. van Olphen. 2005. Challenging the health impacts of incarceration: The role for community health workers. Californian Journal of Health Promotion 3 (2): 38–48.

Chapter 9

Sandra Echeverria and Ana Diez-Roux

Emergent Chronic Conditions

In the United States, heart disease, cancers, stroke, chronic lower respiratory disease, and diabetes account for more than two-thirds of all deaths in the nation and approximately 75 percent of the nation’s total health care expenditure (Centers for Disease Control and Prevention 2004). While chronic health conditions tend to affect all racial/ethnic groups, little work has been done to systematically assess differences in chronic disease patterns for the Latino population and Latino men more specifically. Moreover, little work exists documenting the emergence of chronic diseases that may disproportionately affect Latino men and how structural, social, and cultural factors may uniquely shape disease patterns for this population. This chapter describes the epidemiology of key chronic conditions among Latino men, with a special emphasis on disease patterns for emergent chronic diseases. The chapter focuses on diabetes, heart disease, and cancer (specifically stomach, liver, and gallbladder cancers) because of the burden of these conditions in the Latino community generally and Latino males more specifically. Notable differences by gender, race/ethnicity, age, and Latino subgroups are discussed, when data are available, for each of these health conditions. Rather than provide an extensive review of the major risk factors associated with diabetes, heart disease, and cancer (for which much work already exists), we present a conceptual model describing the ways in which specific structural and cultural factors may shape chronic disease outcomes among Latinos. Our goal is to stimulate new thinking on the health of Latino men and the need to incorporate these specific factors in future research, program, and policy initiatives. 158

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Data Sources

National and state data on the health of all Latinos and Latino subgroups remain limited, despite increasing efforts (and mandates) to include representative samples of the Latino population. For example, as of 2000 the National Health and Nutrition Examination Survey (NHANES), one of the most comprehensive national surveys that collects self-reported and medically confirmed health data, has included only a representative sample of Mexican Americans. Although people of Mexican origin represent 58.5 percent of the Latino population, (Guzman 2001) and thus routine monitoring of this population is crucial, this nonetheless means that national health data on other Latino subgroups remain unavailable. Data on growing groups such as people from the Dominican Republic or Central and South Americans will either be unavailable or limited to specific geographic areas and potentially nonrepresentative samples. Moreover, the limitation of NHANES Latino data to Mexican Americans, although understandable from the perspective of sample sizes needed for comparisons, may mean that researchers and public health officials will increasingly rely on these national figures to extrapolate to other Latino subgroups or to the Latino population in general, thereby potentially under- or overestimating the health status of Latinos. As evidence, in a diabetes fact sheet produced by the National Diabetes Information Clearinghouse (NDIC), figures on Mexican Americans were used to estimate diabetes prevalence for all Latinos (National Institute of Diabetes and Digestive and Kidney Diseases 2005). Further, as the 1982–1984 Hispanic Health and Nutrition Examination Survey (HHANES)—one of the last surveys to include a nationally representative sample of Mexicans, Puerto Ricans, and Cubans—demonstrated, health conditions can vary substantially across Latino subgroups (Flegal et al. 1991; Marks, Garcia, and Solis 1990; Pappas, Gergen, and Carroll 1990; Solis et al. 1990). For select health outcomes, for example, Puerto Ricans were found to have a less favorable disease profile than all other Latino racial/ethnic groups, while the health of Cubans tended to mirror that of nonLatino whites. Cancer data on Latinos are further plagued with issues of identification and classification of Latino ethnicity and the general limited coverage of Latino subgroups. The National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program is the nation’s most authoritative source of data on cancer incidence, survival, and mortality. Although SEER first began coding data on ethnicity in 1992 (O’Brien et al. 2003), much work remains to be done to ensure the accuracy of Latino cancer data. For example, it was only in 1993 that the majority of states included a specific item on Latino origin in death certificates, with most of this information still being provided by subjective assessments of

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hospital personnel on the racial/ethnic identity of the decedent (Hahn 1992). In one study that compared information recorded on death certificates to that selfreported by participants in the National Mortality Followback Survey, the authors found a 20 percent underestimate of Latino ethnicity on death certificates when compared to the survey data (Poe et al. 1993). Other studies have found undercounts ranging from a low of 2 percent (Rosenberg et al. 1999) to 10 percent (Sorlie, Rogot, and Johnson 1992) and as high as 14 percent (Kelly et al. 1996). In order to capture more data on Latinos, some registries apply methods of Latino classification based on Spanish surnames to augment data from medical records. However, even the more valid methods developed to date (Perkins 1993) may undercount Latinos without Spanish surnames or include those that do not necessarily identify as Latino (e.g., natives from Spain). Further, SEER data comprise approximately seventeen regions across the United States. These regions cover about 26 percent of the total U.S. population and represent 23 percent of the white population, 40 percent of Latinos, 23 percent of African Americans, 42 percent of American Indians and Alaska Natives, 53 percent of Asians, and 70 percent of Hawaiian/Pacific Islanders (National Cancer Institute 2005). Although Latinos are better represented in SEER data than other racial/ethnic groups (e.g., African Americans), there is nonetheless limited cancer data for Latino subgroups. In fact, the majority of Latinos captured in the SEER dataset are people of Mexican origin (Ramirez and Suarez 2001). The aggregate effect of misclassification in medical records, death certificate data, and the lack of agreement between racial/ethnic identity that is self-reported in population statistics (e.g., U.S. census) and vital statistics data is unknown. Consequently, some have questioned the accuracy of overall Latino cancer rates and any comparisons that can be made between Latinos and other racial/ethnic groups (Stewart et al. 1999). Another gap that must be noted is the limited data on the health of Latin American indigenous groups emigrating to the United States, as well as the lack of data on Latino migrant farmworkers. Select studies conducted among these populations (Bean, Browning, and Frisbie 1984; Deren et al. 2005; Foxman, Frerichs, and Becht 1984; Montenegro and Stephens 2006; Pellet 1994; Sundquist 1995) suggest that Latino health would appear much worse if these populations were captured in national data systems. In sum, the lack of consistent and reliable national data on Latinos remains a major obstacle for studying chronic disease patterns in the Latino community. This chapter presents the most current national data on chronic disease outcomes available for Latino men, but it is limited by the specific groups represented in national datasets (e.g., the Mexican American population in NHIS

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data and region-specific data included in SEER data). The Latino population represents people with diverse nationalities, ethnic and racial origins, and distinct social class and life experiences. Disease patterns in one group may not represent other groups. Thus, the interpretation of descriptions of Latino health must be made with these caveats in mind. A welcome sign of the importance of documenting Latino subgroup differences is the Hispanic Community Health Study funded in 2006 by the National Heart, Lung and Blood Institute of the National Institutes of Health. This study is a longitudinal, multisite cohort study comprised of Mexican, Puerto Rican, Cuban, and Central/South American Latino subgroups that promises to be one of the largest and most comprehensive studies assessing the presence and progression of health conditions in the Latino population. Diabetes National Trends

Data from the 2004 National Health Interview Survey (NHIS) indicated that 7 percent of the U.S. population (approximately 21 million individuals) eighteen years of age or older have been diagnosed with diabetes (Lethbridge-Cejku, Rose, and Vickerie 2006). Studies have shown that diabetes has been steadily increasing over the last few decades, with some estimates indicating a more than 60 percent national increase from 1990–2001 across all ages, levels of education and smoking, racial/ethnic groups, and both sexes (Mokdad et al. 2003). This increase in diabetes has been strongly associated with the rising trend in obesity and overweight of the U.S. population, including Latinos (Ford, Williamson, and Liu 1997; Mokdad et al. 2003; Resnick et al. 2000). Epidemiology among Latinos

A growing body of literature has documented that Latinos and African Americans have higher diabetes-related morbidity and mortality than other racial/ethnic groups (Flegal et al. 1991; Harris et al. 1998). While diabetes is the seventh leading cause of death in the U.S. general population (for both sexes and all ages), it is the fifth leading cause of death among the total Latino population (National Center for Health Statistics 2001). The most recently available data from the National Health Interview Survey (2004) (Lethbridge-Cejku, Rose, and Vickerie 2006) indicate that the age-adjusted self-reported prevalence of diagnosed diabetes among all Latinos was 10.4 percent (s.e.  0.54), compared to 6.1 percent (s.e.  0.17) among non-Latino whites. Data from the 2000–2001 NHANES, a nationally representative survey evaluating the presence of health conditions through self-report and medical/biological

14.5

Liver

0.8

10.9

8.9

206.8

1.4

4.9

5.1

145.8

2.7

5.8

8.7

30.3

4.5

9.3

0.5

6.50

5.2

282.9

0.8

7.0

9.1

57.4

166.3

72.5

8.9

13.5

8.3

2.7

6.8

Male

0.8

2.8

2.5

185.9

1.3

2.6

4.2

43.2

49.9

5.4

11.4

4.5

2.3

5.5

Female

228.2

–

–

–

–

–

–

6.2

2.5

6.1

Total

Non-Latino whites

0.5

7.2

5.9

286.6

0.8

7.9

10.1

58.5

171.5

73.3

12.5

7.6

Male

Sources: Lethbridge-Cejku, Rose, and Vickerie 2006; MMWR 2003; American Heart Association 2006; National Center for Health Statistics 2005; U.S. Cancer Statistics Working Group 2005; Hoyert et al. 2006.

0.8

3.0

3.0

190.3

1.3

2.8

4.8

44.2

47.7

10.9

6.6

Female

Total population

Prevalence expressed as a percent; incidence expressed as a rate per 100,000 population; mortality expressed as a rate per 100,000 population.

Note

Gallbladder cancer

Liver cancer

Stomach cancer

Diseases of the heart

Mortality Rates (age-adjusted)

1.4

14.8

Gallbladder

43.7

Stomach

141.0

21.6

4.3

5.6

45.5

9.3

9.2

Colorectal

Prostate

Lung

Cancers (incidence rate, age-adjusted)

Coronary

All types (age-adjusted)

Heart disease (prevalence)

6.7

10.4 2.4

10.4

Total

Glucose intolerance

10.3

Female

Undiagnosed

Diagnosed

Male

All Latinos

Select Chronic Conditions among Latinos, Non-Latino Whites, and the Total Population

Diabetes (prevalence)

Table 9.1

232.3

–

–

–

–

–

–

6.9

11.6

5.7

2.6

7.1

Total

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exams, also found higher prevalence of diabetes in Latino subgroups. Specifically, Latinos of Mexican origin were almost twice as likely as non-Latino whites to have been diagnosed with diabetes (age-adjusted prevalence of 9.6 percent; 95 percent CI  8.2–11.1 vs. 4.8 percent; 95 percent CI  3.7–5.9, respectively) (MMWR 2003). Overall, there are no differences in the distribution of diagnosed diabetes between Latino men and Latinas. In both the 2004 NHIS and 2000–2001 NHANES, Latino men and women had a similar prevalence of diagnosed diabetes of approximately 10 percent. However, Latino men were 50 percent more likely to have been diagnosed with diabetes than non-Latino white men (see table 9.1). Latino men are also more likely to die from diabetes than Latinas and non-Latino white men. According to U.S. vital statistics, the age-adjusted death rate for Latino men in 2002 was 38.1 (per 100,000 U.S. standard population for the year 2000) compared to 33.6 per 100,000 for Latinas (National Center for Health Statistics 1999–2002). The age-adjusted diabetes death rate for non-Latino white men was 25.9 per 100,000. Most of the data on the epidemiology of diabetes among distinct Latino subgroups comes from HHANES (Flegal et al. 1991) conducted between 1982–1984. The HHANES was modeled after the NHANES and thus collected data on both self-reported and medically confirmed health conditions. The survey included a representative sample of the largest Latino subgroups living in the United States (i.e., Cubans, Mexican Americans, and Puerto Ricans). HHANES results indicated that the prevalence of diabetes among Cuban Americans was similar to that of non-Latino whites but was nearly twice as high in Mexican Americans and Puerto Ricans. While the prevalence of undiagnosed diabetes was comparable across the three Latinos subgroups, it was higher than in non-Latino whites. Although national data on growing Latino populations such as Central and South Americans and persons originating from the Dominican Republic remain unavailable, surveys have been conducted in regions of the country known to have diverse Latino subgroups. For example, one report examined results from the Behavioral Risk Factor Surveillance System (BRFSS) for six geographic areas of the United States (California, Florida, Illinois, New York/New Jersey, Texas, and Puerto Rico) (MMWR, 2004). The BRFSS is a state-based household telephone survey of adults eighteen years of age or older, where participants selfreport on a wide range of health conditions, including diabetes. The report combined data for the period 1998–2002 and found that the age-adjusted prevalence of diagnosed diabetes was nearly twice as high among Latinos as among non-Latino whites (9.8 percent versus 5.0 percent). Region-specific results

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showed that the age-adjusted prevalence of diabetes was highest among Latinos living in California (10.9 percent), followed by those surveyed in Texas and Illinois (10.5 percent), Puerto Rico (10.0 percent), New York/New Jersey (8.0 percent), and Florida (7.2 percent). The implication of these results is that the distinct Latino subgroups living in each region of the country account for the observed differences in diabetes prevalence (e.g., Mexican Americans in California and Puerto Ricans in the New York/New Jersey area). However, since data on Latino ethnicity were not collected, the study only indirectly suggests possible differences in diabetes prevalence by Latino subgroup membership. Further limitations of this survey are that only Latinos with telephones were surveyed (thereby potentially underestimating prevalence for poorer Latinos with low or no telephone coverage) and undiagnosed diabetes was not evaluated. Another study using the sampling procedures of the BRFSS (including the same survey questions) found a slightly higher prevalence of diagnosed diabetes (11.3 percent) among New York City Puerto Ricans compared to the native Puerto Rican population (9.6 percent) (MMWR 1999; Perez-Cardona and Perez-Perdomo 2001). According to the authors, the more salient feature of this survey was that it demonstrated that obtaining data at the local level and for specific racial/ethnic populations was not only feasible but also necessary to better understand the distribution of the growing diabetes epidemic in specific population groups. Heart Disease National Trends

An estimated 71 million individuals suffer from cardiovascular disease (CVD) in the United States (American Heart Association 2006). In 2002, an estimated 1.4 million individuals died from cardiovascular-related diseases, claiming about as many lives per year as the next five leading causes of death combined. Of all of the CVD-related conditions, coronary heart disease (CHD) is the leading cause of cardiovascular death in the United States for all racial/ethnic groups combined and for both men and women (Centers for Disease Control and Prevention 2004; National Center for Health Statistics 1999–2002; National Center for Health Statistics 2005), and is the focus of this review. NHIS data for 2003 indicated that the prevalence of coronary heart disease among Latino (largely Mexican American) males was lower (5.6 percent) than among white males (8.9 percent). Latina females had a CHD prevalence of 4.3 percent compared to a prevalence of 5.4 percent for non-Latina whites. Mortality due to diseases of the heart in 2003 was also lower among Latino males, with an age-adjusted death rate of 206.8 per 100,000 persons compared to an age-adjusted

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death rate of 282.9 for white males. Women of all racial/ethnic backgrounds have consistently been found to have lower rates of coronary heart disease rates when compared to men. Latinas had an age-adjusted death rate of 145.8 for diseases of the heart, compared to 185.9 for non-Latina white women. The Latino Heart Disease Paradox

The epidemiology of heart disease among Latinos has received particular attention in the literature because of the ongoing debate over whether Latinos truly have a lower morbidity and mortality of cardiovascular diseases, despite being poorer and having numerous CVD-related risk factors. Some have termed this a Latino health paradox (Markides and Coreil 1986). In the late 1980s, several studies using vital statistics registries linked to national survey data showed that Latinos were approximately 30 percent less likely to die from heart disease than their white counterparts (Karter et al. 1998; Liao et al. 1997; Mitchell et al. 1991; Sorlie et al. 1993; Stern et al. 1987). However, a small number of studies failed to detect this “protective effect” and found a similar or higher CVD-related mortality in Latinos compared to whites (Espino, Parra, and Kriehbiel 1994; Kattapong and Becker 1993). Four general hypotheses have been proposed to account for this Latino health paradox (Palloni and Arias 2004). The data artifact hypothesis suggests that misclassification of Latino ethnicity and information on cause of death as recorded in death certificates (known to misclassify cause of death more often for Latino individuals) could result in underestimates of select causes of deaths in Latinos (Becker et al. 1990). However, this would not explain the lower total mortality rates observed among Latinos. Additionally, while substantial problems exist with vital registry data for minority groups, death counts for Latinos have actually improved in the last few years. In a recent study (Smith and Bradshaw 2006), the authors concluded that there is no “Latino paradox” since the change in Latino deaths for those aged sixty-five or older was only half as great as the change in population size, thereby suggesting a relatively large omission of deaths due to the change in coding of Latino ethnicity from Spanish surname to Latino-origin questions. The healthy migrant hypothesis suggests that Latinos who emigrate to the United States are a healthier and more resilient group of individuals than those who do not emigrate (Rosenwaike 1987). However, Abraido-Lanza et al. (1999) used national survey samples of Mexican American, Puerto Rican, and Cuban participants linked to the National Death Index and showed that for each ethnic group U.S.-born Latinos (i.e., nonimmigrants) had a lower overall mortality than

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U.S.-born whites. In one of the more comprehensive assessments of the Latino health paradox, Palloni and Arias (2004) assumed that if migrants were generally healthier than their U.S.-born counterparts, then this health selection should attenuate over time as immigrants adopt a less favorable health profile. The authors found no convergence of mortality patterns between foreign- and U.S.-born Latinos based on length of stay in the United States. The salmon bias hypothesis posits that Latino immigrants may be more likely to return to their home countries as they age and/or become very ill and are thus counted in population estimates (i.e., denominators) but not in mortality data (i.e., numerators). Abraido-Lanza et al. (1999) also examined this hypothesis and demonstrated that Puerto Ricans and Cubans had lower overall mortality than their white counterparts, despite the fact that U.S.-born and island Puerto Ricans are counted in vital registry data and Cubans are not readily able to return to their home countries. Lastly, culturally defined behaviors and strong social ties and support systems have also been proposed as potential mechanisms explaining the Latino health paradox. While large-scale studies explicitly testing these factors are limited, some studies have shown that measures of social integration such as marital status and type of community of residence do not explain the apparent health advantage of Latinos (Abraido-Lanza et al. 1999; Palloni and Arias 2004). Cohort studies specifically designed to assess cardiovascular disease among Latinos add more complexity to this debate. For example, the Corpus Christi Project (Texas) reported higher or similar age-adjusted rates of hospitalization and death after hospitalization for acute myocardial infarction (Goff et al. 1993; Nichaman et al. 1993), despite relying on U.S. census population data to establish denominators and information on ethnicity as reported in death certificates when determining CHD mortality rates (Pandey et al. 2001). Findings from the San Antonio Heart Study have generally shown that Mexican American Latinos have a higher rate of cardiovascular disease and mortality than non-Latino whites. However, differences in risks between Mexican Americans and whites often were not statistically significant (Hunt et al. 2002; Stern and Wei 1999) or were only statistically significant among the diabetic population (Hunt et al. 2003). The San Luis Valley Diabetes Study (Swenson et al. 2002), on the other hand, supported earlier findings indicating a general pattern of lower CHD mortality among Latinos. To address the problem of misclassification of cause of death, the study assessed cause of death with medical chart reviewers blinded to the ethnicity of the decedent. The authors reported that among individuals with Type II diabetes (the only statistically significant findings), the hazard

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ratio of CHD mortality when comparing Latinos (men and women combined) to non-Latino whites was 0.44 (95 percent CI  0.26, 0.74), after adjusting for conventional and diabetes-related risk factors. The authors speculated that this decreased mortality risk may be due to competing causes of death, such as cancers and alcohol-related causes, which were more common among diabetic Latinos. The Multiple Risk Factor Intervention Trial (MRFIT) (Thomas et al. 2005) was initiated between 1973–1975 and included a nonprobabilistic sample of 5,846 Mexican, Cuban, and Puerto Rican men and 300,647 non-Latino white men recruited across fourteen U.S. states. Vital status was ascertained through the Social Security Death Index and the National Death Index. Results indicated a significantly lower twenty-five-year risk of mortality from CVD (HR  0.78, CI  0.70,0.86) and CHD (HR  0.69, CI  0.61,0.78) among Latinos when compared to non-Latino white men, after adjusting for age, CVD-related risk factors, and area-level income. Latino men, however, experienced higher mortality for stomach and liver cancers. The authors suggest that the decreased CVD risk may be due to a healthy migrant effect among the largely foreign-born sample, and that depending on the outcome being investigated Latino cultural or social exposures may confer either a protective or health-damaging effect. Cancers Common Forms among Latino Men

There are three forms of cancers commonly diagnosed in Latino men and all men generally. These include prostate, lung, and colorectal cancer. Among Latino men, it is estimated that prostate cancer accounts for approximately 34 percent of diagnosed cancer cases, followed by colorectal cancer (12 percent), and lung and bronchus cancer (10 percent) (Diaz 2006). For these common cancer sites, incidence and mortality rates are lower in Latino men than non-Latino white men. In 2002, the age-adjusted incidence rate (IR) for prostate cancer was estimated at 141.0 per 100,000 persons for Latino men and 166.3 per 100,000 persons for white men. For lung cancer, the IR was estimated at 45.5 per 100,000 persons for Latino men and 72.5 per 100,000 persons for white men. Latino men had an incidence rate of 43.7 per 100,000 persons for colorectal cancer, while the IR among white men was 57.4 per 100,000 persons (National Center for Health Statistics 2005). Mortality from these common cancers was also lower among Latino men when compared to non-Latino white men. For example, Latino men were approximately 30 percent, 50 percent, and 40 percent less likely to die from prostate, lung and colorectal cancer, respectively, than nonLatino white men (O’Brien et al. 2003).

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In contrast to common cancer sites, the incidence and mortality rate for cancers of the stomach, liver, and gallbladder are much higher in Latino men than in their white counterparts. These disparities have received little attention in cancer research and are important to review, as they represent a growing source of morbidity and mortality among Latino men. In the early part of the twentieth century, stomach (gastric) cancer was the single leading cause of cancer death in the United States and in many industrialized nations worldwide (Lynch and Smith 2005). Stomach cancer has significantly decreased in recent years for all population groups in the United States, but Latinos continue to experience one of the highest incidence and mortality rates of stomach cancer. Among Latino men, the age-adjusted stomach cancer incidence rate is 60 percent higher than among non-Latino white males. Mortality from stomach cancer is also substantially higher. The age-adjusted stomach cancer death rate for Latino males was 8.9 per 100,000 persons in 2002, compared to 5.2 per 100,000 for non-Latino white males. Although Latinas have higher incidence and mortality from stomach cancer when compared to non-Latina white females, incidence and mortality rates are 70 percent greater among Latino men when compared to Latinas. Liver cancer is one of the fastest growing cancers in the United States and has been consistently increasing among Latinos over the past decade (Howe et al. 2006). Among all racial and ethnic groups, Latinos have the second highest incidence and mortality rates of liver cancer, second only to Asian Pacific Islanders (Howe et al. 2006). When compared to non-Latino white males, Latino males are more than twice as likely to develop and die from liver cancer. A similar pattern of increased incidence and mortality rates is observed when comparing Latino males to Latina females (this excess male-to-female risk is observed among whites as well). Specifically, the incidence rate for liver cancer is approximately 2.5 times higher for Latino males when compared to Latina females, and Latino men have a twofold increased risk of dying from liver cancer compared to Latinas. Gallbladder cancer is a relatively rare cancer in the United States, with a death rate close to 1 per 100,000 persons recorded in 2002 (U.S. Cancer Statistics Working Group 2005). However, Latinos are disproportionately affected by this chronic disease. Compared to non-Latino white males, Latino males have a 75 percent higher gallbladder cancer incidence. Latino males are also 60 percent more likely to die from gallbladder cancer than their non-Latino white counterparts. The incidence and mortality pattern, however, is even less favorable for Latinas. Latinas are almost twice as likely to die from gallbladder cancer when compared to Latino males, and have an increased incidence rate of 70 percent when compared to Latino males.

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Incidence and mortality data by Latino subgroup for stomach, liver, and gallbladder cancer are not available. Possible differences by subgroups have been indirectly assessed through geographic or regional comparisons, implying that any observed difference is due to the majority Latino group residing in a given area. For example, using SEER data Ramirez and Suarez (2001) showed substantial geographic variation in stomach, liver, and gallbladder cancer incidence and mortality (among other cancers) among Latinos. Liver cancer showed the most pronounced variation across regions. For example, the incidence of liver cancer among Latino males ranged from 7.4 (per 100,000 persons) for those living in California, 9.4 per 100,000 persons for New York City residents, and 12.6 per 100,000 persons for Latino men residing in Texas. Additionally, there was substantial variation within each region when Latino men were compared to non-Latino white men. Incidence rate ratios (Latino men vs. non-Latino white men) ranged from 1.7 in 100,000 to 2.8 in 100,000. More recent SEER data shows similar variability in cancer incidence by region (U.S. Cancer Statistics Working Group 2005). Again, the extent to which this variability represents actual subgroup differences remains speculative, as Latino subgroup ethnicity are not collected in SEER data, and thus each region is likely to include a mix of different Latino populations. Bridging Structural and Cultural Factors

The dominant paradigm in chronic disease epidemiology has focused on individual-level risk factors for disease, often isolated from their structural and contextual determinants. We propose a conceptual model (see fig. 9.1) that links structural conditions and cultural factors to better understand chronic disease outcomes among Latino men (and Latinos generally). The model is influenced by theories and frameworks rooted in social epidemiology and population health (Diez-Roux 1998; Diez-Roux and Nieto 1997; Frohlich et al. 2004; Krieger 1994, 2001; Link and Phelan 1995), life course perspectives (Ben-Shlomo and Kuh 2002; Lynch and Smith 2005), and Latino health research (Abraido-Lanza et al. 2006; Portes and Zhou 1993; Rogler 1994). Structural conditions are generally defined as the political, economic, institutional, and community-based forces that provide people with life opportunities. These broader structures create a hierarchy of opportunities and set the context in which people relate to one another and can express their desires and abilities (Stronks et al. 1996). The importance of considering the structural conditions under which Latino men live, and ultimately express health, is crucial, as Latinos are disproportionately affected by poverty, anti-immigrant legislation, hazardous or insecure employment conditions, and tend to emigrate from and live in disadvantaged communities.

Figure 9.1

1. Acculturation 2. Values and norms 3. Gender roles

Latino cultural factors

1. Social class 2. Employment conditions 3. Neighborhood/community context 4. Immigration background 5. Health insurance and access

Structural conditions

- Biologic mechanisms

- Psychosocial determinants

- Health behaviors

Structural and cultural factors related to chronic disease among Latino men.

Old age

Adulthood

Childhood

Birth

Proximate determinants

Chronic diseases among Latino men

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Cultural factors relate to the values, norms, and behaviors that are unique to Latino communities. We review the strengths and limitations of two commonly studied Latino cultural domains: acculturation and male gender norms. More important, in our conceptual model we view structural and cultural factors as tightly interrelated and interdependent. As Abraido-Lanza et al. (2006) have eloquently argued, “to understand Latino realities in the United States, it is critical to describe the context in which ongoing cultural negotiations take place and the dynamics that reproduce and reconfigure ‘Latino culture’ according to the equally complex American settings in which immigrants and other people of color find themselves.” The conceptual model we propose also considers the effect of these fundamental conditions (i.e., structural and cultural factors) across the lifespan of individuals and lead to more proximate determinants of disease. The key areas of the model are discussed below. Structural Conditions

As this book highlights, the relation between structural conditions and the health of Latinos remains an important area of inquiry. In our model, we consider five structural factors potentially influencing health: social class or socioeconomic position; employment conditions; neighborhood or community context; immigration history, immigration status, and the social context of the country of origin; and health insurance and health care access. These structural conditions operate at multiple levels of organization, ranging from individual to area-level, and national contexts to highlight the importance of placing individual risk factors within the broader social context in which Latino men live. Social class has been repeatedly shown to be a powerful determinant of chronic diseases (including cardiovascular disease and cancer) in multiple populations (Adler et al. 1994; Williams and Collins 1995). However, very few studies have examined the relation of social class or socioeconomic position to chronic diseases in Latino men. On average, socioeconomic indicators for U.S. Latinos are similar to those for African Americans but significantly worse than those observed for whites. Socioeconomic position could therefore contribute to differences between Latinos and whites in some chronic health conditions and could also explain variation between Latinos. While African American men have generally born the burden of increased mortality and morbidity from occupation-related exposures in construction, agriculture, and traffic-related occupations, Latino men are emerging as the group with the highest unintentional fatal occupational injury rate in the country (Richardson et al. 2004; U.S. Department of Labor 2003). The immigrant status of many Latino men increases the likelihood that they are

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employed in jobs that not only expose them to physical and chemical hazards (likely to increase cancer risk), but which also have psychosocial characteristics such as low support and control over the work process coupled with high demands, placing them at greater risk for cardiovascular disease. Associations between employment conditions and cardiovascular disease, cancers, and diabetes among Latino men have been infrequently examined (Arcury et al. 2006; Pransky, Robertson, and Moon 2002; Rothlein et al. 2006). The social context in which individuals live is receiving increasing attention in the literature. Specifically, recent work has highlighted the role of neighborhood factors in health (Cubbin, Hadden, and Winkleby 2001; Diez-Roux 2001, 2003; Eschbach, Mahnken, and Goodwin 2005; Jenny, Schoendorf, and Parker 2001). U.S. Latinos live in many different types of communities, and neighborhood characteristics may explain important variations in health within the Latino population as well as differences between Latino subgroups. For example, one recent study (Eschbach, Mahnken, and Goodwin 2005) found that the incidence of several cancers among Latinos increased as the percent of Latinos living in the census tract decreased. The study of neighborhood characteristics may also contribute to our understanding of the Latino health paradox. Predominantly immigrant neighborhoods may have some attributes that are health protective despite their relative socioeconomic disadvantage. These attributes may be related to cultural norms and neighborhood resources such as density of street life, walkability, or social connections. Thus, the health protection experienced by some Latinos may be related to health-enhancing features of the areas where they currently live, or the places from which they emigrated. In contrast, other features of predominantly immigrant neighborhoods, such as proximity to sources of environmental pollution or quality of housing, may be health damaging. Immigration history, immigration status, and characteristics of the country of origin may also affect the health of Latinos, specifically chronic diseases in Latino men, through multiple interrelated pathways. Immigration history and immigration status, for example, may structure employment opportunities and labor conditions among Latinos and consequently affect income and educational opportunities as well as health insurance status. Immigration history may also affect access to services (such as social services) as well as the ability and desire to live in certain communities. Immigration history is also related to the process of acculturation and its many health consequences (discussed below). Although infrequently studied, social characteristics of the country of origin are also likely to be related to the health of Latinos. Social characteristics of the country of origin may have shaped reasons for immigration and may also

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affect the type, quality, and frequency of connections Latinos maintain with their native country, which consequently may have implications for health. Latinos have been consistently shown to have lower levels of health insurance coverage than other racial/ethnic groups residing in the United States (Carillo et al. 2001; American College of Physicians 2000; Right to Equal Treatment 2003). This is especially true for Latino immigrants, noncitizens, and the undocumented (Carrasquillo, Lantigua, and Shea 2000). Lack of health insurance has obvious implications for access to health care. However, access to health care is also affected by other factors, including the way in which the health system is structured and organized, the availability of Spanish-speaking providers, and location and hours of service, all of which may influence access to care even among those with health insurance. For Latino men, lack of health insurance and access to care may hamper early detection and treatment of cancer as well as the early detection and treatment of important risks factors for cardiovascular disease (Diaz 2006; Howe et al. 2006; Pollack et al. 2006). Lack of health insurance and access to care also has important implications for the treatment of chronic diseases once they are diagnosed, and for quality of life and survival in persons with chronic diseases. Cultural Factors

A second component of our conceptual model addresses cultural dimensions potentially related to health among Latinos. The most commonly studied Latino cultural factors include the general concept of “acculturation” and Latinospecific concepts of “familialismo,” “personalismo,” “respeto,” “marianismo,” and “machismo” (Cuellar and Arnold 1995). We focus on acculturation and machismo in this review. Acculturation is generally defined as a process in which individuals from one culture acquire characteristics of the lifestyle of another culture (Morales et al. 2002). While acculturation has been central in understanding health variations within the Latino community, there is great variability among U.S. Latinos in the degree to which they have adopted the cultural (and lifestyle) norms prevalent in the majority of the U.S. population and how this affects health (Dixon, Sundquist, and Winkleby 2000; Gordon-Larsen et al. 2003; Jenny, Schoendorf, and Parker 2001; Lara et al. 2005; Neuhouser et al. 2004; Popkin and Udry 1998; Sundquist and Winkleby 1999). Debate still exists regarding the extent to which diet and some behaviors (such as alcohol intake and physical activity) are clearly associated with acculturation (Abraido-Lanza, Chao, and Gates 2005; Cantero et al. 1999; Crespo et al. 2001; Morales et al. 2002). There is also increasing evidence that patterns of health care use differ by acculturation

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status, with less acculturated individuals less likely to use preventive health services such as cancer screening (Solis et al. 1990). Thus, the effects of acculturation on health may be more complex than it first appears. While male gender norms obviously influence patterns of relation between men and women and may lead to gender differences in health, there is a need to move beyond a purely culturalist interpretation of the role of machismo in Latino health (Torres 1998). For example, a more nuanced understanding of male gender roles and its effect on health is likely to emerge when it is related to structural conditions such as level of education and employment opportunities available to Latino men. Moreover, the misperception of machismo as a purely Latino male phenomenon can neglect patterns of oppression and discrimination faced by women across all racial and ethnic groups and around the globe. Life Course Perspective

Our model incorporates a life course perspective in which structural and cultural factors shape chronic disease outcomes at each stage of development in a person’s life. A life course perspective posits that adult health can be a result of cumulative effects of unhealthy exposures across a lifespan, the early development and subsequent tracking of health-related behaviors, or the result of exposures at critical periods during development (Ben-Shlomo and Kuh 2002). For example, some research suggests that the higher incidence and mortality from stomach cancer among Latino men is likely due to early life exposures to Helicobacter pylori in countries with a high prevalence of the virus (Hunt 2004; Megraud and Lehours 2004; Sugiyama 2004). Incorporating a life course perspective in the patterning of disease in the Latino population may help us not only explain racial/ethnic differences but also understand the etiology of chronic diseases more generally. In sum, our proposed conceptual model suggests the complex interconnection between structural conditions and cultural factors and the specific pathways that may lead to chronic disease outcomes among Latinos. However, we do not suggest that research projects incorporate every component of the model in the design of any given study. Instead, we hope this framework challenges researchers to consider these issues as they specify research questions, and at a minimum that they incorporate these ideas in their interpretation of research findings. Latino health research has been stymied by an either/or approach to understanding how structural factors and culture operate to produce disease. The field would benefit greatly from recognizing the interconnection of these dimensions and the multiple pathways through which they may operate over the life course to affect chronic diseases in adulthood.

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Conclusion

Latino men face a substantial burden of major chronic diseases that has received little attention in public health to date. Research on the causes of this elevated risk has largely focused on individual-level or biologic determinants of chronic disease outcomes. We argue that a more comprehensive and public health-relevant understanding of the causes of chronic disease in Latino men will emerge from a consideration of causal models that incorporate structural and cultural determinants operating over the life course. The reversal of the generally higher incidence and mortality rates for diabetes and select cancers, and the controversy surrounding heart disease, will need to incorporate research, programmatic, and policy initiatives that explicitly address how current and past structural and cultural factors have shaped Latino men’s health. Thus, to increase the accuracy and health policy relevance of future research, we propose the following recommendations. Research on the health of Latinos requires the systematic collection of reliable data at the local, state, and national level. This will require that information recorded on death certificates, for example, follow a standardized procedure for collecting data on Latino ethnicity. Similarly, cancer registries must enhance their collection of data on Latinos, including expanding the coverage and quality of the state cancer registries, having all cancer cases report both their racial and ethnic identity, introducing social and demographic variables in the registry (e.g., measures of socioeconomic position), and disseminating cancer reports by Latino subgroups. There is an urgent need to collect data on the distinct Latino subgroups residing in the United States. To this end, national surveys (e.g., NHIS) should periodically purposely sample different Latino subgroups and ask all respondents included in the survey to report their specific Latino ethnicity, Latino generation (e.g., first, second, or third generation), place of birth, and length of residency in the United States. Acculturation measures must include more specific measures of the norms, values, beliefs, and practices that are postulated to influence health. This will also require considering the extent to which Latinos adopt or incorporate into U.S. culture and the specific cultural group (e.g., white or African American) with which this dynamic interaction occurs. More research is needed on the effect of structural, contextual, and life course measures to explain the health of Latino men. As an example, the childhood social class of Latino males may explain the increased prevalence of certain chronic health conditions (e.g., cancers) in adult life. Future studies should consider how individual-level and contextual structural conditions shape Latino men’s health over the life course.

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Chapter 10

Antonio Polo and Margarita Alegría

Psychiatric Disorders and Mental Health Service Use among Latino Men in the United States

There is limited research about the effects of demographic, especially structural factors, on the physical and mental health of the 41 million Latinos in the United States (U.S. Department of Health and Human Services 2001). Generally mental health problems in the United States are less frequent in higher socioeconomic status subgroups. Because Latinos are disproportionately low income, especially immigrants, they offer an important opportunity to determine whether these structural determinants operate similarly for mental health problems in Latino populations. Few studies have examined the mental health profile and service use patterns of men across racial/ethnic groups, and particularly those of Latino men as compared to non-Latino white men (Connell 1993; U.S. Department of Health and Human Services 2001). This chapter provides an overview of the mental health of U.S. Latino men surveyed in the National Latino and Asian American Study (NLAAS) (Alegría and Takeuchi et al. 2004) and contrasts them with non-Latino white men surveyed in the National Comorbidity Survey-Replication (NCS-R) (Kessler and Merikangas 2004). The NLAAS is a national psychiatric epidemiologic study estimating the prevalence of psychiatric disorders and mental health service usage in a representative sample of Asians and Latinos. The NCS-R (Kessler and Merikangas 2004) uses overlapping measures and methodology to estimate psychiatric disorders and mental health service use in a national sample of the total U.S. population. Using data from these two parallel studies, Latino men are compared to non-Latino white men across sociodemographic, sociostructural, and clinical characteristics, including lifetime and past-year rates of depressive, anxiety, and substance use disorders. 183

184

Antonio Polo and Margarita Alegría

Method

The NCS-R was administered from February 2001 through April 2003 to Englishspeaking, noninstitutionalized adults ages eighteen and older living in civilian housing in the coterminous United States (70.9 percent response rate) (Kessler and Merikangas 2004). The NLAAS Latino data were collected between May 2002 and November 2003 from English- and Spanish-speaking residents (ages eighteen and older) in the noninstitutionalized population of the coterminous United States (75.5 percent response rate) (Heeringa et al. 2004). The 2,554 Latinos (1,127 men) who participated in NLAAS were comprised of individuals from four Latino subgroups (Mexican, Puerto Rican, Cuban, and Other Latinos). Both samples were developed using an integrated methodology as part of the NIMH Collaborative Psychiatric Epidemiology Surveys (CPES), allowing the analysis of pooled data sets (Hartley 1962, 1974; Heeringa 2007). Design and methodological information regarding the combined NLAAS/NCS-R dataset can be found on the CPES Web site (Heeringa 2007). Results Comparative Sociodemographic and Sociostructural Characteristics of Men

Sociodemographic, sociostructural, and contextual characteristics influence men’s intra- and interpersonal behavior and are salient in understanding men’s interpretations of and reactions to signs and symptoms of mental illness, including whether they attribute clinical significance to their mental health problems (Alegría et al. 2001) and whether they seek mental health care. Descriptive statistics from the combined NLAAS and NCS-R data (see table 10.1) reveal that Latino men are significantly younger, with lower household income and educational attainment, than non-Latino white men. Latino men are also twice as likely to be unemployed as their non-Latino white counterparts, three times more likely to be uninsured, more likely to have never been married, and less likely to reside in the Northeast or Midwest region of the United States. Significant differences were found among the four subgroups of Latino men (Mexican, Puerto Rican, Cuban, and other Latino) in terms of age, education, marital status, employment, poverty ratio, U.S. region of residence, language of interview, and insurance status (see table 10.2). Roles, Stressors and Supports, and Immigration Characteristics

Understanding Latino men’s social roles, supports, and stressors can provide insight into the social processes, cultural factors, and institutional conditions (e.g., limited social mobility) linked to their risk of mental illness. We found

32.2

22.0

17.4

50–64

65

31.1

27.7

26.7

12 years

13–15 years

16 years

21.8

13.6

Never married

Widowed/separated/divorced

3.5

24.5

Out of labor force/other

Unemployed

72.0

Employed

Employment

64.6

Married

Marital status

14.6

11 years

Education

28.3

35–49

%

whites

(0.4)

(1.4)

(1.4)

(1.2)

(1.7)

(1.8)

(1.7)

(1.5)

(1.9)

(1.4)

(1.7)

(1.6)

(1.7)

(2.0)

Standard error

N ⴝ 1816

a

NCS-R non-Latino

7.1

17.1

75.8

12.1

31.7

56.2

9.7

19.5

25.7

45.1

6.3

12.4

29.8

51.5

%

(1.2)

(1.7)

(1.9)

(1.2)

(1.5)

(2.2)

(1.1)

(1.7)

(1.3)

(2.3)

(0.9)

(0.9)

(1.4)

(2.1)

Standard error

N ⴝ 1127

NLAAS Latinos

***

***

***

***

Sig.

8.1

20.8

71.1

13.6

37.6

48.7

11.1

26.6

32.6

29.7

7.0

9.9

27.3

55.9

%

(1.6)

(2.5)

(2.8)

(2.0)

(3.3)

(3.9)

(2.0)

(2.4)

(2.7)

(2.9)

(1.8)

(1.7)

(2.3)

(3.5)

Standard error

N ⴝ 403

Latinos

b

NLAAS U.S.-born

Demographics of NCS-R Non-Latino White and NLAAS Latino Males (Unadjusted)

18–34

Age

Table 10.1

6.4

14.6

79.1

11.1

27.6

61.4

8.7

14.5

20.9

55.9

5.8

14.1

31.6

48.4

%

(1.4)

(1.9)

(2.3)

(1.3)

(2.3)

(2.7)

(1.3)

(2.1)

(1.4)

(2.3)

(1.3)

(1.1)

(1.9)

(2.4)

*

*

***

n.s.

Sig.

(Continued)

Standard error

N ⴝ 724

Latinos

NLAAS immigrant c

Continued

65.8 21.1 10.7 2.5

(1.4) (1.5) (1.1) (0.5)

(0.0) (0.0)

(3.8) (2.8) (2.9) (2.8)

21.3 29.1 29.8 19.8

100.0 0.0

(0.2)

(1.1) (1.4) (1.8) (1.9)

5.6

9.6 16.9 38.6 34.9

Standard error

Sig.

(2.4) (1.3) (2.7) (0.5)

(3.5) (3.5)

(1.4) (2.0) (4.1) (4.3)

(0.2)

(1.9) (1.8) (2.5) (1.7)

***

***

***

***

***

U.S.-born Latinos include all people of Latin American backgrounds born on the U.S. mainland.

47.3 13.6 37.1 2.1

45.3 54.7

14.7 9.3 31.7 44.3

3.7

23.1 28.2 30.6 18.1

Standard error

*p  .05; **p  .01; and ***p  .001; n.s.  not significant

Immigrant Latinos include all people born in Latin America, including the island of Puerto Rico.

c

b

%

54.1 16.1 26.4 3.5

85.3 14.7

10.0 12.2 30.8 47.1

4.5

19.7 21.5 33.7 25.1

%

N ⴝ 1127

N ⴝ 1816

%

Latinos b

whites a

(3.1) (2.2) (3.8) (1.0)

(3.1) (3.1)

(1.7) (3.0) (5.1) (5.8)

(0.3)

(2.1) (1.7) (3.4) (3.3)

Standard error

N ⴝ 403

NLAAS U.S.-born NLAAS Latinos

NCS-R non-Latino

1752/1802 (97.2%) of the Non-Latino whites were U.S.-born.

a

Insurance status Private Public Uninsurance Other

Language of interview English Spanish

Poverty ratio (nonpoor to poor) U.S. region Northeast Midwest South West

Annual household income 14,999 15,000–34,999 35,000–74,999 75,000

Table 10.1

42.5 11.9 44.6 1.1

17.3 82.7

18.0 7.3 32.3 42.4

3.2

25.6 32.9 28.4 13.1

%

(3.0) (1.3) (3.0) (0.4)

(2.8) (2.8)

(1.8) (2.4) (4.2) (4.4)

(0.2)

(2.6) (2.4) (2.6) (1.7)

Standard error

N ⴝ 724

Latinos

NLAAS immigrant c

***

***

n.s.

***

***

Sig.

30.3

20.0

9.9

50–64

65

29.6

26.1

12.0

13–15 yrs.

16 yrs.

36.1

22.6

Never married

Widowed/separated/divorced

7.6

Out of labor force/other

Unemployed

62.7

29.7

Employed

Employment

41.3

Married

Marital status

32.2

11 yrs.

12 yrs.

Education

39.9

35–49

%

(2.6)

(4.3)

(3.7)

(3.4)

(3.2)

(3.1)

(1.7)

(3.8)

(2.0)

(3.9)

(4.1)

(2.5)

(3.2)

(2.8)

6.2

25.6

68.1

21.9

20.8

57.3

24.5

20.9

24.5

30.1

23.0

23.5

21.2

32.2

%

(1.7)

(3.8)

(3.7)

(3.0)

(1.9)

(3.3)

(4.5)

(3.4)

(2.9)

(4.0)

(2.2)

(2.1)

(2.7)

(2.7)

Standard error

N ⴝ 213

Standard error

Cuban

N ⴝ 276

Puerto Rican

Demographics of NLAAS Latino Males (Unadjusted)

18–34

Age

Table 10.2

6.1

14.8

79.1

9.0

29.9

61.1

7.1

14.6

25.9

52.4

4.5

10.2

30.7

54.6

%

(1.6)

(2.6)

(2.7)

(1.5)

(2.1)

(3.0)

(1.3)

(2.7)

(1.9)

(3.3)

(0.9)

(1.2)

(2.0)

(3.1)

Standard error

N ⴝ 398

Mexican

10.0

16.2

73.8

14.5

37.4

48.0

12.7

30.6

23.8

32.9

5.5

12.7

29.5

52.3

%

(1.9)

(3.3)

(3.7)

(2.4)

(3.6)

(3.6)

(2.4)

(3.5)

(3.0)

(3.8)

(2.3)

(2.1)

(2.7)

(4.0)

*

***

***

***

p value

(Continued)

Standard error

N ⴝ 240

Other Latino

Continued

30.7

22.8

35,000–74,999

75,000

13.0

23.1

8.2

Midwest

South

West

40.0

Spanish

18.6

Uninsured

%

(1.5)

(2.4)

(4.7)

(4.5)

(2.8)

(2.8)

(1.9)

(3.2)

(4.7)

(5.9)

(0.5)

(3.3)

(2.6)

(2.9)

(2.6)

2.2

27.3

28.0

42.5

75.8

24.2

2.7

92.1

0.0

5.2

5.5

25.5

27.0

25.5

22.0

(1.1)

(3.8)

(2.7)

(3.2)

(3.4)

(3.4)

(1.7)

(2.8)

(0.0)

(2.3)

(1.0)

(5.0)

(2.6)

(3.2)

(4.4)

Standard error

N ⴝ 213

Standard error

Cuban

N ⴝ 276

Puerto Rican

*p  .05; **p  .01; and ***p  .001; n.s.  not significant

4.2

26.2

Public

Other

51.0

Private

Insurance status

60.0

English

Language of interview

55.7

Northeast

U.S. region

4.9

23.9

Poverty ratio (nonpoor to poor)

22.6

15,000–34,999

%

14,999

Annual household income

Table 10.2

1.4

43.4

11.7

43.4

58.4

41.6

57.6

30.0

10.5

1.9

3.1

16.2

29.2

30.7

23.8

%

(0.6)

(3.6)

(1.7)

(3.3)

(4.5)

(4.5)

(6.4)

(7.1)

(2.4)

(0.5)

(0.2)

(2.3)

(3.1)

(2.7)

(2.5)

Standard error

N ⴝ 398

Mexican

3.3

30.0

9.8

56.9

44.8

55.2

33.1

26.1

4.8

36.1

4.7

20.5

35.8

22.5

21.2

%

(1.5)

(3.2)

(2.6)

(2.9)

(4.9)

(4.9)

(6.1)

(5.5)

(2.0)

(5.2)

(0.5)

(3.5)

(4.6)

(4.2)

(3.6)

Standard error

N ⴝ 240

Other Latino

***

***

***

**

n.s.

p value

Psychiatric Disorders and Mental Health Service Use

189

Latino subgroup differences in acculturative stress, everyday discrimination, and lack of neighborhood safety, but not in family cultural conflict (table 10.3). These different stressors were not uniformly higher among one of the four subgroups. For example, while Mexican men reported the highest scores in acculturative stress, Puerto Ricans and Other Latinos reported the highest scores in everyday discrimination. Similarly, while significant group differences were found in each of the indicators of support, none were uniformly higher or lower among one of the subgroups of Latino males. More than three-fourths of Latino men indicate being satisfied with U.S. economic opportunities, suggesting that despite disproportionate economic hardship and marginalization, most Latino men believe they have options for financial mobility. Less than 10 percent of Latino men, irrespective of subgroup membership, reported primary responsibility for household chores and 30–40 percent believed they had the final say when making key decisions. Also, 40.9–54.9 percent of the Latino men reported equal sharing of household chores and 32.9–47.9 percent reported equal sharing of household expenses. Our results suggest a pattern of moderate traditional gender role socialization, whereby men express dominance in decision-making and hold a greater burden of financial responsibilities. Regardless of Latino men’s subgroup, nativity plays a fundamental role in both the opportunities for maintaining close family ties and the exposure to stressors in the U.S. culture, as shown in table 10.3. The vast majority of Latino men were immigrant (first generation) or children of immigrants (second generation). A greater percentage of Puerto Rican men had spent 70 percent of their life in the United States. Our findings also suggest that there is substantial variability across subgroups of Latino men in terms of their agreement with the decision to move to the United States, likely due to the political and economic circumstances of the sending communities/countries as well as the divergent U.S. immigration policies toward these subethnic Latino groups. Prevalence of DSM-IV Lifetime and Past-Year Psychiatric Disorders

NCS-R non-Latino white men reported higher lifetime prevalence rates of any psychiatric disorders (38.5 percent) than did NLAAS Latino men (28.8 percent) across disorders commonly assessed in both the NLAAS and the NCS-R (table 10.4). Ethnic/racial differences were found in lifetime major depression, panic disorder, social phobia, generalized anxiety disorder (GAD), and drug abuse. In all cases, non-Latino white men had higher lifetime rates than Latino men. Past-year prevalence rates of any psychiatric disorder were also significantly higher among non-Latino white men than among Latino men (17.6 percent vs. 12.9 percent; see table 10.4). Significant race/ethnicity differences were found

(0.8)

Standard error

8.6

%

9.0

14.7

Neither satisfied nor dissatisfied

Dissatisfied/very dissatisfied

76.4

Very satisfied/satisfied

(2.1)

(2.4)

(3.2)

(0.1) (0.2)

10.0

Ethnic identity

Friend support

Perception of U.S. economic opportunities

(0.1)

9.3

10.7

(0.2)

(0.2)

Family cohesion

5.7

(0.1) (0.2)

Family support

Supports

Lack of neighborhood safety

18.7

Acculturative stress

Everyday discrimination

6.4

1.7

Family cultural conflict

Stressors

Standard error

2.5

13.3

84.2

%

9.8

10.4

11.1

10.3

4.8

14.5

2.2

6.1

Mean

(1.1)

(4.3)

(3.8)

Standard error

(0.3)

(0.1)

(0.1)

(0.2)

(0.2)

(0.6)

(0.3)

(0.1)

Standard error

N ⴝ 213

Mean

Cuban

N ⴝ 276

Puerto Rican

5.4

9.8

84.8

%

7.9

10.1

11.0

9.3

5.4

16.9

3.1

6.0

Mean

(0.8)

(1.6)

(1.3)

Standard error

(0.1)

(0.1)

(0.1)

(0.1)

(0.1)

(0.6)

(0.2)

(0.1)

Standard error

N ⴝ 398

Mexican

8.3

15.6

76.1

%

8.4

9.7

11.0

9.2

5.6

18.0

2.6

6.2

Mean

(2.2)

(2.3)

(2.3)

Standard error

(0.2)

(0.2)

(0.1)

(0.3)

(0.2)

(0.8)

(0.2)

(0.1)

Standard error

N ⴝ 240

Other Latino

Table 10.3 Stressors, Supports, Gender Roles, and Immigration Characteristics of NLAAS Latino Males (Age Adjusted)

p value

***

**

*

**

*

***

***

n.s.

p value

44.4

47.9

19.0

Same with partner

Partner/mostly partner

47.6

11.7

Both

Spouse/partner

Born outside of U.S.

43.6

33.7

22.6

1st

2nd

3rd

Immigrant generation

56.5

43.5

U.S.-born

Nativity

Nativity, generation, and life in the U.S.

40.7

Respondent

Final say in major decisions

33.1

Respondent/mostly respondent

Responsibility with household expenses

Partner/mostly partner

7.2

48.4

Same with partner

Respondent/mostly respondent

Responsibility with household chores

Gender rolesa

(3.2)

(2.2)

(3.4)

(3.5)

(3.5)

(2.9)

(6.2)

(5.7)

(3.3)

(4.1)

(4.1)

(5.2)

(5.5)

(2.7)

4.5

0.0

23.0

77.0

77.0

23.0

6.2

53.6

40.2

4.8

37.6

57.6

54.6

40.9

(0.0)

(3.9)

(3.9)

(3.9)

(3.9)

(1.7)

(5.9)

(5.3)

(1.2)

(4.9)

(4.4)

(4.6)

(5.1)

(1.4)

3.6

20.6

22.2

57.2

57.2

42.8

11.1

52.2

36.7

13.2

32.9

53.9

50.7

45.8

(2.2)

(2.6)

(4.1)

(4.1)

(4.1)

(2.4)

(3.3)

(2.9)

(2.3)

(3.6)

(3.3)

(3.6)

(3.4)

(0.8)

6.0

24.8

15.8

59.4

59.4

40.6

12.5

57.8

29.7

11.8

45.7

42.5

39.1

54.9

(4.3)

(2.6)

(4.3)

(4.3)

(4.3)

(3.3)

(5.0)

(4.2)

(3.9)

(4.6)

(5.4)

(3.9)

(3.9)

(1.8)

(Continued)

**

*

n.s.

*

n.s.

74.9

70

29.5

No

Not at all difficult

%

(1.6)

(7.4)

(6.1)

(2.4)

(2.6)

(6.9)

(3.8)

(4.1)

(8.2)

(7.0)

(7.0)

(3.5)

(2.8)

(2.1)

3.3

11.9

10.2

24.2

50.5

22.7

13.2

12.5

51.6

62.4

37.6

43.3

22.2

34.5

(1.7)

(2.1)

(1.3)

(3.8)

(3.7)

(3.3)

(2.2)

(2.5)

(3.3)

(6.5)

(6.5)

(6.4)

(1.9)

(6.7)

Standard error

**p  .01

***p  .001

n.s.  not significant

Items on immigration characteristics apply only to male immigrants (n  712–719).

*p  .05

b

a

Items on gender roles apply only to those who reported a partner/spouse (n  761–764).

2.6

27.7

56.3

Not very difficult

No relatives or friends

6.5

6.9

Somewhat difficult

23.6

Very difficult

Ease of visiting friends/family

Not planned at all

7.7

30.3

Somewhat planned

Poorly planned

38.4

Carefully planned

Degree of planning of U.S. move

70.5

Yes

Wanted to move to the U.S.

Immigration characteristicsb

7.9

17.2

Standard error

N ⴝ 213

30–70

%

Cuban

N ⴝ 276

Puerto Rican

30

Percent of life in U.S.

Table 10.3 Continued

1.0

34.2

15.1

21.0

28.7

34.1

13.3

28.3

24.3

26.3

73.7

50.5

33.4

16.1

%

(0.8)

(5.0)

(3.2)

(2.8)

(3.5)

(4.8)

(2.3)

(4.1)

(3.0)

(4.8)

(4.8)

(4.3)

(3.1)

(2.9)

Standard error

N ⴝ 398

Mexican

3.1

32.1

13.1

29.8

21.8

21.2

15.1

25.8

37.8

30.9

69.1

52.3

24.8

22.9

%

(2.0)

(4.5)

(3.2)

(4.8)

(5.3)

(3.4)

(3.6)

(4.3)

(4.3)

(4.2)

(4.2)

(4.2)

(2.8)

(3.4)

Standard error

N ⴝ 240

Other Latino

**

*

*

**

p value

Psychiatric Disorders and Mental Health Service Use

193

in past-year prevalence rates of GAD (3.4 percent vs. 0.9 percent), alcohol abuse (4.4 percent vs. 2.1 percent), and drug abuse (2.0 percent vs. 1.0 percent). With the exception of lifetime depressive disorders and last-year GAD, the risk profile for lifetime mental illness of U.S.-born Latino men appears quite similar to that of non-Latino white men (see table 10.4). In fact, the overall lifetime rate across all eleven psychiatric disorders is almost identical (38.5 percent vs. 37.9 percent). Similarly, past-year rates were not different between these two groups, with the exception of GAD (3.7 percent vs. 0.9 percent). Many of the ethnic/racial differences noted earlier appear to be due to the lower risk found among immigrant Latino men. In particular, the lifetime risk of any substance use disorder was more than 2.5 times higher for U.S.-born Latino men than for immigrant Latino men (27.0 percent vs. 10.6 percent). Pastyear disorders, however, revealed fewer differences. The rates of substance use disorders, as a group, were also approximately 2.5 times higher among U.S.born white men than immigrant Latino men (6.0 vs. 2.3 percent). The age-adjusted prevalence rates for most lifetime and past-year disorders (table 10.5) were not significantly different across the four Latino subgroups. However, when compared to all other Latino men, Puerto Rican men reported higher lifetime rates of any depressive disorder, major depression, PTSD, and any lifetime disorders than the other subgroups of Latino men. Cuban men, relative to all other Latino men, reported lower lifetime prevalence rates of any substance abuse disorder and of drug abuse disorder, in particular. The lifetime rates of Mexican men were not significantly different than those of other Latino men across any of the eleven disorders assessed. Perceptions of Mental Health and Substance Use Problems among Latino Men

Latino men who completed the NLAAS survey were asked whether or not they believed they had a mental health problem in the past year. We compared this subjective response to having need for services with their assessment of pastyear psychiatric disorders based on the WHM-CIDI. Of those Latino men who met criteria for any past-year depressive, anxiety, or substance use disorders, less than half (41.5 percent) believed they had a mental health related problem in the past year (data not shown). Of those who did not meet criteria for any past-year psychiatric disorder (e.g., nervous, emotional, drug, or alcohol problem), only 3.9 percent said they believed they had a mental health related problem in that same time period. These findings underscore the urgency to increase awareness and educate Latino men regarding the impact of mental health conditions (Chatterji, Takeuchi, Lu, and Alegría 2007).

Social phobia

Any disorder

Drug dependence

Drug abuse

38.5

4.1

11.7

8.3

Alcohol abuse

Alcohol dependence

21.4

19.8

Any substance

3.6

3.5

12.4

Panic disorder

6.1

1.9

Agoraphobia

PTSD

19.4

Any anxiety

GAD

2.9

16.5

Major depression

Dysthymia

16.6

Any depressive disorder

3.1 28.8

(0.5)

8.7

7.3

17.2

17.7

3.2

2.8

7.5

2.0

2.6

12.1

1.8

10.1

10.4

1.8

(0.7)

(0.7)

(1.2)

(1.2)

(0.3)

(0.8)

(0.8)

(0.4)

(0.3)

(1.1)

(0.3)

(1.2)

(1.2)

error

%

2.3

(0.5)

(0.9)

(0.9)

(2.1)

(2.2)

(0.6)

(0.8)

(1.1)

(0.5)

(0.7)

(1.5)

(0.6)

(1.1)

(1.2)

error

Standard

37.9

5.5

15.1

10.7

26.2

27.0

4.0

3.7

9.3

3.1

3.1

14.8

1.8

10.9

3

(1.2)

(1.9)

(2.0)

(3.9)

(4.2)

(1.0)

(1.7)

(2.1)

(0.9)

(1.3)

(2.7)

(0.8)

(2.0)

(2.0)

error

Standard

N ⴝ 403

10.9

%

N ⴝ 1127

N ⴝ 1816

Standard

(Group B)

(Group A)

%

Latinos

whites (Group C)

U.S.-born Latinos

Non-Latino

22

1.2

3.9

4.8

10.4

10.6

2.5

2.2

6.1

1.2

2.2

10.0

1.8

9.5

10.1

%

1.8

(0.5)

(0.8)

(1.2)

(1.2)

(1.2)

(0.8)

(0.6)

(1.1)

(0.5)

(0.8)

(1.6)

(0.6)

(1.2)

(1.4)

error

Standard

N ⴝ 724

(Group D)

Latinos

Immigrant

DSM-IV Disorders for NCS-R Non-Latino White and NLAAS Latino Men (Adjusted)

Lifetime diagnosis

Table 10.4

**

n.s.

*

n.s.

n.s.

n.s.

n.s.

*

**

*

n.s.

**

n.s.

***

***

Sig.

Group B a

vs.

Group A

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

*

Sig.

Group C a

vs.

Group A

***

**

***

n.s.

***

***

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

Sig.

Group D a

vs.

Group C

11.0

1.3

1.7

7.0

3.4

1.8

5.8

4.4

1.9

2.0

0.6

Any anxiety

Agoraphobia

Panic disorder

Social phobia

GAD

PTSD

Any substance

Alcohol abuse

Alcohol dependence

Drug abuse

Drug dependence

(1.0)

(0.2)

(0.3)

(0.3)

(0.6)

(0.7)

(0.2)

(0.5)

(0.6)

(0.2)

(0.3)

(0.8)

(0.3)

(0.5)

(0.5)

12.9

0.4

1.0

1.8

2.1

3.9

1.7

0.9

4.5

1.1

2.0

7.2

1.4

5.8

6.0

*p  .05; **p  .01; ***p  .001; n.s.  not significant

Bonferroni-adjusted tests.

a

1.6

Dysthymia

17.6

6.5

Major depression

Any disorder

6.6

Any depressive disorder

Past year diagnosis

(1.2)

(0.2)

(0.2)

(0.4)

(0.5)

(0.5)

(0.4)

(0.4)

(0.8)

(0.4)

(0.6)

(1.1)

(0.5)

(0.9)

(0.9)

15.0

0.4

1.7

2.6

3.5

6.0

1.9

1.0

5.0

2.0

2.8

8.2

1.3

6.9

6.9

(1.6)

(0.2)

(0.6)

(0.7)

(1.0)

(1.1)

(0.5)

(0.7)

(1.3)

(0.7)

(1.2)

(1.7)

(0.7)

(1.4)

(1.4)

11.3

0.4

0.4

1.2

1.1

2.3

1.6

0.8

4.1

0.5

1.4

6.4

1.4

5.0

5.4

(1.6)

(0.4)

(0.3)

(0.3)

(0.4)

(0.5)

(0.7)

(0.3)

(0.9)

(0.2)

(0.7)

(1.5)

(0.6)

(0.9)

(1.0)

*

n.s.

*

n.s.

**

n.s.

n.s.

***

n.s.

n.s.

n.s.

*

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

*

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

*

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

9.5

2.4

7.2

Social phobia

GAD

PTSD

Any disorder

Drug dependence

Drug abuse

Alcohol Dependence

39.0

6.5

12.6

9.3

22.3

3.8

Panic disorder

23.2

4.9

Agoraphobia

Alcohol abuse

17.0

Any anxiety

Any substance

3.1

Dysthymia

(4.5)

(2.1)

(2.7)

(2.3)

(4.3)

(4.3)

(2.2)

(1.2)

(2.9)

(1.4)

(1.8)

(3.0)

(1.1)

(2.1)

Major depression

16.9

(2.1)

Any depressive disorder 16.9

error

25.1

1.8

3.1

2.9

8.1

8.8

3.3

3.4

3.4

1.5

1.3

10.0

3.1

13.1

14.6

%

(2.4)

(1.0)

(0.8)

(1.2)

(2.4)

(2.1)

(0.8)

(0.9)

(1.5)

(0.5)

(0.7)

(1.4)

(1.1)

(1.6)

(1.7)

error

Standard

N ⴝ 276

N ⴝ 213

Standard

(Group B)

(Group A)

%

Cuban

Puerto Rican

27.5

3.1

9.9

7.5

17.4

17.8

3.4

2.4

7.2

2.0

3.4

11.4

1.3

10.0

10.0

%

(1.8)

(0.6)

(1.2)

(1.2)

(1.8)

(2.0)

(0.8)

(1.1)

(1.1)

(0.6)

(1.0)

(1.4)

(0.6)

(1.2)

(1.2)

error

Standard

N ⴝ 398

(Group C)

Mexican

27.2

1.3

8.2

5.8

14.5

15.5

2.1

3.8

6.9

1.2

0.5

11.5

2.0

10.1

11.2

%

(4.0)

(0.8)

(2.0)

(1.4)

(2.6)

(2.8)

(0.9)

(1.5)

(2.1)

(0.7)

(0.3)

(2.5)

(1.3)

(1.8)

(2.3)

error

Standard

N ⴝ 240

(Group D)

Other Latino

DSM-IV Disorders of NLAAS Latino Men across Subethnic Groups (Adjusted)

Lifetime diagnosis

Table 10.5

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

*

n.s.

n.s.

n.s.

n.s.

Sig.

differences

subgroup

test of

Overall

*

n.s.

n.s.

n.s.

n.s.

n.s.

*

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

*

*

Sig.

B, C, D

Groups

vs.

Group A

n.s.

n.s.

***

n.s.

n.s.

*

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

Sig.

A, C, D

Groups

vs.

Group B

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

Sig.

A, B, D

Groups

vs.

Group C

3.7

2.3

1.1

Alcohol dependence

Drug abuse

Drug dependence

(2.4)

(0.5)

(1.3)

(1.7)

(1.5)

(2.0)

(1.3)

(1.0)

(2.6)

(0.7)

(1.9)

(2.7)

(1.0)

(2.0)

(2.0)

12.2

0.7

0.7

0.4

2.1

2.6

2.3

1.3

2.9

1.2

1.0

7.1

1.2

5.4

5.9

*p  .05; **p  .01; ***p  .001; n.s.  not significant

21.5

4.8

Any disorder

6.3

8.0

Social phobia

Alcohol abuse

1.8

Panic disorder

Any substance

3.9

Agoraphobia

2.1

10.7

Any anxiety

2.9

2.0

Dysthymia

PTSD

9.9

Major depression

GAD

9.9

Any depressive disorder

Past-year diagnosis

(1.7)

(0.5)

(0.5)

(0.3)

(0.9)

(0.8)

(0.6)

(0.7)

(1.3)

(0.4)

(0.5)

(1.7)

(0.8)

(1.1)

(1.1)

13.9

0.5

1.5

1.6

2.2

4.5

2.2

0.8

4.7

1.1

2.5

7.8

1.1

6.5

6.5

(1.2)

(0.4)

(0.5)

(0.6)

(0.6)

(0.6)

(0.5)

(0.5)

(1.2)

(0.5)

(0.8)

(1.3)

(0.5)

(1.0)

(1.0)

12.2

0.0

0.0

2.2

3.2

4.1

0.2

0.4

4.3

0.6

0.5

5.6

2.0

5.0

6.0

(3.3)

(0.0)

(0.0)

(1.1)

(1.6)

(1.7)

(0.2)

(0.2)

(1.9)

(0.4)

(0.3)

(1.9)

(1.3)

(1.4)

(2.0)

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

*

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s.

0.86

0.08

50–64

65

0.83

0.62

Latino U.S.-born

Latino immigrant

1.00

1.71

1.48

1.92

16 yrs.

13–15 yrs.

12 yrs.

11 yrs.

Education

1.00

White

Race/ethnicity

1.00

1.36

35–49

(1.0, 3.6)*

(0.9, 2.4)

(1.1, 2.8)*

(0.4, 1.0)*

(0.6, 1.2)

(0.0,0.2)*

(0.5,1.4)

(0.9,2.0)

1.10

1.13

1.00

1.00

0.47

0.64

1.00

0.08

0.94

1.57

1.00

OR

(0.8, 1.6)

(0.8, 1.6)

(0.7, 1.4)

(0.3, 0.8)*

(0.4, 1.0)

(0.0,0.2)*

(0.6,1.5)

[1.0,2.5)

95% CI

n ⴝ 441

n ⴝ 302 95% CI

disorder

disorder

OR

Any anxiety

Any depressive

2.82

2.23

1.42

1.00

0.25

0.75

1.00

0.13

0.57

1.00

OR

(1.4, 5.6)*

(1.2, 4.1)*

(0.9, 2.3)

(0.1, 0.4)*

(0.5, 1.2)

(0.1,0.3)*

(0.4,0.9)*

95% CI

n ⴝ 207

disorder

Any substance

Sociodemographic and Sociostructural Factors among NLAAS and NCS-R Men

18–34

Age

Table 10.6

1.54

1.39

1.23

1.00

0.44

0.72

1.00

0.06

0.60

1.04

1.00

OR

(1.1, 2.2)*

(1.0, 2.0)

(0.9, 1.6)

(0.3, 0.6)*

(0.5, 1.1)

(0.0,0.1)*

(0.4,0.9)*

(0.8,1.4)

95% CI

n ⴝ 715

Any disorder

1.36

2.56

Never married

Widowed/separated/divorced

2.51

3.94

Out of labor force/other

Unemployed

1.30

1.33

15,000–34,999

14,999

0.84

0.69

0.88

Midwest

South

West

*Significant odds ratio at the p  .05 level.

1.00

Northeast

U.S. region

1.00

1.29

75,000

35,000–74,999

Annual household income

1.00

Employed

Employment status

1.00

Married

Marital status

(0.8, 2.2)

(0.6, 1.3)

(0.5, 1.1)

(0.6, 1.3)

(0.8, 2.3)

(0.8, 2.0)

(0.8, 2.0)

(1.7, 9.3)*

(1.7, 3.7)*

(1.7, 3.9)*

1.05

0.87

0.99

1.00

1.08

1.43

1.21

1.00

2.38

2.23

1.00

1.73

1.50

1.00 (1.1, 2.1)*

(0.7, 1.6)

(0.6, 1.2)

(0.7, 1.5)

(0.6, 1.9)

(1.0, 2.1)

(0.9, 1.6)

(1.2, 4.5)*

(1.6, 3.1)*

(1.1, 2.7)*

1.31

0.71

1.08

1.00

0.92

0.69

1.00

1.00

1.00

0.96

1.00

2.45

2.75

1.00 (1.9, 4.1)*

(0.7, 2.3)

(0.4, 1.2)

(0.5, 2.2)

(0.5, 1.7)

(0.3, 1.5)

(0.6, 1.5)

(0.5, 2.2)

(0.5, 1.8)

(1.5, 4.1)*

1.08

0.73

0.95

1.00

1.01

1.02

1.07

1.00

2.15

1.84

1.00

2.18

1.93

1.00 (1.5, 2.5)*

(0.7, 1.7)

(0.5, 1.1)

(0.6, 1.5)

(0.6, 1.6)

(0.7, 1.5)

(0.8, 1.4)

(1.2, 3.8)*

(1.3, 2.6)*

(1.6, 3.1)*

200

Antonio Polo and Margarita Alegría

Sociodemographic and Sociostructural Factors Associated with Past-Year Psychiatric Disorders

Using main effect models across four disorder categories (any past-year depressive, anxiety, substance use, and any disorders), men ages sixty-five and older reported significantly lower risk for past-year psychiatric disorders, relative to men ages eighteen to thirty-four (table 10.6). Immigrant Latino men, relative to non-Latino white men, had lower risk for any depressive, anxiety, substance use, and psychiatric disorder. In contrast, no observed differences were found in the risk of past-year disorders between U.S.-born Latino men and non-Latino white men. Relative to men with at least sixteen years of education, those with less than high school (less than eleven years of education) reported increased odds for any depressive disorder, any substance use disorder, and any psychiatric disorder. Men who had never been married were at higher odds for all disorder categories except for depressive disorders, while those with disrupted marriages (widowed, separated, or divorced) had higher odds for all four disorders. Being out of the labor force or being unemployed rendered men at increased risk of any depressive disorder, any anxiety disorder, and any disorder. Of those eighteen to thirty-four years of age, the odds of having any pastyear disorders for immigrant Latinos is lower than for non-Latino whites. The odds are also lower for immigrant Latinos ages thirty-five to forty-nine than for non-Latino whites within the same age range (OR  0.24; 95 percent CI  0.10, 0.59). Immigrant Latinos also exhibit lower odds for any past-year psychiatric disorder within those who had less than a high school degree (OR  0.17; 95 percent CI  0.07, 0.39), high school (OR  0.24; 95 percent CI  0.10, 0.56), thirteen to fifteen years of school (OR  0.31; 95 percent CI  0.13, 0.74), and more than a bachelor’s degree (OR  0.32; 95 percent CI  0.12, 0.84), than for non-Latino whites within those respective educational levels. The odds of having any psychiatric disorders in the past year for immigrant Latinos is less likely for the employed (OR  0.32; 95 percent CI  0.12, 0.84) and for the unemployed (OR  0.14; 95 percent CI  0.04, 0.57) than for non-Latino whites with the same employment status (fig. 10.1). Any protective effect against psychiatric disorders that immigrant Latino men exhibit relative to non-Latino white men is not observed for those who are fifty or older. Our data suggest that, relative to non-Latino white men, as Latino immigrant men in the United States get older, they are at comparable odds for psychiatric disorders as their non-Latino white counterparts. Our results corroborate the resiliency of young immigrant Latino men under adverse conditions such as unemployment and low education (Davila, Pagan and Viladrich 1998); however, if a significant percentage of Latino immigrants face long-term

Psychiatric Disorders and Mental Health Service Use

201

Employment status Odds past-year disorder

3 2.5 Employed*

2

Out/other

1.5 1

Unemployed*

0.5 0 Non-Latino whites

Immigrant Latino

*Significant difference between compared groups Figure 10.1

Mental health and employment of immigrant Latino men and non-Latino

white men.

Odds past-year disorder

U.S. region 1.2 1

Northeast*

0.8

Midwest

0.6

South

0.4

West

0.2 0 Non-Latino whites

Immigrant Latino

*Significant difference between compared groups Figure 10.2 Psychiatric disorders for immigrant Latino men and non-Latino white men by U.S. region.

structural unemployment and poverty as they age, societal forces can erode their social status and eventually lead to comparable levels of psychiatric illness. Environmental context also appears to be related to the mental health of Latino men (see fig. 10.2). The odds of having any past-year disorder for immigrant Latinos residing in the Northeast is lower than for non-Latino whites in the same region (OR  0.32; 95 percent CI  0.12, 0.84); this same pattern of relatively lower odds was not found in other regions. Rates of Unmet Need

We did not find significant differences in the levels of unmet need for mental health services across Latino and non-Latino men (fig. 10.3). In other words, the likelihood of receiving past-year services among those with a diagnosed pastyear psychiatric disorder was equally low across the three groups.

202

Antonio Polo and Margarita Alegría

Unmet need 100% 80%

67.3%

70.1%

Whites with any 12-month disorders (n  477)

U.S.-born Latino with any 12-month disorders (n  74)

74.8%

60% 40% 20% 0% Immigrant Latino with any 12-month disorders (n 85)

Note: Bonferroni adjusted p-value for non-Latino whites compared to U.S.-born LatinosNS; and for non-Latino whites compared to immigrant LatinosNS Figure 10.3

Rates of unmet need across race/ethnicity.

Sociodemographic and Sociostructural Factors Associated with Past-Year Mental Health Service Use

Adjusted odds ratios for service use among non-Latino white and Latino men are presented in table 10.7. Separate models were computed for general (general practitioners, family doctors, nurses, occupational therapists, and/or other health professionals specifically for a mental health problem), specialty (psychiatrists, psychologists, other mental health therapists/professionals, use of a mental health hotline), human sector (social worker, religious/spiritual advisor, counselor outside of a mental health setting), and any mental health service use in the past year (at least one visit to any of the providers under the general, specialty, and human sector composites). Relative to non-Latino whites, Latino immigrants were less likely to use both specialty services and any psychiatric services for mental health problems. Relative to married men, men in the widowed, separated, or divorced category reported higher odds of mental health service use within the specialty, the human sector, and any service categories. Annual household income was significantly related to the likelihood of using specialty services in the past year; men with lower incomes were less likely to report a specialty service visit. The number of past-year disorders was associated with increased odds of past-year general service use, specialty service use, and any service use for mental health problems. For U.S.-born Latino men whose household income was less than $15,000 a year, the odds of having used any services in the past year are greater than for

2.36

0.40

50–64

65

0.71

0.59

Latino U.S.-born

Latino immigrant

1.00

1.30

1.33

1.20

16 yrs.

13–15 yrs.

12 yrs.

11 yrs.

Education

1.00

White

Race/ethnicity

1.00

1.89

35–49

OR

(0.6, 2.4)

(0.8, 2.2)

(0.8, 2.1)

(0.3, 1.1)

(0.4, 1.2)

(0.2, 0.9)*

(1.4, 4.0)*

(1.3, 2.8)*

0.69

0.66

0.77

1.00

0.37

0.59

1.00

0.13

0.99

1.02

1.00

OR

(0.4, 1.2)

(0.4, 1.0)*

(0.5, 1.2)

(0.2, 0.7)*

(0.3, 1.1)

(0.0, 0.4)*

(0.5, 2.1)

(0.6, 1.8)

95% CI

n ⴝ 251

95% CI

Specialty

General

n ⴝ 220

0.68

0.61

0.63

1.00

0.74

1.39

1.00

0.04

0.50

0.73

1.00

OR

(0.3, 1.8)

(0.3, 1.3)

(0.3, 1.5)

(0.3, 1.7)

(0.8, 2.5)

(0.0, 0.2)*

(0.2, 1.1)

(0.4, 1.2)

95% CI

n ⴝ 108

Human sector

Service type

Sociodemographic and Mental Health Factors Associated with Past-Year Service Use

18–34

Age

Table 10.7

0.72

0.79

0.81

1.00

0.53

0.70

1.00

0.15

1.36

1.27

1.00

OR

(Continued)

(0.4, 1.2)

(0.5, 1.2)

(0.5, 1.3)

(0.4, 0.8)*

(0.5, 1.1)

(0.1, 0.4)*

(0.8, 2.3)

(0.8, 2.0)

95% CI

n ⴝ 435

Any service

Continued

0.76

0.91

Never married

Widowed/separated/divorced

2.06

2.16

Out of labor force/other

Unemployed

1.36

0.80

15,000–34,999

14,999

1.00

0.72

Northeast

Midwest

U.S. region

1.00

1.03

75,000

35,000–74,999

Annual household income

1.00

Employed

Employment status

1.00

OR

Married

Marital status

Table 10.7

OR

(0.5, 1.3)

(0.4, 1.4)

(0.3, 1.8)

(0.6, 3.1)

(0.7, 1.6)

(1.0, 4.7)

(1.1, 3.9)*

(0.5, 1.6)

0.58

1.00

0.45

0.33

0.70

1.00

1.95

1.80

1.00

3.64

1.41

1.00

(0.3, 1.1)

(0.3, 0.8)*

(0.2, 0.7)*

(0.5, 1.0)

(0.9, 4.2)

(1.0, 3.1)*

(1.9, 7.0)*

(0.8, 2.4)

95% CI

n ⴝ 251

95% CI

Specialty

General

n ⴝ 220

1.51

1.00

0.90

0.96

1.62

1.00

1.28

1.87

1.00

2.65

1.43

1.00

OR

(0.6, 3.8)

(0.4, 1.9)

(0.4, 2.1)

(0.9, 2.9)

(0.4, 3.7)

(0.8, 4.5)

(1.6, 4.5)*

(0.8, 2.4)

95% CI

n ⴝ 108

Human sector

Service type

0.69

1.00

0.57

0.66

0.93

1.00

2.24

1.47

1.00

1.97

1.13

1.00

OR

(0.4, 1.2)

(0.4, 0.9)*

(0.4, 1.2)

(0.7, 1.3)

(1.1, 4.5)*

(0.9, 2.4)

(1.3, 3.0)*

(0.8, 1.7)

95% CI

n ⴝ 435

Any service

1.04

West

1.35

0.38

0.71

Public

Uninsured

Other

1.97

Yes

5.09

6.40

7.49

1

2

3+

*Significant odds ratio at the p  .05 level.

1.00

0

Number of disorders past year

1.00

0.72

No

Yes

Any substance use past year

1.00

0.94

No

Yes

Any anxiety disorder past year

1.00

No

Any depression past year

1.00

Private

Insurance status

0.97

South

(1.7, 33.8)*

(2.1, 19.2)*

(2.2, 11.8)*

(0.3, 1.7)

(0.4, 2.1)

(1.0, 4.0)

(0.2, 2.4)

(0.2, 0.9)*

(0.6, 2.9)

(0.6, 2.0)

(0.6, 1.7)

7.71

6.33

2.04

1.00

1.22

1.00

1.03

1.00

1.55

1.00

3.38

0.88

2.84

1.00

1.05

0.70

(1.8, 33.4)*

(2.2, 17.9)*

(1.0, 4.2)

(0.5, 3.2)

(0.5, 2.1)

(0.7, 3.3)

(1.0, 11.1)*

(0.4, 1.8)

(1.1, 7.2)*

(0.6, 2.0)

(0.4, 1.3)

0.99

3.31

2.62

1.00

2.62

1.00

1.14

1.00

1.81

1.00

0.35

0.46

2.02

1.00

1.72

1.11

(0.2, 4.6)

(1.0, 11.2)

(1.2, 5.7)*

(0.9, 8.0)

(0.5, 2.5)

(0.8, 4.1)

(0.1, 2.0)

(0.2, 1.1)

(0.8, 4.9)

(0.7, 4.0)

(0.5, 2.7)

10.78

9.83

3.81

1.00

0.75

1.00

0.79

1.00

1.60

1.00

2.01

0.71

2.97

1.00

1.07

0.90

(3.2, 36.2)*

(3.8, 25.2)*

(1.9, 7.6)*

(0.4, 1.5)

(0.4, 1.7)

(0.9, 2.8)

(0.7, 5.4)

(0.4, 1.2)

(1.4, 6.4)*

(0.6, 1.8)

(0.5, 1.5)

Antonio Polo and Margarita Alegría

Odds used any services

206

Insurance status 3.5 3 2.5 2 1.5 1 0.5 0

Private Public Uninsured* Other Non-Latino white

Immigrant Latino

*Significant difference between compared groups Figure 10.4

Insurance status of U.S.-born Latino men and non-Latino white men.

non-Latino white men with the same income level, after adjusting for other covariates (OR  4.33; 95 percent CI  1.03, 18.26). The likelihood of having used any services in the past year for immigrant Latinos without insurance is significantly lower (OR  0.04; 95 percent CI  0.003, 0.52) than for uninsured non-Latino whites, after adjusting for sociodemographic, sociostructural, and clinical variables (fig. 10.4). Discussion

Our results indicate the importance of addressing Latino men’s sociostructural risk profile, including their low educational achievement, high unemployment, elevated uninsured rates, and soaring poverty. Our data support the importance of recognizing how sociodemographic differences across the major subgroups of Latinos may lead to divergent circumstances in their lifestyle in the United States (e.g., uninsured rates high for Mexicans but low for Puerto Ricans; overrepresentation of elderly in Cubans in contrast to Mexicans). Our contrasts underline the sharp differences in stressors, supports, and immigration characteristics across Latino subgroups, with Mexicans reporting higher acculturative stress and Puerto Ricans describing greater perceived discrimination. Our findings also depict the changing gender roles of Latino men. More report that they share household responsibilities, but they, particularly Mexicans and Cubans, still perceive that they are mainly responsible for household expenses. Prevalence rates are very similar for U.S.-born Latino men as compared to non-Latino white men, although non-Latino white men report higher lifetime prevalence of any psychiatric disorders than do Latino men. Rates also varied significantly between immigrant Latinos and non-Latino whites, indicating that the relationship of socioeconomic status (as defined by education and employment) and health may vary as a function of culture. Our findings are consistent

Psychiatric Disorders and Mental Health Service Use

207

with evidence that the social gradient may be reversed or neutral for Latino immigrants (Steffen 2006) as compared to Westernized societies. There are some data suggesting that immigrants with low socioeconomic status in some nonWestern societies demonstrate better health outcomes because of a stronger sense of community and social networks (Cockerham, Snead, and Dewaal 2002). The opposite relationship is observed for those in Western societies (Adler et al. 1994), where lower socioeconomic status for non-Latino whites is linked to worst health outcomes (Alderete, Vega, Kolody, and Aguilar-Gaxiola 2000). Examining how sociostructural characteristics might influence health in divergent ways depending on men’s cultural background is paramount since it may suggest that culture moderates the relation of health and class. Further differences were found between immigrant Latinos residing in the Northeast compared to non-Latino whites in the same region, lending support to the theory of segmented assimilation proposed by Portes and Zhou (1993). The context of reception, including state policies and laws that favorably affect immigrants and their families, may play a role in the degree to which Latino men are able to uphold their ethnic identity and preserve a social network with family and other members of the immigrant subgroup. Contextual forces may account for some of the variability observed in the mental health profile of the Latino men across U.S. regions, relative to white men. Our results also corroborate the resiliency of young immigrant Latino men under adverse conditions such as unemployment and low education (Davila, Pagan, and Viladrich 1998), given that as Latino immigrant men age, their risk for psychiatric disorder becomes comparable to their non-Latino white counterparts. Younger Latino adults whose self-identity is less defined by their income or education may have better health outcomes than younger non-Latino whites under conditions of disadvantage. However, if a significant percentage of Latino immigrants face long-term structural unemployment and poverty as they age, market forces can erode their social status and eventually lead to comparable levels of psychiatric illness. Our results also demonstrate the importance of attending to anxiety disorders for men as a primary goal for secondary and primary prevention, given its high prevalence in this population. Nativity differences are quite striking for substance use disorders, emphasizing the importance of targeting efforts toward U.S.-born Latinos. The Latino paradox observed for substance use disorders attests to the significance of understanding the mechanisms of lower risk for psychiatric disorders among immigrant men. There were substantial similarities in prevalence rates across Latino subgroups after age adjustments.

208

Antonio Polo and Margarita Alegría

Our results also underscore the very low levels of recognition of mental health problems among Latino men, emphasizing the necessity for social marketing campaigns to create awareness and problem recognition as well as dissemination of resources for mental health care. Efforts to inform Latino men about mental health conditions that can lead to detrimental effects including unemployment and work absenteeism may be particularly effective (Chatterji, Takeuchi, Lu, and Alegría 2007). Overall, our findings on mental health service use underscore the importance of differential pathways to mental health care for men depending on race/ethnicity and of the impact of comorbidity in the likelihood of seeking care for mental health conditions. Furthermore, they demonstrate limited access to mental health services among Latino males and the need for urgent action to remediate these mental health service inequalities. However, we did not find significant differences in unmet need across Latino and non-Latino men; these findings diverge from a review of other epidemiological studies, where Cabassa, Zayas, and Hansen (2006) conclude that Latinos have greater underutilization or unmet need for mental health problems than their nonLatino white counterparts. However, one should not lose sight that between two-thirds and three-fourths of men, independent of race/ethnicity with a pastyear psychiatric disorder report receiving no mental health care for their illness. This leads to the wider question: Are mental health services simply inadequately designed to meet the needs of men in general? Recommendations

Several recommendations are offered as potential strategies to reduce the impact of structural factors on the mental health of Latino males, thereby reducing the risk of psychiatric illness and improving access to mental health services among Latino men in the United States. Policy interventions targeting the reduction of poverty and the augmentation of educational achievement among Latino men and their families should be explored. Examples of policy interventions that could be used are the expansion of the Earned Income Tax Credit Return in areas with high Latino density and Title 1 programs in the schools where poor Latino youth are overrepresented. Changes in health policies such as expanded coverage for men under Medicaid and State’s Children Health Insurance Program should also be considered. Policy alliances should be created between working unions linked to Latino men’s employment (e.g., construction, service industries) and advocacy groups so as to promote better recruitment packages that include insurance benefits. Aside from the psychological barriers obstructing men from seeking

Psychiatric Disorders and Mental Health Service Use

209

services, perhaps one policy change that could impact mental health service use among men, especially Latino men, would be access to insurance among recent immigrants and undocumented populations. Factors should be identified that contribute to risk of psychiatric disorders among older Latino men, particularly those fifty years old and above. NonLatino white men and Latino men may have a very different course of psychiatric illness. Future research that tracks the expectations and needs of immigrant and U.S.-born Latinos over time will likely shed light on these developmental trends. Although the rates of psychiatric disorder did not vary widely across Mexicans, Cubans, Puerto Ricans, and Other Latinos, there is evidence that some of the mechanisms that may be responsible for their risk for psychopathology may vary (Alegría et al. 2007). Future studies are needed to more directly test which risk and protective factors are salient for each of these subgroups of Latino men in an effort to tailor interventions. Our data emphasize the importance of place (e.g., environmental context) as a risk or protective factor for psychiatric disorders. This work is especially important for understanding the interaction of structural factors with enclave compositional factors in Latino communities. Ethnographic studies of how the Northeast region differs from other regions in the United States for ethnic minorities might shed light on protective factors to reduce the risk of psychiatric illness. More research should be conducted on interventions with U.S.-born Latino men at increased likelihood for substance use disorders. Availability of alternative social networks in immigrant enclaves might protect them from substance disorders. Prevention efforts for mental health should target Latino men. Although the lifetime rates of disorders differ between non-Latino white men and Latino men, past-year rates are strikingly similar. This suggests that immigrant Latinos may be at higher risk for late onset of depressive, anxiety, and substance use disorders, and that over time they may present with similar or greater disorder profiles as non-Latino white men. Regular screening accompanied by early referral for psychological problems is needed and may be particularly helpful for Latino men. Findings which were not unique to Latino men are worth noting. High levels of unmet need were present across racial/ethnic groups of men. In addition, co-occurring mental health and other health problems appeared as a strong predictor of mental health service use, across different types of providers. Research is needed to identify interventions for Latino men who do not recognize and attend to their psychiatric illness before they become disabled or impaired. Public mental health recognition campaigns may be useful, with a

210

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particular focus on anxiety disorders, given that they are so prevalent among men regardless of their race/ethnicity. Given the differential pathways to mental health care between Latino and non-Latino white men, an assessment of the mental health outcomes obtained for men in these different sectors of care is urgently needed. It is important to determine whether these differential pathways lead to disparities in mental health outcomes and disability. Outreach to men engaged in mental health service delivery is immediately required, given the high rates of unmet need. Introducing community agents that might serve as referral sources and patient liaisons that can help Latino immigrants navigate the health care delivery system should be tested as a promising approach. Note The NLAAS data used in these analyses were provided by the Center for Multicultural Mental Health Research at the Cambridge Health Alliance. The project was supported by NIH Research Grant #U01 MH62209 funded by the National Institute of Mental Health as well as the Substance Abuse and Mental Health Services Administration/Center for Mental Health Services and the Office of Behavioral and Social Science Research. This publication was also made possible by Grant #P50 MH073469–02 from the National Institute of Mental Health. References Adler, N. E., T. Boyce, M. A. Chesney, S. Cohen, S. Folkman, R. L. Kahn, and S. L. Syme. 1994. Socioeconomic status and health: The challenge of the gradient. American Psychologist 49: 15–24. Alderete, E., W. A. Vega, B. Kolody, and S. Aguilar-Gaxiola. 2000. Lifetime prevalence of and risk factors for psychiatric disorders among Mexican migrant farmworkers in California. American Journal of Public Health 90: 608–614. Alegría, M., T. McGuire, M. Vera, G. Canino, L. Matías, and J. Calderón. 2001. Changes in access to mental health care for the poor and the non-poor with managed care: Results from the health care reform in Puerto Rico. American Journal of Public Health 91: 1431–1434. Alegría, M., N. Mulvaney-Day, M. Woo, M. Torres, S. Gao, and V. Oddo. 2007. Correlates of twelve-month mental health service use among Latinos: Results from the National Latino and Asian American Study (NLAAS). American Journal of Public Health 97: 76–83. Alegría, M., D. Takeuchi, G. Canino, N. Duan, P. Shrout, X. Meng, W. Vega, et al. 2004. Considering context, place and culture: The National Latino and Asian American Study. International Journal of Methods in Psychiatric Research 13: 208–220. Cabassa, L., L. Zayas, and M. Hansen. 2006. Latino adults’ access to mental health care: A review of epidemiological studies. Administrative Policy in Mental Health 33: 316–30. Chatterji, P., M. Alegría, M. Lu, and D. Takeuchi. 2007. Psychiatric disorders and labor market outcomes: Evidence from the National Latino and Asian American Study. Health Economics 16: 1069–1090. Cockerham, W., M. Snead, and D. Dewaal. 2002. Health lifestyles in Russia and the socialist heritage. Journal of Health and Social Behavior 43: 42–55.

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Connell, R. 1993. The big picture: Masculinities in recent world history. Theory and Society 22: 597–623. Davila, A., J. Pagan, and G. Viladrich. 1998. The impact of IRCA on the job opportunities and earnings of Mexican-American and Hispanic-American workers. International Migration Review 32: 79–95. Hartley, H. 1962. Multiple frame surveys. In Proceedings of Social Statistics Section, American Statistical Association 203–206. ———. 1974. Multiple frame methodology and selected applications. Sankhya, Ser C. 36 (pt. 3): 99–118. Heeringa, S., J. Wagner, M. Torres, N. Duan, T. Adams, and P. Berglund. 2004. Sample designs and sampling methods for the Collaborative Psychiatric Epidemiology Studies (CPES). International Journal of Methods in Psychiatric Research 13 (4): 221–240. Heeringa, S. 2007. National Institutes of Mental Health (NIMH) data set, Collaborative Psychiatric Epidemiology Survey Program (CPES): Integrated weights and sampling error codes for design-based analysis. http://www.icpsr.umich.edu/cocoon/cpes/ using.xml?sectionWeighting. Kessler, R., and K. Merikangas. 2004. The National Comorbidity Survey Replication (NCS-R). International Journal of Methods in Psychiatric Research 13: 60–68. Portes, A., and M. Zhou. 1993. The new second generation: Segmented assimilation and its variants. The Annals of the American Academy of Political and Social Science 530: 74–97. Steffen, P. 2006. The cultural gradient: Culture moderates the relationship between socioeconomic status (SES) and ambulatory blood pressure. Journal of Behavioral Medicine 29: 501–510. U.S. Department of Health and Human Services. 2001. Mental health: Culture, race and ethnicity. A supplement to mental health: A report of the Surgeon General. Rockville, MD: USDHHS, SAMSHA, CMHS.

Chapter 11

George Ayala

Social Determinants of HIV/AIDS A Focus on Discrimination and Latino Men Who Have Sex with Men

Acquired immune deficiency syndrome (AIDS) is not evenly distributed in the general population. In fact, the AIDS epidemic in the United States has had a disproportionate impact on Latinos, particularly Latino men, and more specifically Latino men who have sex with men. For example, Latinos are four times more likely than non-Latino whites to receive an AIDS diagnosis (CDC 2005a) and in 2004, men made up the majority (79 percent) of new AIDS diagnosis among Latinos (CDC 2005b). Given this profile of exceptional rate of infection, it is a research and policy priority to identify the structural determinants of HIV risk among Latino males. Twenty-five years after the first American AIDS diagnosis was made in Los Angeles, California, the primary mode of transmission for men in the United States continues to be sex between men regardless of race or ethnicity (CDC 2009). Of all the Latino men living with AIDS in the United States at the end of December 2007, 60 percent were men who had sex with men (CDC 2009). During 1999–2002, the number of new human immunodeficiency virus (HIV) diagnoses increased 17 percent among gay men and other men who have sex with men in states that conducted names-based HIV/AIDS surveillance at the time (CDC 2003). Moreover, recent HIV sero-prevalence studies lead researchers to believe that one in five Latino men who have sex with men may be infected with HIV (CDC 2009; Diaz and Ayala 2001; Valleroy et al. 2000). At the heart of early community-based responses to the HIV/AIDS epidemic was an implicit understanding that there were social and structural underpinnings to a disease that was once known as GRIDS (gay-related immunodeficiency syndrome). As the HIV/AIDS industry became more professionalized, public health 212

Social Determinants of HIV/AIDS

213

approaches to HIV prevention programs began to predominate. With few exceptions (Kegeles, Hays, and Coates 1996; Kelly et al. 1992; Stiffman, Dore, and Cunningham 1995), the operating paradigm within HIV prevention became more influenced by individualistic deficit models for understanding and defining the risk for HIV infection. HIV risk was (and continues to be) typically framed as intrapersonal in nature linked to individual knowledge, attitudes, self-efficacy, motivation, intention, or skills. HIV prevention therefore focused on changing individual behavior with little regard to interpersonal, social, cultural, environmental, and/or other influences (Mays, Cochran and Zamudio 2004; Trickett 2002). In the late 1990s, the HIV prevention sector began to target HIV-positive individuals, a logical consequence to the availability of new testing technologies and treatment advancements (Janssen et al. 2001). Knowing and disclosing one’s status became important in an effort to urge people to take responsibility for their health and behavior. The emphasis on responsibility for preventing HIV transmission continues to implicate the individual as the sole agent in creating risk and therefore the sole agent for eliminating it. This emphasis specifically asks individuals to vigilantly question their own intentions, motivations, attitudes, and personal conduct and those of their sexual partners (Fisher and Fisher 2000). Although individual behavior-change models have achieved some important success in reducing HIV transmission over the course of the twenty-fiveyear history of the epidemic (Holtgrave and Curran 2006), the nonrandom, social character of the HIV/AIDS epidemic and its disproportionate effects on Latino men who have sex with men compel us to shift our focus away from the individual and on to social and structural factors, which may better explain why the HIV/AIDS epidemic concentrates itself in marginalized populations (Krieger 1999, 2003). Reexamining the usefulness of individual behavior change paradigms for prevention and exploring the social and structural determinants for the sexual health of Latino men might point to alternative intervention strategies (Coates 1990; Mays, Cochran, and Zamudio 2004; Merzel and D’Afflitti 2003; Peterson and Carballo-Diegues 2000). This chapter provides a brief overview of HIV/AIDS epidemiology among Latinos in the United States, reviews the HIV/AIDS research literature documenting the psychological correlates of HIV infection for men who have sex with men, with a focus on Latino gay men, and links those to social discrimination and HIV/AIDS-related stigma as possible structural culprits for the epidemic’s social shape. Concentrated Epidemics with Structural Underpinnings

The HIV/AIDS epidemic has impacted Latinos disproportionately. Latinos account for 20 percent of persons living with AIDS, 19 percent of the cumulative

10,059

Puerto Rico

7,844

16,345

California

Florida

21,597

New York

17

99

29

31

20

of total (%)

at end of 2004 a

84,001

reported

Proportion

with HIV/AIDS

1,008

910

1,648

2,267

9,207

in 2004

cases

Latinos living

Latino AIDS

17

100

35

30

21

of total (%)

Proportion

38

23

18

94

26.8

in 2004

per 100,000

case rate

Latino AIDS

73,284

21,369

123,964

124,656

742,094 (81%)

2004

through

cumulative

43,475

6,602

105,805

53,342

462,760 (62%)

2004 a

through

cumulative

MSM,

among all

among all men,

AIDS cases

AIDS cases

AIDS epidemiologic profile for Latinos and all men, 2004

AIDS Cases in States with Concentrated Latino Populations, 20 04–20 05

Total in U.S.

Table 11.1

3,492,480 (20)

3,762,746 (99%)

12,572,990 (35%)

2,958,970 (16)

43,077,110 (14.6)

(% of total)

2004–2005

population

Latino

812,110 (23)

1,655,082 (100%)b

3,584,050 (29%)

931,720 (31)

12,502,230 (29)

(% of total)

2005

poverty,

Latinos in

Number of

data, 2004–2005

Population and poverty

3,566

2,339

2,079

1,996

1,956

1,010

New Jersey

Illinois

Pennsylvania

Massachusetts

Connecticut

Arizona

25

30

24

14

15

21

25

170

221

156

222

256

403

881

30

34

28

14

15

22

27

15

79

42

62

20

40

15

8,393

10,061

14,249

24,184

25,858

33,588

55,635

6,840

3,573

7,311

13,695

17,518

11,469

41,803

1,848.290 (31)

35,171 (10)

513,600 (8)

531,950 (4)

1,502,090 (12)

1,397,180 (16)

8,314,779 (37)

572,300 (31)

122,970 (35)

159,550 (31)

146,510 (28)

366,590 (24)

366,760 (26)

2,765,970 (33)

Sources: CDC 2006a; Kaiser Family Foundation 2006.

Forty-four percent of Puerto Rico’s population is living in poverty.

b

Nationwide the exposure category for 10 percent of AIDS cases is not reported or goes undetermined. Many of these cases are later reclassified into the men who have sex with men (MSM) exposure category. In New York, Florida, and New Jersey, the exposure category for 16 percent, 14 percent, and 14 percent of AIDS cases, respectively, is unreported.

a

7,349

Texas

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AIDS cases reported through December 2004, and 21 percent of new AIDS cases reported in 2004 (Kaiser Family Foundation 2006). As of December 31, 2007, the number of people living with AIDS in the United States was 551,932, of which 92,943 were Latino (CDC 2009). Ethnically and by place of birth, Latinos are differentially affected by the HIV/AIDS epidemic. In 2005, Latinos born in the United States made up the largest proportion—32 percent of reported AIDS cases of all Latino groups. That same year, Puerto Ricans and Mexicans accounted for 18 percent and 17 percent of estimated adult Latino AIDS cases, respectively (CDC 2006b). The number of AIDS cases per 100,000 is an important indicator of disease impact within particular communities at the population level. In 2005, the AIDS case rate per 100,000 Latinos was 26.4 as compared to 7.5 per 100,000 whites. The highest AIDS case rate in the United States is among blacks, who have a rate of 75 per 100,000 (CDC 2006b). Nationally, AIDS case rates per 100,000 Latinos is highest along the Northeast corridor, ranging from 42.3 per 100,000 Latinos in Massachusetts to 111.7 in Washington, D.C. (Kaiser Family Foundation 2006). In fact, the AIDS epidemic among Latinos in the United States is geographically concentrated within New York, California, Puerto Rico, Florida, Texas, and New Jersey, home to 80 percent of all Latinos living with AIDS at the end of 2004 (Kaiser Family Foundation 2006). Table 11.1 presents U.S. AIDS cases among Latinos, men, and men who have sex with men by states, and Puerto Rico, with concentrated Latino epidemics, large Latino populations, and high numbers of Latinos living in poverty through 2004. It is important to note that, in general, the AIDS epidemic for Latinos is concentrated in states where Latinos represent a disproportionate number of those living in poverty. The AIDS epidemic among Latinos is also largely concentrated in large metropolitan areas. Eighty-nine percent of new AIDS diagnoses occur in metropolitan areas of 500,000 people or more. The six U.S. cities with the highest number of newly diagnosed Latinos are New York, Los Angeles, Miami, San Juan, Houston, and Chicago, in that order, representing 61 percent of all new Latino AIDS cases in 2004 (CDC 2006a). Men make up the majority of HIV and AIDS cases in the United States. In 2005, there were an estimated 28,037 men diagnosed with HIV and/or AIDS in the thirty-three states with confidential name-based HIV infection reporting systems in place, representing 74 percent of all reported cases that year. More than 20,000 of them (72 percent) were men who have sex with men (CDC 2006b). These figures do not include the state of California, which at the time was not yet reporting name-based HIV infection diagnoses. California’s epidemic is overwhelmingly male, with the majority of new HIV infections and AIDS case

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diagnoses happening among men who have sex with men (California Department of Health Services 2006). Nationwide, 68 percent of all male AIDS cases cumulatively reported through 2005 were among men who have sex with men (CDC 2006b). Although the primary mode of exposure for all Latino groups, except for Puerto Ricans, is male-to-male sexual contact, modes of exposure vary by ethnicity (among Puerto Rican–born Latinos, the main mode of HIV exposure is injection drug use). For example, in 2005, 64 percent of newly reported AIDS cases among Latinos born in Mexico were among men who have sex with men, whereas the proportion was 50 percent for U.S.-born Latinos. Forty-three percent of newly reported AIDS cases among Puerto Rican–born Latinos were injection drug users. By the end of 2005, there were 325,165 men living with AIDS, and 62,117 (19 percent) of them were Latino. Of Latino men living with AIDS, 38,078 (63 percent) were men who have sex with men (CDC 2006b). Until recently, the disproportionate impact of the HIV/AIDS epidemic on Latino men who have sex with men was largely attributed to higher sexual risk for HIV among this population. Sexual risk behavior is typically attributed to individuals’ low level of information and knowledge, inaccurate assessments of risk, low perceptions of personal vulnerability, and a lack of motivation or personal intentions to practice safer sex (Fisher, Fisher, and Harman 2003; Fisher and Fisher 2000; Fishbein et al. 1991; Catania, Kegeles, and Coates 1990). However, evidence is mounting that suggests persistent racial and ethnic disparities in HIV/AIDS is structural in origin and can more appropriately be attributed to the compounding effects of discrimination on the health of disenfranchised populations (Krieger 1999, 2003). Racial prejudice can affect health outcomes in at least two ways (Cain and Kington 2003). First, racial and ethnic discrimination usually result in social practices and economic policy that restrict employment, housing, education, and health care opportunities, which in turn can produce negative health outcomes. Second, racial and ethnic discrimination can produce negative emotional and stress responses in those experiencing the discrimination. The resulting range of physical outcomes has been documented in the health disparities literature (Williams, Neighbors, and Jackson 2003). The social and sexual lives of Latino gay men have been affected by at least three forms of discrimination—racism, heterosexism, and economic disenfranchisement—which together can produce experiences of social alienation, depression, and personal shame (Ayala and Diaz 2001; Diaz 1998; Diaz et al. 2001). Experiences of discrimination might explain why Latino men who have sex with men continue to be disproportionately affected by the AIDS epidemic. Given the social shape of the epidemic among Latinos and Latino men in the

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United States, we have chosen to focus the remaining sections of this chapter on Latino gay men as a strategy for shedding light on the social and structural determinants of HIV/AIDS. Understanding health risk—in this case, those factors believed to either heighten the risk for HIV transmission or compromise motivation, skills, support networks, and other resources necessary to protect against HIV transmission—is one which draws connections to underlying social and structural factors. Therefore, what follows is a review of some contemporary psychological (intrapersonal) correlates of HIV risk among men who have sex with men and their connection to social discrimination and HIV/AIDS-related stigma. Psychological Correlates of HIV Risk

A variety of studies of gay men and other men who have sex with men have found significant associations between HIV risk behavior and psychological or intrapersonal factors. Among these are loneliness, anxiety, anger, low selfesteem, substance abuse, and depression (Boulton et al. 1995; Gold and Skinner 1992; Parson 1999; Stall et al. 2001, 2003). Higher rates of depression and drug dependence are reported by U.S.-born than among foreign-born Latino males. Reducing symptoms of depression and other mental health issues are associated with reductions in HIV-related risk behaviors (Hutton et al. 2004). The role of childhood sexual abuse has also emerged as an important factor to consider in understanding gay men’s risk behavior. For example, Lenderking et al. (1997) found that gay men sexually abused as children reported more lifetime male sex partners and were more likely to have had unprotected receptive anal intercourse in the past six months. Other researchers reported similar findings with gay men in general (Jinich et al. 1998; Strathdee 1998) and more recently with Latino men who have sex with men (Arreola 2006). Substance abuse, including abuse of crystal methamphetamine, among gay men is strongly associated with the risk for HIV infection and continues to complicate HIV prevention efforts with men who have sex with men, including Latino gay men (Halkitis, Parsons, and Stirrat 2001). For example, one study of Latino gay men in Miami-Dade County (n262) found that more than 50 percent of men used club drugs, and 36 percent had used them in the last three months. Lifetime and three-month rates for this group were ecstasy (36 percent and 20 percent), cocaine (34 percent and 12 percent), amyl nitrites (28 percent and 9 percent), and crystal methamphetamine (20 percent and 15 percent). Thirty-six percent had used two or more drugs (polydrug use) in their lifetime, and 20 percent reported polydrug use in the last three months. Club drug users had significantly more sex partners in the last twelve months than nonclub

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drug users (Fernandez et al. 2005). In another survey, study of men who have sex with men conducted as part of the Centers for Disease Control’s multisite National HIV Behavioral Surveillance System, investigators found that Latino men who have sex with men and use crystal methamphetamine during sex were between eight and ten times more likely to have received a new HIV diagnosis (Bingham et al. 2006). Multiple HIV/AIDS prevention studies indicate that gay men and other men who have sex with men are less likely to practice safe sex with close, regular relationship partners compared with sexual partners considered to be more casual (Misovich, Fisher, and Fisher 1996). In a three-city (Los Angeles, Miami, and New York) probability sample of Latino gay men (n912), 37 percent of respondents reported unprotected anal intercourse (UAI) with their last two sexual partners within the past twelve months. A little more than half of the 37 percent of men who reported UAI did so with a primary partner they considered to be a lover or a boyfriend (Diaz and Ayala 2001). This may be of particular concern for same-sex couples that are unaware of their HIV sero-status or that are sero-discordant (one partner is HIV-negative and the other is HIV-positive). There is some evidence to suggest that among sero-discordant gay couples, UAI is more likely to occur among Latino gay men (Remien et al. 2001). Misinformation, lack of social support (partner, relational, friendship), experiences of heterosexism, and difficulty with communication or negotiation skills specific to relationships can create unique barriers to safer sexual practices for gay couples (Haas 2002; Hays, Kegeles, and Coates 1997; Powell-Cope 1998). For example, when communication is impaired due to unexpressed fears about HIV transmission, potential illness, relationship instability, loss, future uncertainty, and the desire to protect each other against these concerns, many aspects of the relationship important for sustaining health-promoting behaviors can be negatively affected. In addition, key emotional issues between gay, sero-discordant couples, when left unaddressed, can compromise the couple’s capacity to guard against HIV exposure (Beckerman, Letteney, and Lorber 2000). Addressing these issues and legitimizing the emotional and intimacy needs of both members of a gay relationship may be critical to HIV prevention efforts (Remien et al. 1995). This is important in the context of contemporary debates about same sex marriage and the social movement for institutional recognition and legal protections of same sex couples. Social Discrimination and HIV/AIDS Stigma

The psychological correlates of HIV risk behavior for gay men and other men who have sex with men, which are often interrelated, may have a common

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basis in the considerable stigma and discrimination that many gay men, especially Latino gay men, experience and must navigate in their day-to-day lives (Diaz et al. 2001; Meyer 1995). For some Latino gay men, financial hardship, family rejection, stigma, and disparities in access to health care and prevention education create barriers to health-promoting behaviors—preventing their fair and full participation in community life (Diaz, Ayala, and Bein 2004). For the purposes of this chapter, we define social discrimination as mean, unfair, or unequal treatment (including acts of verbal or physical violence) intended to marginalize or subordinate individuals or communities based on their real or perceived affiliation with socially constructed stigmatized attributes. Dominant forms of discrimination are based on race/ethnicity, gender, sexual orientation, disability (including HIV sero-status), age, and class. Discrimination serves to maintain inequities between different groups. At the cultural level, discrimination is justified in ideology and expressed in discourse or interactions among and between individuals and institutions. At the structural level, the consequences of discrimination can be characterized by differences in proximity to social and economic resources often resulting in differences in health—both physical and mental well-being (Krieger 2003; Millett et al. 2006). Heterosexism for example, is predicated on an ideological system that denies, denigrates, and stigmatizes any nonheterosexual form of behavior, identity, relationship, or community. Like racism and sexism, heterosexism pervades societal customs and institutions. It operates through invisibility, social hostility, and the denial of civil and/or human rights. Examples of heterosexism in the United States include the continuing ban against lesbian and gay military personnel; widespread lack of legal protection from antigay discrimination in employment, housing, and services; hostility to lesbian and gay committed relationships, as evidenced by passage of federal and state laws against same-sex marriage; and the existence of sodomy laws in more than onethird of states (Herek 2004). Various forms of social discrimination (i.e., racism, poverty, and heterosexism) have been associated with increased behavioral risk for HIV infection (Choi, Yep and Kumekawa 1998; Diaz 1998; Diaz, Ayala, and Bein 2004). For example, socioeconomic status has long been associated with disparities in health status (Adler et al. 1994; Krieger 1999; Williams and Collins 1995) and has specifically been shown to be a significant factor in HIV infection (Krueger et al. 1990; Simon et al. 1995; Zierler et al. 2000). This research suggests that the influence of socioeconomic status on broader health outcomes (e.g., mortality, chronic diseases) is mediated by differences in access to care, experiences of racism, social conditions (e.g., crime), lifestyle patterns (e.g., smoking, exercise, and eating habits),

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and psychological well-being (e.g., stress) (Adler et al. 1993; Krieger et al. 1993; McLeod and Kessler 1990; Otten et al. 1990; Stokols 1992; Williams and Collins 1995; Winkleby 1999). However, HIV prevention research has rarely focused on exploring the precise mechanisms by which such social forces operate to heighten the risk for HIV infection (Amaro and Raj 2000; Farmer 1999). One study of African American heterosexual men and women living in rural areas offers some revealing insights about possible pathways by which social discrimination influences the risk for HIV infection. Investigators documented the organizing effects that racism and poverty have on sexual partner selection, which in turn produce sexual network patterns such as concurrent partnerships that facilitate the transmission of HIV and other sexually transmitted infections (Adimora et al. 2001). Economically disenfranchised communities had fewer vital institutions to organize social opportunities, leading to boredom and increased recreational use of drugs. Moreover, poverty limited sexual partner choices, as few prospective partners were available in their neighborhoods (a function of early death, drug addiction, or incarceration of the men—consequences related to social discrimination). In addition, poverty limited their ability to travel elsewhere to meet partners and could prompt additional “side relationships” to provide monetary support. The potentially damaging social and economic consequences of racism and the negative effects of both racism and antigay stigmatization on individual well-being are well established in the research literature (Diaz et al. 2001; DiPlacido 1998; Finch et al. 2001; Jones 1992; Klonoff, Landrine and Ullman 1999; Meyer 1995; Rosser and Ross 1989; Schuman, Steeh and Bobo 1985; Waldo 1999; Williams 1990). This stigmatization—and the strategies used to cope with (and minimize exposure to) such stigmatization can shape both opportunities an individual has to meet sexual partners, as well as meanings attached to those relationships (Ayala and Diaz 2001). For example, social structures supportive of racial identity and important sources of social connectedness may exert heterosexist conformity pressure, while those supportive of gay identities may fail to support Latino men and may exert racially biased conformity pressure (Contrada et al. 2000; Greene 1997; Hidalgo 1995; Walters 1998; Wilson and Miller 2002). In this regard, issues associated with multiple stigmatization (i.e., being the target of both racism and heterosexism) faced by Latino gay men, including how Latino gay men manage competing loyalties to their families or communities of origin versus their families or communities of choice, are important to understand. HIV/AIDS stigma also operates to heighten the risk for HIV transmission. Although much of our knowledge about HIV/AIDS-related stigma comes from

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studies conducted with the general population (Herek 1999), stigma is as much a problem for men who have sex with men as for anyone else. For example, in the same three-city probability sample of Latino gay men mentioned earlier, the prevalence of HIV/AIDS stigma among HIV-negative men was startling. More than half of the sample (57 percent) believed that HIV-positive individuals are responsible for getting infected, and close to half (46 percent) of the sample believed that HIV-positive persons are to be blamed for the spread of AIDS. In addition, 52 percent of the sample saw HIV-positive men as more sexually promiscuous, and 18 percent believed that they are people who cannot be trusted. A substantially large proportion of HIV-positive men in the same sample reported that being HIV-positive had impacted negatively their social and sexual lives, beyond the physical/medical challenges posed by their HIV infection. For example, about half of the sample felt that HIV had made it more difficult for them to find sex (46 percent) and an even larger proportion (58 percent) felt that HIV made it more difficult to find lover relationships. Two-thirds (66 percent) of the sample reported that HIV had made it harder for them to enjoy sex. The overwhelming majority (82 percent) of HIV-positive men thought sexual partners might reject them if they knew their HIV sero-status. Nearly half (46 percent) of all HIV-positive participants reported having been treated unfairly because of their sero-status, and 45 percent believed that they had to hide their status to find acceptance from their families and friends. Further analysis demonstrated that for HIV-positive men, experiences of racism, homophobia, and financial hardship, when combined with HIV/AIDS-related stigma, predicted loneliness, low self-esteem, and psychological symptoms of emotional distress more strongly than experiences of racism, homophobia, and poverty alone (Diaz 2006). Keeping a Steady Eye on the Social Shape of the HIV/AIDS Epidemic

In the HIV/AIDS sector, the risk for HIV infection is typically framed as a problem at the individual level. This is not exactly accurate, as evidenced by recent research literatures, which increasingly point to social and structural forces that give shape to the epidemic. The more complicated reality is that HIV risk is the property of interpersonal context (Diaz 2001), is relational in nature (Mays, Cochran, and Zamudio 2004), and is driven by a number of larger social and structural forces like racism, poverty, and heterosexism. Given the diversity of affected communities, multiplicity of discrimination experiences, and variation in interpersonal contexts of risk, we must question the continuing viability of HIV/AIDS research, policy, and practice that bases itself only on the individual.

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Nonetheless, mainstream descriptions of the HIV/AIDS epidemic in the United States are at times problematic because they often paint an incomplete and misleading picture about what is happening at the national level. These descriptions often start with statements about the disproportionate toll HIV/AIDS has taken in communities of color, including Latino communities, with no mention of gay men and other men who have sex with men. Men who have sex with men continue to make up the majority of new HIV infections and the majority of people living with HIV/AIDS nationally across race and ethnicity. The HIV/AIDS epidemic’s affect on women and families is intricately tied to the lives of these men. Our ability to formulate responsive research agendas, strategic policy responses, and effective prevention interventions requires a more direct discussion about gay men and the underlying social and structural basis of the HIV/AIDS epidemic. The alternative is that we collude with silence and denial about sexuality, drug use, and economic inequality, permitting to go unchecked the role that HIV-related stigma, heterosexism, and racism has in complicating our prevention efforts. References Adimora, A., V. Shoenbach, F. Martinson, K. Donaldson, R. Fullilove, and S. Aral. 2001. Social context of sexual relationships among rural African Americans. Sexually Transmitted Diseases 28 (2): 69–76. Adler, N., T. Boyce, M. A. Chesney, S. Cohen, S. Folkman, R. L. Kahn, and S. L. Syme. 1994. Socioeconomic status and health: The challenge of the health gradient. American Psychologist 49 (1): 15–24. Adler, N., W. Boyce, M. Chesney, S. Folkman, and S. Syme. 1993. Socioeconomic inequalities in health: No easy solution. JAMA: Journal of the American Medical Association 269: 3140–3145. Amaro, H., and A. Raj. 2000. On the margin: Power and women’s HIV risk strategies. Sex Roles, 42 (7/8): 723–749. Arreola, S. G. 2006. Childhood sexual abuse and HIV among Latino gay men: The price of sexual silence during the AIDS epidemic. In Sexual Inequalities and Social Justice, ed. N. Teunis and G. Herdt. Berkeley: University of California Press. Ayala, G., and R. M. Diaz. 2001. Racism, poverty and other truths about sex: Race, class and HIV risk among Latino gay men. Revista Interamericana de Psicologia 35 (2): 59–77. Beckerman, N. L., S. Letteney, and K. Lorber. 2000. Key emotional issues for couples of mixed HIV status. Social Work in Health Care 31 (4): 25–42. Bingham, T., N. Harawa, G. Ayala, D. Fearman-Johnson, M. Janson, and J. Carlos. 2006. Crystal methamphetamine use and new HIV infections in Latino men who have sex with men (MSM): Los Angeles Men’s Survey 2004. AIDS and Behavior. MS. Boulton, M., J. McLean, R. Fitzpatrick, and G. Hart. 1995. Gay men’s accounts of unsafe sex. AIDS Care 7: 619–630. Cain, V.S., and R.S. Kington. 2003. Investigating the role of racial/ethnic bias in health outcomes. American Journal of Public Health 93: 191–192. California Department of Health Services. 2006. Cumulative AIDS cases as of October 31, 2006. California AIDS Surveillance Report. California Office of AIDS, Sacramento. http://www.dhs.ca.gov/ps/ooa/Statistics/AIDScase2006.htm.

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Kegeles, S., R. B. Hays, and T. J. Coates 1996. The Mpowerment Project: A communitylevel HIV prevention intervention for young gay men. American Journal of Public Health 86 (8): 1129–1136. Kelly, J. A., J. S. St. Lawrence, L. Y. Stevenson, A. C. Hauth, S. C. Kalichman, Y. E. Diaz, T. L. Brasfield, J. J. Koob, and M. G. Morgan. 1992. Community HIV/AIDS risk reduction: The effects of endorsements by popular people in three cities. American Journal of Public Health 82 (11): 1483–1489. Klonoff, E., H. Landrine, and J. Ullman. 1999. Racial discrimination and psychiatric symptoms among blacks. Cultural Diversity and Ethnic Minority Psychology 5 (4): 329–339. Krieger, N. 2003. Does racism harm health? Did child abuse exist before 1962? On explicit questions, critical science and current controversies: An eco-social perspective. American Journal of Public Health 93: 194–199. ———. 1999. Embodying inequality: A review of concepts, measures, and methods for studying health consequences of discrimination. International Journal of Health Services 29 (2): 259–352. Krieger, N., D. Rowley, A. Hermann, B. Avery, and M. Phillips. 1993. Racism, sexism, and social class: Implications for studies of health, disease, and well-being. American Journal of Preventive Medicine 9 (suppl.): 82–122. Krueger, L., R. Wood, P. Diehr, and C. Maxwell. 1990. Poverty and HIV seropositivity: The poor are more likely to be infected. AIDS 4: 811–814. Lenderking, W. R., C. Wold, K. H. Mayer, R. Goldstein, E. Losina, and G. R. Seage. 1997. Childhood sexual abuse among homosexual men: Prevalence and association with unsafe sex. General Internal Medicine 12: 250–253. Mays, V. M., S. D. Cochran, and A. Zamudio. 2004. HIV prevention research: Are we meeting the needs of African American men who have sex with men? Journal of Black Psychology 30: 78–103. McLeod, J., and R. Kessler. 1990. Socioeconomic status differences in vulnerability to undesirable life events. Journal of Health and Social Behavior 31: 162–172. Merzel, C., and J. D’Afflitti. 2003. Reconsidering Community-based health promotion: Promise, performance, and potential. American Journal of Public Health 93 (4): 557–574. Meyer, I. H. 1995. Minority stress and mental health in gay men. Journal of Health Social Behavior 36: 35–56. Millett, G. A., J. L. Peterson, R. J. Wolitski, and R. Stall. 2006. Greater risk for HIV infection of black men who have sex with men: A critical literature review. American Journal of Public Health 96: 1007–1019. Misovich, S. J., J. D. Fisher, and W. A. Fisher. 1996. The perceived AIDS preventive utility of knowing one’s partner well: A public health dictum and individuals’ risky sexual behavior. Canadian Journal of Human Sexuality 5: 83–90. Otten, M., S. Teutsch, D. Filliamson, and J. Marks. 1990. The effect of known risk factors on the excess mortality of black adults in the United States. JAMA: Journal of the American Medical Association 263: 845–850. Parson, J. T. 1999. Correlates of sexual HIV transmission risk behaviors among HIV men who have sex with men. National HIV Prevention Conference 1999, August 29–September 1, abstract no. 181. Peterson, J. L., and A. Carballo-Diegues. 2000. HIV prevention among African American and Latino men who have sex with men. In Handbook of HIV Prevention, ed. J. L. Peterson and R. J. DiClemente, 217–224. New York: Kluwer Academic/Plenum Publishers.

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Wilson, B., and R. Miller. 2002. Strategies for managing heterosexism used among African American gay and bisexual men. Journal of Black Psychology 28 (4): 371–391. Winkleby, M., C. Cubbin, D. Ahn, and H. Kraemer. 1999. Pathways by which SES and ethnicity influence cardiovascular disease risk factors. In Socioeconomic Status and Health in Industrial Nations: Social, Psychological, and Biological Pathways, ed. N. Adler, M. Marmot, B. McEwen, and J. Stewart, 191–209. New York: New York Academy of Sciences. Zierler, S., N. Krieger, Y. Tang, W. Coady, E. Siegfried, A. DeMaria, and J. Auerbach. 2000. Economic deprivation and AIDS incidence in Massachusetts. American Journal of Public Health 90: 1064–1073.

Russell Homan, Patricia A. Homan, Chapter 12

and Olveen Carrasquillo

Health Coverage, Utilization, and Expenditures among Latino Men

The Agency for Health Care Research and Quality (AHRQ) publishes the annual National Health Disparities Report (NHDR), which provides a comprehensive review of data obtained from many distinct sources regarding healthcare disparities among members of racial and ethnic minorities versus non-Hispanic whites (NHWs). The 2006 NHDR found that Hispanics had worse access to care than non-Hispanic whites in 83 percent of core measures examined (AHRQ 2006b). In addition, while disparities have been steadily improving for blacks and Asians, most of the disparities in access to care were getting worse for Hispanics. Perhaps no measure of access to care is as important as that of health insurance, which is continually cited as the key health disparity issue facing the Latino community in the United States (Hargraves and Hadley 2003; Harrell and Carrasquillo 2003; Kirby, Taliaferro, and Zuvekas 2006). Indeed, in 2006, nearly one-third of Latinos in the United States lacked health coverage versus 11 percent of NHWs (DeNavas-Walt, Proctor, and Lee 2006). Further, the number of Latinos without coverage has nearly doubled during the past twelve years (Shah and Carrasquillo 2006). This crisis in the Latino community has been extensively described (American College of Physicians 2000; Doty and Holmgren 2006). Studies have examined coverage among ethnic subgroups (Carrasquillo and Barbot 2000) analysis among females (Rodriguez and Carrasquillo 2003), longitudinal trends in coverage (Shah and Carrasquillo 2006), role of immigration status (Carrasquillo, Carrasquillo, and Shea 2000), language barriers (Doty 2003), reasons for these gaps in coverage (Flores, Abreu, and Tomany-Korman 2006), and potential interventions. To date, however, detailed data on insurance coverage for Latino men has not been published. 229

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In addition, few studies have examined other aspects of access among Latino males, such as having a usual source of care, visits to providers, health expenditures, and health screenings. This chapter addresses these gaps in the literature by employing a health services approach to describe disparities in access faced by Latino men. Our findings are framed within the analytic framework of the book, which examines the role of social and structural factors as key to understanding the health of Latino males. Data Sources

Historically one of the most significant structural barriers to examining access to care among Latino males has been limited data. Fortunately, over the past twenty-five years several large national and regional ongoing surveys have been developed or modified so that important questions concerning insurance coverage and other measures of access can be examined among subgroups of Latino men. In this section, we present some of these sources of publicly available data and discuss the strengths and limitations of each. (Note: As the sample sizes for each survey described below vary from year to year, the sample size estimates are approximations). The survey most commonly used to provide health insurance coverage data is the Annual Social and Economic Supplement (ASEC) to the Census Bureau’s Current Population Survey (CPS), which samples over 230,000 persons (U.S. Census Bureau 2006). The CPS includes an extensive series of questions on health insurance coverage, socio-demographics, and immigration status. Foreign-born persons are queried as to whether they are noncitizens; however, additional immigration details, such as undocumented status, are not covered. Demographic questions concerning Latino ethnicity are limited to Mexican origin, Puerto Rican, and Cuban. Fortunately, the survey also includes questions about country of birth and maternal and paternal country of birth, which allows estimates to be obtained for recent immigrant groups such as Dominicans and Central Americans. With the CPS’s large sample size, insurance estimates with fairly narrow standard errors are possible for some of the largest Latino groups, such as Mexicans, Puerto Ricans, Cubans, and Dominicans. Further, state-level analysis for Latinos is possible for those with large Latino populations (e.g., California, New York, Texas, Florida, New Jersey, and Illinois). Analysts can also examine data at the level of metropolitan statistical areas (MSA). As an example, one can examine the proportion of uninsured Latinos in the Miami-Dade MSA. The major limitation of the CPS is that it only provides data on health insurance and does not include data on other markers of access or utilization.

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Another survey commonly used to examine access to care is the National Health Interview Survey (NHIS), which samples nearly 100,000 persons, including oversampling of Hispanics (nearly 20,000 were sampled) (NHIS 2006). Hispanics can self-identify as Mexican, Mexican/ American, Cuban, Puerto Rican, or Dominican or other. Thus, subgroup analysis of the four largest Latino groups is possible. While the health insurance questions are not as extensive as the CPS, the survey includes data on utilization, including preventive services. In addition, the survey also includes information on county of birth and nativity, as well as a modified version of the Marin acculturation scale, allowing analysts to examine the role of such factors on specific aspects of health care utilization. Although, some state-level analysis is possible, these require use of restricted variables and again would only be possible for states with the largest Latino populations. One other national survey commonly used to examine access to health care is the Medical Expenditure Panel Survey (MEPS). The MEPS, which contains extensive questions about health care utilization, is also the only source of nationally representative individual-level health expenditure data (MEPS 2007). MEPS data can also be linked to NHIS questions on citizenship and country of birth. Through such linkages, estimates such as health expenditures for U.S.-born versus immigrant Latinos have been possible. However, the major limitation is that the survey only samples about thirty thousand persons. Thus, while estimates for Latinos as a whole are quite stable, standard error estimates for most Latino subgroups are large. Data from surveys at the state and local level can also provide important access data for Latino populations. Two well-conducted surveys that include access data for Latino groups and are potentially useful for analysts interested in regional data are the California Health Interview Survey (2006) and the New York City Community Health Survey (New York City Department of Health and Mental Hygiene 2006). Health Coverage

Unlike every other industrialized country, the United States does not guarantee health insurance for all of its residents. The political basis for this peculiar attribute of our nation is continually and extensively debated. In the most simplistic terms, this structural factor is usually framed within the context of the role government should have in meeting the needs of its residents versus individual responsibility. What role market forces should play in health care is also part of this debate. Since 1965, there has been consensus that most elders should be covered by a system of national health insurance that we call

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Medicare. For all others, what has historically emerged is a system of health coverage that is primarily based on employment. Insurance coverage is based on what kind of employment one has, whether the employer offers comprehensive health benefits, and whether the person has worked long enough for that employer to be eligible for such benefits. The other structural system for health coverage that has emerged is a state-based patchwork of insurance for low-income persons primarily through Medicaid and Medicaid-like programs such as the State Children’s Health Insurance Programs (SCHIP). Methods

To examine health insurance coverage among Latino men, we used the March 2006 CPS. As noted, in the CPS, Mexican, Puerto Rican, and Cuban Latino subgroups are self-identified. To identify Dominicans, we used information on nativity and parental nativity to assign Dominican status to Hispanic respondents who did not identify themselves as Mexican, Puerto Rican, or Cuban and who reported they or at least one of their parents was born in the Dominican Republic. Latinos who were not assigned to any of these subgroups were listed as “Other Latino.” Population estimates were produced using weights provided with the CPS. All reported percentages had a 90 percent confidence interval of less than plus or minus 10 percentage points, reflective of sampling error. Because of smaller sample sizes, and to obtain more stable estimates, some citizenship and subgroup percentages were obtained from a three-year average of the annual percentages from the 2004–2006 CPS surveys. Overall Coverage

In 2005, 35 percent of all Latino males were uninsured versus 21 percent of black males and 12 percent of all non-Hispanic white (NHW) males (table 12.1). Numerically, this represents 7.8 million Latino men without health coverage. Although Latinos comprise 15 percent of the male population in the United States, they make up 33 percent of the country’s uninsured population. The most important individual level predictor of having coverage among Latinos males was citizenship status. Sixty percent of non-U.S. citizen Latino males lacked coverage in 2005. These four million noncitizen Latinos make up 55 percent of all uninsured Latino males. Although the CPS does not estimate the proportion who are undocumented, other studies have shown lack of coverage is most acute among the undocumented. Surveys in New York City and Los Angeles estimate that nearly 80 percent of undocumented residents lack coverage (Capps, Ku, and Fix 2002). Due to their immigrations status, most of these undocumented Latinos are employed in the informal economy, such as

Health Coverage, Utilization, and Expenditures Table 12.1

233

Health Insurance Coverage of Latino Males Uninsured rates among males by age for 2005 (%) ⬍19

19–35

36–64

⬎64

All years

NHWs

8

24

12

1

12

Blacks

13

37

22

4

21

Latinos

22

53

36

7

35

Mexican

25

56

39

7

38

Puerto Rican

11

36

18

3

20

Cuban

21

36

29

2

23

Dominican

17

44

33

10

29

Other

19

52

36

8

35

U.S.-born

18

37

22

2

23

Naturalized

32

41

28

4

28

Noncitizen

55

68

53

19

60

Age

Subgroup

Citizenship status

Source: Data from Current Population Survey 2003–2006 (U.S. Census Bureau 2006).

“off-the books” types of employment, and thus receive no benefits. As a result, many working Latinos are unable to obtain coverage for themselves and their families. Thus, only 28 percent of noncitizen Latinos had employer insurance versus 48 percent of naturalized Latinos and 45 percent of U.S.-born Latinos. Of note, a small minority of the undocumented Latinos are able to obtain employer coverage by using social security numbers belonging to others and working for employers that provide coverage. Additionally, it is nearly impossible for the undocumented, unlike low-income citizens, to obtain government insurance such as Medicaid or SCHIP. Thus, this individual-level barrier needs to be framed with the context of structural factors, such as employment opportunities and types of occupations available to Latino immigrants in the United States, and regulations preventing many immigrants from participating in public insurance programs. The major implication of our finding is that any attempt to improve coverage among Latino males must specifically address the structural barriers faced by Latino males residing in the United States who are noncitizens. Lack of coverage is also a significant health issue among Latino U.S. citizens. Indeed, the uninsured rates among U.S.-born Latino males are nearly double that of NHWs (fig. 12.1). Further, nearly a third of foreign-born Latinos

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80 70

Uninsured rate (%)

60 50 40 NHWs 30

U.S.-born Naturalized

20

Noncitizens

10 0

100%

100–150%

150%

Income as percent of poverty level Figure 12.1

Health insurance coverage among Latinos by income and citizenship status.

Source: Data from the 2003–2006 Current Population Survey (U.S. Census Bureau 2006).

who became U.S. citizens (naturalized citizens) also lacked coverage. In our analysis, the strongest predictor of health coverage for Latinos who are U.S. citizens was family income, a pattern that is also evident for most other racial and ethnic groups. Indeed, next to citizenship status, income was the most important individual-level factor related to coverage. Combined, these two factors account for much of the disparities in insurance between Latinos and other groups. For example, while 28 percent of NHWs living in poverty lack coverage, the figure is nearly double that for poor Latinos (44 percent). However, these differences are markedly attenuated when one also adjusts from citizenship status. Indeed, although a quarter of U.S.-born Latinos below the poverty income level are uninsured, these numbers are similar to those among NHWs and black men at these income levels. Paradoxically, while increasing income is associated with increased insurance coverage for all groups, disparities in coverage between Hispanics and NHWs actually increase at higher incomes. For example, 10 percent of NHW males living above 150 percent of the federal poverty level are uninsured versus 44 percent of Latino men. Noncitizens remain most vulnerable, with 53 percent of noncitizen Latinos in this income group lacking coverage. Again, the primary mediator of these insurance disparities is structural, namely employment type. Despite rates of labor force participation that are similar to NHWs, Latinos are much more likely to be employed in lower income occupations. Such occupations are less likely to provide health insurance as an

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45 Uninsured rate (%)

40 35 30

NHWs

25

Blacks

20

Latinos

15 10 5 0 AZ

Figure 12.2

CA

FL

IL

NJ

NY

TX

State Health insurance coverage among men in states with large Latino

populations. Source: Data from the 2003–2006 Current Population Survey (U.S. Census Bureau 2006).

employee benefit (Enthoven and Fuchs 2006). As a result, only 40 percent of Latinos had employer-sponsored health insurance versus 66 percent of NHWs and 48 percent of blacks. However, even among higher income occupations, Latinos were less likely to have coverage. For example, while 73 percent of whites and 65 percent of blacks with incomes above 150 percent of the federal poverty level have employer insurance, only 53 percent of Latinos with incomes above this level have employer coverage. The sectors Latinos are employed in, such as small businesses, service, agriculture, and nonunionized labor often do not provide coverage. In addition, even when insurance is also offered by the employer, Latinos are more likely to be ineligible for such coverage due to multiple part-time jobs or not enough employment tenure. Lastly, there has also been some controversy about whether Latinos have lower rates of accepting insurance coverage when such coverage is available to them. That is, potentially, some community/social-cultural barriers exist among Latino men that, for cultural reasons, prompt them to go without coverage. Existing data, however, refutes this assumption. Most studies suggest these so-called take-up rates are similar among Latinos and NHWs (Doty 2003), while others suggest take-up rates for Latinos are only a few percentage points lower (Cooper and Schone 1997). Thus, it is clear the main barriers to health coverage among Latino men is structural—namely, working for an employer who does not offer coverage—and not community level sociocultural-based differences in take-up rates. Another possible structural/ community level explanation for lack of coverage is that some Latinos groups have traditionally been based in states with high uninsured rates (such as Texas, California, and New Mexico; see fig. 12.2).

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Table 12.2

Uninsured Rates among Latino Males and Females Age

Gender

Citizenship

Males

U.S.-born

Females

⬍19

19–35

36–64

18

37

22

⬎64

2

Naturalized

32

41

28

4

Noncitizen

55

68

53

19

U.S.-born

17

31

20

2

Naturalized

32

31

27

3

Noncitizen

51

60

50

19

Source: Data from Current Population Survey 2003–2006 (U.S. Census Bureau 2006).

However, our analysis of data in the states with the largest Latino populations shows large disparities in coverage between NHWs and Latinos in all these states. The most striking findings were that while coverage rates for NHWs vary widely among states, Latinos are equally vulnerable across most states. Indeed, even in states where the proportion of the uninsured NHW populations is under 10 percent, over 30 percent of Latinos males in those states lacked coverage. An example is New Jersey, where less than 10 percent of NHW males are uninsured but where 40 percent of Latinos lack coverage. These data highlight that even in states considered among national leaders in insurance reform, and which have generous policies toward government coverage, Latino males remain at high risk of being uninsured. The policy and public health implication of this finding is that for Latino men it is likely that reform initiatives will need to be national rather than state level. Prior reports have documented gaps in coverage among Latinas and the importance of coverage on preventive health services utilization among Latinas (Echeverria and Carrasquillo 2006; Rodriguez and Carrasquillo 2003). When we compare the data for Latinos versus that of Latinas, we find distinct patterns (table 12.2). In particular, while Latinas as a whole are more likely to lack coverage than NHW or black females, among males the disparities between Latinos and NHWs or blacks is much more pronounced. The bulk of this difference is seen among young adults, with Latina females benefiting from less restrictive barriers to government coverage for women who are pregnant or postpartum. In many states, such women, even when undocumented, qualify for temporary Medicaid. In contrast, among groups of non–child bearing age gender disparities are more attenuated. As an example, such disparities are narrowed among Latinos age thirty-six to sixty-four and are not evident among Latino children. These data suggest that gender disparities are not due to sociocultural

Health Coverage, Utilization, and Expenditures

237

70

% per group

60 50 40 30

Employer Coverage

20

Medicaid

10

Nonemployer private

0 White Figure 12.3

Black

Latino

Sources of health insurance coverage among men age nineteen to thirty-five.

Source: Data from the 2003–2006 Current Population Survey (U.S. Census Bureau 2006).

norms about Latino men thinking they do not need health coverage, but rather structural policies that provide public health insurance for females during pregnancy. Young adults of all races and ethnicity are the largest segment of America’s uninsured population. In addition, it is among young men where, in absolute terms, the largest age disparities between Latinos and NHWs are evident. Figure 12.3 shows that the primary source of coverage for most young men is employer coverage. Unlike women, the elderly, or children, it is nearly impossible for this Latino population to qualify for government coverage such as Medicaid, SCHIP, or Medicare. Given the structural limitations in employer coverage listed earlier, it is not surprising that over half of all Latino men ages nineteen to thirty-five are uninsured versus 37 percent of blacks and 24 percent of NHW men. Further, nearly three-quarters of all Latino men aged nineteen to thirty-five whose incomes were under the poverty level were uninsured. Even among those with incomes above the 150 percent of poverty level, disparities persisted, with 45 percent of such Latinos being uninsured versus 20 percent of NHWs and 30 percent of blacks. By citizenship status, 67 percent of noncitizen Latino young men were uninsured, versus 41 percent of naturalized citizens. Further, even among U.S.-born Latino young men, over a third (37 percent) lacked coverage. The cultural stereotype has been that these young adults choose not to have health insurance because they believe they are invincible and will not need health care (Amsden 2007). Studies have clearly shown, however, that most such young adults lack coverage simply because their employer does not provide it and they cannot afford to purchase it on their own. In fact, 60 percent of adults ages nineteen to twenty-nine who lack health insurance say they cannot

238

Homan, Homan, and Carrasquillo

70 60

% per group

50 40 30

NHWs

20

Blacks Latinos

10 0 Private only Figure 12.4

Medicare only

Medicare and Private

Medicare and Medicaid

Sources of insurance coverage among elders.

Source: Data from the 2003–2006 Current Population Survey (U.S. Census Bureau 2006).

afford coverage (Collins et al. 2006). With cost for insurance premiums being so prohibitive and with competing demands such as housing, many males are forced to gamble with their health care needs (Amsden 2007). Aside from the lack of routine and preventive care that results from being uninsured, the financial consequences when care is needed can also be devastating to young adults. Almost half of young adults who lack health insurance and require medical care will incur debt (Collins et al. 2006). Thus, proposals for health insurance expansion need to address structural barriers of employment opportunities for young Latino men and the prohibitive costs of comprehensive high quality health insurance. Although ethnic disparities in coverage are most pronounced among working-age males, from a health risk perspective, the most concerning disparity for males is among Latino elders. While, it is commonly assumed that Medicare provides universal health coverage for elders, this does not apply to Latinos, where 7 percent of Latino men over age sixty-fie are uninsured versus 1 percent of NHWs. Here again, a large proportion of the disparity can be attributed to immigration status, with 19 percent of male Latino elders who are not U.S. citizens lacking coverage. While some of these uninsured elders may be undocumented residents, in many instances even legal noncitizen elders lack coverage, again due to the structural barriers. In this instance, they did not work in the United States for ten years, as required to qualify for Medicare. In addition, even among those who have Medicare, 48 percent of Latino elders lack supplementary coverage versus only a quarter of NHWs (fig. 12.4). Such supplementary insurance is usually obtained through a plan from a former

Health Coverage, Utilization, and Expenditures

239

White Black Latino

Mexican Puerto Rican Cuban Dominican Other

U.S.-born Latino Naturalized Latino Noncitizen Latino 0% Figure 12.5

20%

40%

60%

80%

SCHIP/Medicaid coverage among male children.

Source: Data from the 2003–2006 Current Population Survey (U.S. Census Bureau 2006).

employer or is self-purchased and provides additional coverage for expenses such as Medicare copayments and deductibles. Prior studies have shown that elders without supplementary coverage are less likely to receive preventive services (DeLaet, Shea, and Carrasquillo 2002). For elderly poor Latinos, Medicaid is an important source of supplementary coverage, but covers less than a quarter of such elders. Of the 7.9 million male Latino children in the United States, 1.8 million are uninsured. The largest individual barrier is again citizenship status, with 32 percent of naturalized children and 55 percent of noncitizen male children being uninsured. By income, 28 percent of Latino children under the poverty level are uninsured as compared to 16 percent of poor NHW and black males. For such low income children, government coverage through SCHIP and Medicaid is critical (fig. 12.5). Unfortunately, coverage through Medicaid is also affected by citizenship status. While over 60 percent of poor U.S.-born Latino children have Medicaid or SCHIP, only a third or less of children who are naturalized or noncitizens have such coverage. The recent repeal of federal regulations that had barred immigrant children from health coverage until they have resided in the United States for at least five years may improve coverage among legal immigrant children.

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In addition, Medicaid is no panacea. First, among low income children the structural barriers that state governments erect to make sure that only eligible children are enrolled prevents many eligible children from participating (Fairbrother, Dutton et al. 2004). Second, the churning issue that occurs due to automatic disenrollment if all the required documentation is not provided at time of renewal, estimated at over 60 percent in some states, is also well known. In response, numerous community level initiatives have been implemented to overcome these structural barriers (Fairbrother, Jain, et al. 2004). Such heroic programs include those that assign community health workers, case managers, or in some instances even social workers to assist applicants in navigating the maze of enrollment barriers (Fairbrother, Stuber, et al. 2004; Flores et al. 2005). While these community level initiatives are commendable, policy analysts have found that the most efficient mechanism to increase the proportion of children covered under these plans is for states to simply make benefit receipt automatic (Remler and Glied 2003). Unfortunately, states remain steadfast that preventing “undeserving” children from participating in the program must remain a priority even if it means many eligible are denied coverage or statutorily disenrolled. The other limitation in Medicaid and SCHIP are the income restrictions. Even among nonpoor, we find that Latino children are three times more likely to be uninsured than NHWs. States have attempted the structural approach of extending SCHIP eligibility to higher income thresholds, in some to as high as 400 percent of the federal poverty level. Latinos of Mexican descent were by far the most likely to be uninsured, with 38 percent lacking coverage in 2005. In addition, given their large proportion of the U.S. Latino population, Mexican-origin Latinos represented 72 percent of all uninsured Latinos males. Again, we find that citizenship status plays a major role. While 62 percent of noncitizen Mexicans were uninsured in 2005, among U.S.-born Latinos of Mexican descent only 23 percent lacked coverage, and among naturalized immigrants, 33 percent lacked coverage. Among Puerto Ricans (who are U.S. citizens) and Cubans (most of whom entered as refugees and asylum-seekers and were granted legal status), rates of coverage were 20 percent and 23 percent respectively, which is similar to U.S.-born Mexicandescent Latinos and also similar to rates for black males. However, it needs to be stressed that even among the U.S.-born, these rates are twice as high as NHWs. Among the group of “other Hispanic,” 35 percent are uninsured (most of these are also recent immigrants, with Salvadorians and Colombians makingup the fifth and sixth largest groups of Hispanics in the United States). In contrast, Dominicans fall in between these groups, with 29 percent lacking

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coverage. Among ethnic subgroups, nearly half of all Cubans and Puerto Ricans had employer coverage (49 percent and 48 percent respectively) versus 38 percent of Mexicans and 37 percent of Dominicans. Use of Health Care Services

To obtain data on utilization of health care services and health expenditures, we used data from the 2004 MEPS Household Component (MEPS-HC). Using this survey, reliable estimates of the overall Latino population and some Latino subgroups such as for Mexican, Puerto Rican, and Cubans are possible. Usual source of care (USC) is a source of ongoing care, such as a physician or nurse practitioner, or a site, such as a medical office or clinic, not including emergency rooms. These sources of care provide primary care, such as routine and preventive care, as well as ongoing care for management of chronic illness. In 2003, 38 percent of Latinos did not have a USC versus only 20 percent of NHWs and 30 percent of blacks. By subgroup, 75 percent of Puerto Ricans and 72 percent of Cubans reported having a USC versus 61 percent of Mexicans and 62 percent of Dominicans. The important structural link between insurance and having USC is evidenced by the fact that only 22 percent of Latinos with insurance lacked a USC. In contrast, 78 percent of Latinos without insurance lacked a USC. Examples of available sources of care for low income uninsured persons are community health centers and the outpatient departments of public hospitals. However, these data suggest that such safety net community resources are not reaching the vast majority of uninsured Latinos. As a result of lacking insurance and a USC, only 50 percent of Latino males had visited an outpatient provider (OP) in the last year, compared to 73 percent of white men and 55 percent of black men. By subgroup, Puerto Rican (62 percent) and Cuban (54 percent) males were the most likely to have visited an OP in that last year. Mexicans were the least likely at 47 percent. Here again the important link to insurance is evident, with only 22 percent of uninsured Latinos having visited an OP in the last year, compared to 62 percent of insured Latinos. However, even if insured, Latinos made fewer visits to providers than NHWs. For example, among those insured, individuals with at least one visit to a provider in the past year visited a median of 2 ( 4) visits per year versus 4 ( 8) median visits per year for insured white men. Young adult males are most vulnerable, and again insurance plays a crucial role. While 56 percent of insured Latinos aged nineteen to thirty-five years had a USC, only 19 percent of uninsured Latinos in this group had a USC. Further, only 18 percent of uninsured Latino young men had visited an outpatient provider in the past year. However, even when accounting for insurance status,

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disparities persist. For example, 32 percent of uninsured NHW white young men had visited a provider in the past year versus 18 percent of such Latinos. Among older men, there are a number of preventive health care measures and screenings that are important for men to undergo on a periodic basis. Thus access to an ongoing source of care is critical. Yet, 43 percent of Latinos age thirty-six to sixty-four lacked a USC versus 20 percent of whites, and 34 percent of blacks. Further, only 49 percent of these Latinos had visited an OP in that last year, compared to 73 percent of NHW middle-aged men. Lastly, among elders, all of whom should have yearly health evaluations, only 85 percent of Latinos had a USC versus 94 percent of NHW elders, and also had fewer visits, with a median of 5 ( 8) versus 9 ( 13) for NHW male elders. Among children, the overall data are more encouraging, with only 13 percent of Latino children lacking a USC, versus 7 percent of NHWs and 10 percent of blacks. Yet, among the insured population, some differences were still evident, with 71 percent of Latino children having seen a doctor within the past year versus 80 percent of NHW children. But, it is among the uninsured where large disparities exist, with only 27 percent of uninsured Latinos having visited an OP in the last year versus 60 percent of white children. Thus, while most Latino children are insured and have a USC, among those without insurance there are large gaps in care. These data suggest that while the safety net seems to be an important community level resource for uninsured NHW children, it is not playing a similar role for Latino children. Due to such limited access to care, it is commonly assumed that Latino communities rely on emergency rooms for care. Yet we find that the opposite is true. In 2003, 10 percent of Latino males visited an emergency room at least once versus 14 percent of NHWs and black males. Among the uninsured, emergency room visits were even lower for Latinos. Only 6 percent of uninsured Latino males had an emergency room visit versus 13 percent of NHWs. Among subgroups, Puerto Ricans (16 percent) and Dominicans (15 percent) had the largest proportion, with at least one emergency room visit versus 11 percent for Cuban and Mexican males. The pattern of lower rates of emergency room visits for Latinos versus NHWs persists across all age groups. As an example, only 12 percent of Latino children had an emergency room visit in the past year versus 15 percent of white and black children. Health Screening Data

There are a number of periodic screenings that Latino men over age fifty need to undergo on a periodic basis. These include having their blood pressure checked every year, a cholesterol test every five years, and periodic colon cancer

Health Coverage, Utilization, and Expenditures Table 12.3

243

Proportion of Elders without Recommended Screening Tests Cholesterol

Blood prostate

Annual blood

levels every

Colon cancer

cancer test every

pressure check

five years

screening

three years

Age  65 Latino

14

8

53

27

NHWs

4

5

32

15

Blacks

4

3

43

17

Age 50–64 Latino

29

23

75

51

NHWs

15

10

49

35

Blacks

18

11

62

35

Source: Data from MEPS 2007.

screening, which may involve either a colonoscopy every ten years or an annual fecal occult blood test. Lastly, thought not universally recommended, screening for prostate cancer is also becoming increasingly routine among most men over age fifty (AHRQ 2006a). In this section, we use MEPS data to examine the use of these screenings among Latino and NHW men and stratify data among men fifty to sixty-five (near elderly) and those sixty-five and over. Among elders, some disparities were evident (table 12.3). For example, 14 percent of Latino elders did not have their blood pressure checked in the last year versus 4 percent of NHWs. Also, 53 percent of Latino elderly men had not had colon cancer screening, versus 43 percent of NHWs. However, the largest disparities were among the near elderly, and not surprisingly it is again health coverage that plays the biggest role. Among uninsured Latinos age fifty to sixty-four, 45 percent did not have their blood pressure checked in the last year versus 23 percent of insured Latinos. Further, 45 percent of uninsured Latinos did not have a screening for cholesterol and 71 percent did not have a prostate cancer test versus 14 percent and 43 percent, respectively, of insured Latinos. For both the insured and uninsured, rates of screening were about ten percentage points lower for Latinos than NHWs. Of all the screening test data, perhaps the most troubling among near elders was colon cancer screening, with only 33 percent of insured Latinos having such screening. Among the uninsured, only 6 percent of Latinos had this screening. In contrast, 54 percent of insured NHWs and 30 percent of uninsured NHWs had colon cancer screening. Thus, as discussed in other chapters, for some services like colon cancer screening, additional culturally tailored interventions are also warranted. However, from a public health perspective, providing health coverage would

$ expenditures (x10)

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Homan, Homan, and Carrasquillo

500 450 400 350 300 250 200 150 100 50 0

Latino NHWs

19

19–35

36–64

65

19

Insured Figure 12.6

19–35

36–64

Not insured

Median health expenditures for Latinos and non-Hispanic whites. Source: Data from MEPS (2007).

have the most important overall effects on preventive health service utilization among Latino males. Health Expenditures

Further evidence documenting disparities in health care among Latino men is with MEPS data (Selden et al. 2001), showing differences in health expenditures among Latinos versus other groups. In 2003, 36 percent of Latinos had no health expenditures (e.g., received no health care) versus 15 percent of NHWs (fig. 12.6). Among subgroups, 40 percent of Mexican males had zero expenditure versus 20 percent of Cubans and 25 percent of Puerto Ricans. Among the uninsured, 66 percent of Latinos had no healthcare expenditures versus 40 percent of uninsured NHWs—again highlighting that, among the uninsured, NHWs seem to have improved access to care versus uninsured Latinos. Yet even among those that used any health care, Latinos used far fewer resources than NHWs. Uninsured Latinos’ health expenditures were a median $240 compared with $390 for male NHWs. This disparity was even greater among the insured, with median expenditures of $440 for Latinos versus $1200 for male NHWs. Among children, 22 percent of Latinos had no healthcare expenditures in 2003 versus only 10 percent of NHW children. Further, among those receiving care in 2003, the median expenditures for male Latino children was $290 versus $540 for NHWs. Similar patterns were observed among the Latino elderly, where 12 percent of Latino elders had no healthcare expenditures compared to only 3 percent of whites. Among those with any health expenditures, elderly Latino men had median overall expenditures of $2,400, compared to $4,500 for whites. Lastly, the critical role of citizenship status in access to care is again highlighted by expenditure data. One recent study found that even after adjusting for gender,

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245

age, poverty level, insurance status, and health status, health expenditures for Latino citizens were $1,870 versus $3,117 for NHWs (Mohanty et al. 2005). For Latino noncitizens, these expenditures were much lower at $962. Public Health Implications

The principal implication of our findings is that the primary barrier affecting access to care for Latinos is structural, namely health insurance. We find that disparities in health coverage are due to structural factors in the types of employment opportunities available to Latino men, which often do not provide health benefits. At the individual level, citizenship status is the primary barrier, but again the root causes are really structural, having to do with immigration policy and the limited employment opportunities available to noncitizen Latino men. While there are existing community level resources available to help eligible Latino children obtain public coverage, as well as community safety net resources for the uninsured, our data shows these are far from adequate. The barriers to these enabling community level factors are multiple and include issues such as lack of familiarity with existing resources, language barriers, and, for the undocumented, immigration-related issues such as fear of deportation if one has contacts with the formal health system. Nevertheless, outreach efforts informing uninsured Latinos of potential sources of care and addressing some of their concerns around immigration should be part of ongoing federal efforts to strengthen the safety net. Such initiatives may include culturally tailored messages providing information on local sources of preventive health care screenings, including the numerous federal, state, and private philanthropic initiatives for free or low-cost screenings that exist in many Latino communities. Health Policy Implications

The primary policy implication of our analyses is that any serious attempt to improve access to care among Latinos will need to address the insurance crisis among noncitizen Latinos. Indeed, we would argue that a litmus test for any proposal that seeks to address the plight of uninsured Latinos is coverage for noncitizens (both legal and undocumented). In particular, proposals for expanding government programs such as SCHIP and Medicaid should apply to all Latinos, regardless of citizenship status. Unfortunately, immigration issues are quite divisive, making policy initiatives aimed at improving the conditions of noncitizens difficult to achieve in the current political context. At present, of the myriad universal coverage proposals that have been introduced by Congress, only the single-payer plans (e.g., HR 676 sponsored by Conyers) proposes coverage for all persons living in the United States regardless of

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immigration status (Conyers 2007). Such proposals currently enjoy support from the majority of Latino Congressional leaders (Shah and Carrasquillo 2006) as well as the Congressional Black Caucus. However, the Obama administration and Senator Baucus have made it clear that undocumented Latinos will be excluded from any health reform proposal that they would consider in the coming year. Another controversial health reform issue concerns forcing people to purchase coverage. Such mandates are attractive to policy makers because they take an inherent structural problem that needs to be addressed at the policy level and converts it into a problem that needs to be addressed by the individual. In Massachusetts, the one state that is already experimenting with mandates, the issue of forcing middle income persons to either buy health insurance or face large fines has had mixed results. For example, some middle income families need to pay over $6,000 in premiums and deductibles before they receive any health benefits. Notably, lack of accessible primary care is an additional barrier that the state is also struggling to address. The other more fundamental structural issue is the current health care system itself, which relies on government coverage for elders and some poor persons, and leaves all others at the mercy of employers. As we have shown, this system is not meeting the needs of Latinos. Indeed, evidence continues to accumulate that, due to spiraling health costs, employers are having trouble filling this gap for other groups as well, with a 10 percent drop in overall employer coverage over the last ten years. Thus, from a policy perspective the issue is whether to continue to rely on employers as the primary source of coverage for nonelderly adults in this country. In contrast, we believe that from a policy perspective it makes more sense to provide insurance to all residents of the United States in a manner similar to Medicare, rather than continuing to rely on employers and mandates for individuals to purchase coverage. While the majority of the U.S. population is sympathetic to such single-payer approaches, the Obama administration and current Democratic leadership have all stated that opposition from Republicans, as well as the health insurance and pharmaceutical industries, prevents them from even considering such approaches.

References Agency for Healthcare Research and Quality (AHRQ). 2006a. Guide to clinical preventive services. Rockville, MD: Agency for Healthcare Research and Quality. ———. 2006b. National healthcare disparities report. Rockville, MD: Agency for Healthcare Research and Quality.

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American College of Physicians. 2000. No health insurance? It’s enough to make you sick. Latino community at great risk. Philadelphia: American College of Physicians. Amsden, D. 2007. The young invincibles. New York Magazine, April 2, 2007. California Health Interview Survey. 2006. http://www.chis.ucla.edu/. Capps, R., L. Ku, and M. Fix. 2002. How are immigrants faring after welfare reform? Preliminary Evidence from Los Angeles and New York City. Washington, DC: Urban Institute. Carrasquillo, O., and O. Barbot. 2000. The uninsured: A call to action for all Latinos. Harvard Journal of Hispanic Policy 12: 33–46. Carrasquillo, O., A. I. Carrasquillo, and S. Shea. 2000. Health insurance coverage of immigrants living in the United States: Differences by citizenship status and country of origin. American Journal of Public Health 90 (6): 917–923. Collins, S. R., J. L. Kriss, K. Davis, M. M. Doty, and A. L. Holmgren. 2006. Squeezed: Why rising exposure to health care costs threatens the health and financial well-being of American families. New York: Commonwealth Fund. Conyers, J., D. Kucinich, J. McDermott, and D. Christensen. 2007. The United States National Health Insurance Act, H.R. 676 (“Expanded & Improved Medicare for All”). http://www.house.gov/conyers/news_hr676_2.htm. Cooper, P. F., and B. S. Schone. 1997. More offers, fewer takers for employment-based health insurance: 1987 and 1996. Health Affairs (Millwood) 16 (6): 142–149. DeLaet, D. E., S. Shea, and O. Carrasquillo. 2002. Receipt of preventive services among privately insured minorities in managed care versus fee-for-service insurance plans. Journal of General Internal Medicine 17 (6): 451–457. DeNavas-Walt, C., B. D. Proctor, and C. H. Lee. 2006. Income, poverty, and health insurance coverage in the United States: 2005. Current Population Reports P60–231. Doty, M. M. 2003. Hispanic patients’ double burden: Lack of health insurance and limited English. New York: Commonwealth Fund. Doty, M. M., and A. L. Holmgren. 2006. Health care disconnect: Gaps in coverage and care for minority adults. New York: Commonwealth Fund. Echeverria, S. E., and O. Carrasquillo. 2006. The roles of citizenship status, acculturation, and health insurance in breast and cervical cancer screening among immigrant women. Medical Care 44 (8): 788–792. Enthoven, A. C., and V. R. Fuchs. 2006. Employment-based health insurance: Past, present, and future. Health Affairs 25 (6): 1538–1547. Fairbrother, G., M. J. Dutton, D. Bachrach, K. A. Newell, P. Boozang, and R. Cooper. 2004. Costs of enrolling children in Medicaid and SCHIP. Health Affairs (Millwood) 23 (1): 237–243. Fairbrother, G., A. Jain, H. L. Park, M. S. Massoudi, A. Haidery, and B. H. Gray. 2004. Churning in Medicaid managed care and its effect on accountability. Journal of Health Care for the Poor and Underserved 15 (1): 30–41. Fairbrother, G., J. Stuber, M. Dutton, R. Scheinmann, and R. Cooper. 2004. An examination of enrollment of children in public health insurance in New York City through facilitated enrollment. Journal of Urban Health 81 (2): 191–205. Flores, G., M. Abreu, V. Brown, and S. C. Tomany-Korman. 2005. How Medicaid and the State Children’s Health Insurance Program can do a better job of insuring uninsured children: The perspectives of parents of uninsured Latino children. Ambulatory Pediatrics 5 (6): 332–340. Flores, G., M. Abreu, and S. C. Tomany-Korman. 2006. Why are Latinos the most uninsured racial/ethnic group of U.S. children? A community-based study of risk factors for and consequences of being an uninsured Latino child. Pediatrics 118 (3): e730–740.

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Hargraves, J. L., and J. Hadley. 2003. The contribution of insurance coverage and community resources to reducing racial/ethnic disparities in access to care. Health Service Research 38 (3): 809–829. Harrell, J., and O. Carrasquillo. 2003. MSJAMA: The Latino disparity in health coverage. Journal of the American Medical Association 289 (9): 1167. Kirby, J. B., G. Taliaferro, and S. H. Zuvekas. 2006. Explaining racial and ethnic disparities in health care. Medical Care 44 (5 suppl.): I64–72. Medical Expenditure Panel Survey (MEPS). 2007. http://www.meps.ahrq.gov/. Mohanty, S. A., S. Woolhandler, D. U. Himmelstein, S. Pati, O. Carrasquillo, and D. H. Bor. 2005. Health care expenditures of immigrants in the United States: A nationally representative analysis. American Journal of Public Health 95 (8): 1431–1438. National Center for Health Statistics. 2006. The National Health Interview Survey. Centers for Disease Control and Prevention. http://www.cdc.gov/nchs/nhis.htm. New York City Department of Health and Mental Hygiene. 2006. New York City Community Health Survey: 2005 Methods. http://www.nyc.gov/html/doh/html/ survey/survey-2005.shtml. Remler, D. K., and S. A. Glied. 2003. What other programs can teach us: Increasing participation in health insurance programs. American Journal of Public Health 93 (1): 67–74. Rodriguez, E., and O. Carrasquillo. 2003. The role of health insurance on Latinas’ health. In Latina health in the United States: A public health reader, ed. M. Aguirre-Molina and C. W. Molina. San Francisco: Jossey-Bass. Selden, T. M., K. R. Levit, J. W. Cohen, S. H. Zuvekas, J. F. Moeller, D. McKusick, and R. H. Arnett. 2001. Reconciling medical expenditure estimates from the MEPS and the NHA, 1996. Health Care Financial Review 23 (1): 161–178. Shah, N. S., and O. Carrasquillo. 2006. Twelve-year trends in health insurance coverage among Latinos, by subgroup and immigration status. Health Aff (Millwood) 25 (6): 1612–1619. U.S. Census Bureau. 2006. Current population survey design and methodology. Technical paper 63RV. http://www.census.gov/prod/2002pubs/tp63rv.pdf.

Chapter 13

Cynthia Alford and David Espino

Mental Health of Elderly Latino Males

The aging population of Latinos is increasing rapidly with accompanying implications for health and well-being. Structural factors may have more impact in the final stage of life than at any other due to the cumulative effects of substandard health care, occupational hazards, and life stress. One of two mental health concerns will likely impair the quality of life experienced by elderly Latinos, and both are influenced by poverty and poor health care access: cognitive impairment, which includes Alzheimer’s disease and associated dementias, and late-life depression. Both are underrecognized and undertreated, and both are major causes of morbidity and mortality in this age group. Demographers estimate that Latinos will constitute 40 percent of the U.S. population over age sixty-five by 2040 (Aponte and Crouch 2002). The 2000 census reports that Latinos comprise 14.5 percent of the U.S. population, with 1.7 million over the age of sixty-five. The three largest Latino subgroups were Mexican, Cuban, and Puerto Rican. Forty percent of Latinos over the age of sixty-five were foreign-born (U.S. Census Bureau 2002). The leading causes of death for older Latino males differ somewhat from those of older non-Hispanic white males, as shown in table 13.1. Diabetes and its complications, now at an epidemic level in the Latino population, is the primary difference. However, compared to both non-Hispanic whites and blacks, Latinos have lower mortality rates from heart diseases, cerebrovascular disease, and malignant neoplasms. This phenomenon, known as the “Hispanic paradox,” has been theorized to result from cultural factors and selective immigration (Franzini 2001), which act to offset lower education rates and incomes. 249

250

Cynthia Alford and David Espino Table 13.1

Leading Causes of Death for Latino Males and White Males over Age Sixty-Five

Latino males

White males

1. Heart disease

1. Heart disease

2. Malignant neoplasm

2. Malignant neoplasm

3. Cerebro vascular disease

3. Lower respiratory disease

4. Diabetes

4. Cerebro vascular disease

5. Chronic lower respiratory disease

5. Influenza/pneumonia

Source: Anderson and Smith 2003.

This advantage declines with length of stay in the United States and with future generations (Vega and Amaro 1994). Although cognitive impairment and depression are not leading causes of death, they are a significant cause of disability and stress in the later years of Latino males and their families. It has been posited that structural factors, such as lower socioeconomic status and limited financial resources, directly affect the older Latino’s perception of environmental mastery/control, which may be predictive of cognitive dysfunction and late-life depression (Briones et al. 2002). Cognitive Impairment

Studies show age-specific prevalence of dementia is higher in Latinos and African Americans than in non-Hispanic whites (Gurland 1999). Olarte and colleagues found that in Puerto Rican and Dominican elders with a family history of Alzheimer’s, unknown environmental factors might accelerate the onset of dementia (Olarte et al. 2006). It has been shown that a lower education level is strongly associated with dementia prevalence in both Latino and non-Latino populations (Gurland 1999). Latino males have lower educational levels compared with non-Hispanic whites, making them disproportionately at risk for cognitive impairment and dementia. An association exists between cognitive impairment and moderate to high levels of depressive symptoms (Black and Markides 1999). Also, in older Mexican Americans, cognitive impairment increased the chance of incident functional loss (disability) over time (Raji 2004). Late-Life Depression

A direct relationship has been established between Latino ethnicity and cognitive impairment, depression, and anxiety (Hargrave 2000). Late-life depression is of critical importance because it is strongly correlated with morbidity and mortality. Studies consistently show that older Latino males are affected by depression less than females.

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251

In the Sacramento Area Latino Study on Aging, the overall rate of depression was 25.4 percent, with older Latino immigrants having a higher rate of 30.4 percent. The depression rate for women was found to be 32.0 percent, compared to 16.3 percent of men. When adjustments for education, income, psychosocial, behavioral, and health problem factors were made, the least acculturated participants were at significantly higher risk of late-life depression (Gonzales 2001). A study of late-life depression among Puerto Rican, Dominican, and nonHispanic white elders in the state of Massachusetts found that the Latino groups had significantly higher rates of depression, but no differences among males were found (Falcon and Tucker 2000). Latinos are less likely to receive recommended treatment for depression than non-Hispanic whites. Attitudes held by ethnic minority patients toward treatment of depression may play a role in undertreatment. In an effort to understand why minorities are less likely to receive care, a telephone survey of 659 non-Hispanic whites, 97 African Americans, and 73 Hispanics recruited from primary care practices found that Hispanics are less likely than nonHispanic whites to find antidepressant medications acceptable and more likely to find counseling acceptable. Racial, gender, and ethnic differences did not explain differences in depression treatment. Clinicians may increase their effectiveness by negotiating treatment options for depression with their patients to identify cultural preferences (Cooper et al. 2003). Therefore, although treatment has been shown to be effective, the propensity for underdiagnosis and insufficient treatment of depression may play a role in Latino males’ increased risk of mortality (Lewis-Fernandez et al. 2005). Death rates are substantially increased when high levels of depressive symptoms are simultaneously present with diabetes mellitus, cardiovascular disease, hypertension, and cancer (Black et al. 1998). In particular, diabetes mellitus combined with severe late-life depression increased the death risk threefold (Black et al. 1999). In Latino males, the presence of diabetes combined with the reluctance of males to seek mental health care disproportionately places them at risk for significant disability and death. The Hispanic Established Populations for Epidemiologic Studies of the Elderly (EPESE) is a population-based study of Mexican Americans aged sixtyfive years and older. This study of 3,050 elders provides detailed information that offers insight into the lives and health issues affecting this group. After reporting the findings of this study, we look at structural and community factors to understand how these factors are interacting to produce health outcomes.

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Table 13.2

Demographics of Hispanic Established Populations for the Epidemiologic Studies of the Elderly Males

Females

(n ⴝ 1,291;

(n ⴝ 1,759;

(n ⴝ 3,050)

42%)

57.7%)

p value

Mean age

73.05

73.09

0.87

Measure

U.S.-born

55.2%

56.5%

0.477

Interviewed in Spanish

76.7%

78.7%

0.19

Living alone

16.6%

34.1%

0.001

Less than eighth grade

82.0%

84.7%

0.50

Yearly household income $20k

8.9%

6.0%

Referent category

$10,000–$19,999

40.5%

30.9%

0.47

$0–$9,999

50.6%

63.1%

0.001

Attend services or mass once a month or more

52.6%

67.4%

0.001

Very or completely satisfied with life

85.4%

81.7%

0.009

Individual Factors

Table 13.2 provides demographic information on 3,050 subjects from the Hispanic EPESE. The data was obtained in 1993–94 via ninety-minute in-home interviews, 72 percent of which were conducted in Spanish. An area probability sample design was used drawing on counties with the largest percentage of Mexican Americans in Colorado, Arizona, Texas, New Mexico, and California. In this cohort the typical older Latino male is a Mexican American of average age seventy-three. He is about as likely to have been born in the United States as in Mexico. He is probably married, and thus does not live alone. His income is most likely less than $20,000 per year, and he has less than an eighth grade education. In this group, 85.4 percent stated they were “very” or “completely” satisfied with life. About half the men reported attending mass once a month or more. The data in table 13.3 show that elder Latino males fare better on many indicators of health than females to a statistically significant degree. Supporting this data, the Latino males also describe themselves as “in good or excellent health” more often than females. Males are likely to be overweight (45.1 percent), but not obese (22.9 percent). In contrast, females are as likely to be obese (34.9 percent) as overweight (34.9 percent).

Mental Health of Elderly Latino Males Table 13.3

253

Chronic Diseases in Older Latinos

p value

Measure

Males

Females

Diabetes

43.1%

56.9%

0.599

Stroke

48.5%

51.5%

0.066

5.2%

6.0%

0.36

12.6%

9.8%

0.013

Cancer Mental illness Hypertension

34.7%

48.8%

0.001

Arthritis

27.7%

41.2%

0.001

Mean of comorbidities

Table 13.4

1.13%

1.35%

0.001

Dementia and Depression in Older Latinos

Measure

Males

Females

p value

Depression (CESD*   16)

17.2%

28.7%

0.001

Cognitive impairment

36.7%

38.8%

0.263

Either depression or impairment

38.2%

42.5%

0.001

Depression and impairment

7.9%

12.5%

0.001

Mean self-esteem

4.69

4.61

0.010

*Center for Epidemiologic Studies Depression Scale

As shown in table 13.4, males also had as good or better mental health than females. A total of 36.7 percent of the men were found to be cognitively impaired, compared to 38.8 percent of women in the study. Additionally, 17.2 percent of the men screened positive for depression; women, 28.7 percent. However, none of these differences are statistically significant. The Hispanic Established Populations for the Epidemiologic Studies of the Elderly (EPESE) found that rates of cognitive impairment varied significantly with age, education, literacy, marital status, language of interview, and immigrant status. Gender was not a significant predictive factor for the development of cognitive impairment. In spite of findings that point to better health for men, there is significantly greater risk of death for Latino men than for Latino women. Follow-up interviews, conducted approximately eight years after the initial EPESE interviews,

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showed that 35.9 percent of males had died, compared to 26.6 percent of females, a statistically significant difference. Survival curves show that men survive at lower rates than females in a parallel curve. The presence of six or more comorbid conditions, loss of function reflected on ADL and IADL screenings, and poor self-reported health are all associated with death. Cognitive impairment, depression, and a combination of the two are also associated with risk of death out to eight years. The study found no detectable difference in the effects of these risk factors by sex. Community Factors Neighborhood

In an investigation of neighborhood composition and late-life depression among older Mexican Americans, a strong correlation was found between poverty and Mexican American ethnicity. As expected, poverty was linked to depression. For every 10 percent increase in poverty, an increased score in the Center for Epidemiological Studies Depression Scale (CES-D) was found (0.763; 95 percent CI 0.06 to 1.47; Briones et al. 2002). Conversely, for each 10 percent increase in the presence of Mexican Americans in a neighborhood, there was a decrease in CES-D scores (0.548; 95 percent CI 0.96 to 0.13. These findings show that a high-density Mexican American neighborhood can provide a strong protective effect against depression. Neighborhood remains a significant social factor impacting the interpretation of mental functioning in the older Latino male. In our study, the neighborhood in which the elder resided influenced differences in cognitive impairment screening scores between Mexican American and non-Latino white elders, with neighborhood differences more prevalent in those with scores less than twenty-four (Espino 2001). These geographic variances could not be explained by age or educational level, indicating that neighborhood differences may be due to urbanization or the quality of educational facilities within those communities. Therefore, it may be more important to account for neighborhood influences in evaluating cognitive impairment in communitydwelling Latino elder populations. Acculturation conceptualized as family attitude and cultural values did not affect the Mini Mental Status Exam (MMSE) scores of older Latinos, suggesting that culture per se is not a factor (Folstein et al. 1975). However, lack of acculturation as functional integration into the broader American society was associated with lower cognitive scores. The researchers theorize that greater cognitive demands of operating in the larger society result in higher scores (Simpao et al. 2005).

Mental Health of Elderly Latino Males

255

Family

There is a number of unifying cultural themes or patterns that underlie health care beliefs and values shared by most Latino groups, which distinguish them from the dominant non-Hispanic white cultural tradition. These factors are magnified in the elder population, who are the carriers of traditions. The most important of these is familismo, which instills a sense of family pride and obligation. It begins early and is nurtured throughout a Latino male’s life. There is no Spanish word for self, and Latinos are socialized to believe that the needs and welfare of the family and vulnerable family members, such as the very young or very old, take precedence over one’s individual needs. Closely related to familismo is jerarquismo, the way individuals relate to each other in terms of the relative positions they occupy within vertical or hierarchical social structures. The family hierarchy emphasizes gerontocracy, or the authority of older persons over younger. The most respect and control over resources is given to the oldest members and the least to the youngest. Similarly, this pattern assigns greater value to machismo, with an emphasis on the male’s authority, respect, and control of resources in the family. Family caregivers are a major, but under acknowledged, part of the Latino male elder health care team. Family care giving is the elder Latino male’s cornerstone of support. Latino families usually function through social reciprocity, accessing shared resources when necessary. The division of labor and resources usually depends on the family members’ needs, according to age and gender. Even in situations where extended family members are living in separate households, grandparents, uncles and aunts, siblings, cousins, in-laws, and even godparents often provide nurture, guidance, support, and control functions. However, new family dynamics are impacting the traditional role of the elder Latino male’s role within the family structure. While having good relations with their adult children, older Latino males may have high, unfulfilled expectations of their children. This change in perspective is due in part to urbanization and greater acculturation of the young. Greater fractioning occurs within the family. The direct care giving falls upon one person, usually the adult daughter or daughter-in-law. Caregiver burnout is common. For older Mexican American males, marriage and well-being are strongly connected (Peek et al. 2006). Analysis of the HEPESE shows that the selfreported well-being of one spouse is associated with the well-being of the other spouse. There is also evidence that wives are affected by the depressive symptoms and life satisfaction of their husbands. However, husbands are not affected by their wives in a similar manner. The authors speculate that traditional, asymmetrical gender roles of male domination result in women

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experiencing greater change in emotional status based on the well-being of their spouse. Research also has determined that Latino males are less likely to selfexpress their own healthcare choices, including advance directives. These conversations are usually difficult to start and take several visits and the appropriate use and recognition of acute events to motivate the patient and family in the ongoing discussion of end of life. Factors that might increase the willingness to talk about end of life include exacerbation of a chronic illness, the death of a close friend or relative, or the patient’s readiness to talk about future concerns. The concept of courtesy is a significant part of the culture. Directly contradicting a health care provider is considered rude or disrespectful. A provider may think that a patient and the patient’s family are in agreement with the plan of action when in fact they are strongly opposed. There is also a strong tendency toward paternalism, and health care providers may be expected to make life-support decisions for their patients. Spirituality and religiosity are also major factors impacting these decisions. Structural factors—that is, education, social inclusion, monolingualism, health care access, and transportation—provide a context for considering the mental health status of older Latino males. Structural Factors Education

A good education is one of the least common characteristics of older Hispanics in the United States. In 1990, only 16 percent of Hispanic elders had completed high school, compared to 60 percent of older non-Hispanic whites. The median educational attainment of Hispanic elders was eighth grade (American Society on Aging 1992). Hispanic elders also had a lower percentage of college graduates in 1988 (4.1 percent) than non-Hispanic white (11.1 percent) or black (4.7 percent) elders. Social Inclusion

A variety of social factors can impact an older Latino male’s level of social inclusion, including ageism, racism, and monolingualism. Ageism, promotes stereotypic attitudes toward older members of society. This has been further reinforced by the developing burden associated with caring for an aging society. Older persons are said to be nonproductive and a burden to society, slow to accept change, unable to look after themselves, slow, deaf, stupid, childlike, sweet, or demented. Non-Hispanic white ethnocentrism is a form of ethnic discrimination that promotes negative attitudes toward non-English-speaking Hispanic whites.

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White ethnocentrism places lesser value on Spanish-speaking whites in society. Contrary to the evidence, this set of biased values assumes that Latino cultures are characterized by ignorant and simplistic views of health care. As a consequence, health providers may develop an impaired relationship with Latino males and their families, who in turn may be less inclined to trust the providers and accept their decisions. This impaired relationship may also make the providers inclined to avoid communicating with Latino males and their families as much as possible. Ethnocentrism among health providers may engender discrimination against older Latino males and decrease the likelihood that they will receive needed services, resulting in increased morbidity and mortality. A secondary data analysis of the relationship of social position to distress and depression using the 1994 National Population Health Survey found that, as with younger adults, mental health in late-life is affected by age, gender, marital status, education, and ethnocultural factors. The authors posit that the life experiences connected to social position are responsible for these effects. Social position shapes both the stressors encountered throughout life and the resources available to cope with those stressors (Cairney and Krause 2005). Specific stressors affecting Latino elders were identified in the HEPESE. Being a woman and having lower income, decreased income, chronic financial strain, and health problems were associated with increased depression symptoms (Chiriboga et al. 2002). Social exclusion can result in increased suicide rates due to increased isolation associated with depression. Language

Language is a significant barrier to good doctor-patient relationships between older Latino males and their health care providers. The inability of the health care provider to accurately ascertain basic health information may incorrectly lead the provider to misinterpret symptomatology and lead to misdiagnosis and inappropriate therapy. Furthermore, older Latino males, as opposed to younger Latinos, have less command of the written Spanish language. Therefore, the older Latino male may be unable to communicate clearly with the health care provider. The language problem is compounded when untrained translators are used. Family members and friends, who frequently serve as translators, are often ill prepared to deal with the complexities of the medical evaluation. These translators frequently have variable translation skills and are often embarrassed to admit this to either the provider or their elder loved one. This frequently results in poor paraphrasing, translator-elder conflict, and reporting bias.

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Health Care Access and Transportation

In this age group, affordability relates to issues beyond health insurance costs. While Medicare A is universal, a significant proportion of the Mexican origin population lacks this basic coverage. They have not been able to apply due to communication barriers or are not eligible because they are not American citizens. Likewise, elders who lack Part B either do not qualify or have not applied to have premiums deducted from their monthly social security entitlement. Medicare and secondary insurance use is unusual in this population. The intergenerational disparity myth posits that the older generation has more resources than the younger generations to devote to mental health care. In fact, if you delete the entitlements, which have strict criteria limiting long-term care options, then the older generation has fewer services available. This is further compounded by the problems associated with social inclusion and exclusion. While the Medicare Prescription Drug, Improvement and Modernization Act offers some relief in this area, the rules are complex. The renaming of MedicareChoice programs to Medicare Advantage programs is no doubt confusing, as is medication coverage under both Part C prescription plans and Part D (Espino et al. 2004). This causes extreme confusion for both older Latino males and their care providers, with many at risk for choosing the least advantageous plan. Ethnic-appropriate, quality health care remains a major barrier. Providers that are truly bicultural and have an interest in caring for frail elders, as well as the ability to shoulder the financial strain of caring for a Medicare population, are rare. Medicare reimbursements to physicians are unreasonably low for the time and effort required to care for a frail older Latino male (Elon 2003). Those bicultural providers willing to care for frail elders are able to pick and choose which patients they care for, leaving families to care for elders with multiple complex, interacting illnesses and limited options for quality care. The disparity in absolute numbers between elder men and women predisposes public policy, research, and health care communities to focus on mental health issues of older Latino women. While a laudable focus, issues of particular need to the older Latino male go unstudied. Geographic accessibility can be a deterrent for accessing health care by Latino elders. The financial burdens of transportation impact patient care even when transportation is available. Frail Latino men are unable to use public transportation. Public transportation for the disabled is extremely limited, and elders must compete with other disabled persons for this scarce resource. Particularly, those Latino males living in rural areas may find it more difficult to access a rural health care system that is already limited. Certainly, if a Latino

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male is Spanish monolingual and lives in a rural area, he may be at a disadvantage for physically accessing health care services. This proves especially true if he has a limited informal family support system. Morbidity and mortality are directly related to the ability to access the health system. Conclusion

Among the EPESE cohort, Latino males seem relatively protected from cognitive decline and late-life depression. Structural factors such as neighborhood seem to have a protective effect, in part due to traditional community and individual support. However, because Latino males tend to delay care due to low health literacy, concerns about cost, and stigma associated with mental health problems, the elderly are disproportionately at risk for later diagnosis and treatment compared to women and non-Hispanic whites. With the advent of promising medications to reduce the burden of organic disorders of the brain in later life, early detection and consistent treatment become priority concerns for elder Latinos. Further research into effects of structural factors and barriers to care on the mental health status of Latinos, in the context of neighborhood characteristics, are clearly needed. References Anderson, R. N., and B. L. Smith. 2003. Deaths: Leading causes for 2001. National Vital Statistics Reports 52 (9): 1–86. Aponte, J., and R. Crouch. 2002. The changing ethnic profile of the United States in the Twenty-first century. In Psychological Intervention and Cultural Diversity, ed. J. Aponte and J. Boston: Allyn and Bacon. Black, S., D. V. Espino, M. Roderick, M. J. Lichtenstein, H. Hazuda, D. Fabrizio, et al. 1999. The influence of noncognitive factors on the mini-mental state examination in older Mexican-Americans: Findings from the Hispanic EPESE. Journal of Clinical Epidemiology 52: 1095–1102. Black, S. A., J. S. Goodwin, and K. S. Markides. 1998. The association between chronic diseases and depressive symptomatology in older Mexican Americans. Journals of Gerontology Series B-Psychological Sciences and Social Sciences 53 (3): 188–194. Black, S. A., and K. S. Markides. 1999. Depressive symptoms and mortality in older Mexican Americans. Annals of Epidemiology 9 (1): 45–52. Briones, D. F., A. L. Ramirez, M. Guerrero, and E. Ledger. 2002. Determining cultural and psychosocial factors in Alzheimer disease among Hispanic populations. Alzheimer’s Disease and Associated Disorders 16 (suppl. 2): S86–88. Cairney, L. M., and N. Krause. 2005. The social distribution of psychological distress and depression in older adults. Journal of Aging and Health 17 (6): 807–835. Chiriboga, D. A., S. A. Black, M. Aranda, K. Markides. 2002. Stress and depressive symptoms among Mexican American elders. Journals of Gerontology Series B-Psychological Sciences & Social Sciences 57 (6): 559–568. Cooper, L. A., J. J. Gonzales, J. J. Gallo, K. M. Rost, L. S. Meredith, L. V. Rubenstein, N. Y. Wang, and D. E. Ford. 2003. The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients. Medical Care 41 (4): 479–489.

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Elon, R. D. 2003. Reforming the care of our elders: Reflections on the role of reimbursement. Journal of the American Medical Directors Association 4 (2): 117–120. Espino D. V., M. J. Lichtenstein, R. F. Palmer, and H. P. Hazuda. 2001. Ethnic differences in mini-mental state examination scores: Where you live makes a difference. JAGS 49: 538–548. Espino D. V., L. O. Oakes, I. Amaya-Grever, O. Olivares, C. A. Alford, and C. P. Mouton. 2004. Health care for Hispanic elder patients. Kansas City, MO: AAFP Press. Falcon, L. M., and K. L. Tucker. 2000. Prevalence and correlates of depressive symptoms among Hispanic elders in Massachusetts. Journals of Gerontology Series B-Psychological Sciences and Social Sciences 55 (2): 5108–5116. Folstein M. F., S. E. Folstein, and P. R. McHugh. 1975. “Min-mental state”: A practical method for grading the cognitive state of patient for the clinician. Journal of Psychiatric Research 12: 189–198. Franzini, L., J. C. Ribble, and A. M. Keddie. 2001. Understanding the Hispanic paradox. Ethnicity and Disease 11 (3): 496–518. Gonzales, H. M., M. N. Hann, L. Hinton. 2001. Acculturation and the prevalence or depression in order Mexican Americans baseline results of the Sacramento Area Latino Study on Aging. Journal of the American Geriatrics Society 49 (7): 948–953. Gurland, B. J., D. E. Wilder, R. S. Lantigua, Y. Chen, E. H. Killeffer, and R. Mayeux. 1999. Rates of dementia in three ethnoracial groups. International Journal of Geriatric Psychiatry 14 (6): 481–493. Hargrave, R., M. Stoeklin, M. Haan, et al. 2000. Clinical aspects of dementia in AfricanAmerican, Hispanic, and white patients. Journal of the National Medical Association 92: 15–21. Lewis-Fernandez, R., A. K. Das, C. Alfonso, M. M. Weissman, and M. Olfson. 2005. Depression in U.S. Hispanics: Diagnostic and management considerations in family practice. Journal of the American Board of Family Practice 18 (4): 282–296. Olarte L., N. Schupf, J. H. Lee, M. X. Tang, V. Santana, J. Williamson, P. Maramreddy, B. Tycko, and R. Mayeux. 2006. Apolipoprotein E epsilon 4 and age at onset of sporadic and familial Alzheimer disease in Caribbean Hispanics. Archives of Neurology 63 (11): 1586–1590. Peek, J. K., J. P. Stimpson, A. L. Townsend, and K. S. Markides. 2006. Well-being in older Mexican American spouses. Gerontologist 46 (2): 258–265. Raji, M. A., S. Al Snih, L. A. Ray, K. V. Paten, and K. S. Markides. 2004. Cognitive status and incident disability in older Mexican Americans: Findings from the Hispanic established population for the epidemiological study of the elderly. Ethnicity and Disease 14 (1): 26–31. Simpao, M. P., D. V. Espino, R.F. Palmer, et al. 2005. Association between Acculturation and structural assimilation and mini-mental examination-assessed cognitive impairment in older Mexican Americans: Findings from the San Antonio longitudinal study of aging. JAGS 53: 1234–1239. U.S. Census Bureau. 2002. The Hispanic population in the United States. Washington, DC: U.S. Census Bureau. Vega, W. A., and H. Amaro. 1994. Latino outlook: Good health, uncertain prognosis. Annual Review of Public Health 15: 39–67.

William Vega, Luisa N. Borrell, and Marilyn Aguirre-Molina

Conclusion New Directions for Research, Policy, and Programs Addressing the Health of Latino Males

The chapters in this volume comprise a unique collection of studies about issues affecting the health of Latino males. To our knowledge, this is the first time this information has been presented in one volume. It should be borne in mind that interpreting the effects of structural factors on health is a synthetic process. Disease is usually produced by multiple personal and nonpersonal factors; therefore, structural data are inadequate to inform us about causes and outcomes, as these are attributable to individual pathologies. Thus, our task requires assembling a mosaic of available data and imposing social-ecological explanations about predisposing factors using a combination of pragmatism and historical experience as a guide. This closing chapter is intended to offer a brief synopsis of the editors’ interpretations of the information contained in the foregoing chapters using assumptions based in cultural research and population health principles. We hope readers will find this chapter useful as a departure point for generating ideas about research and policy implications, and for stimulating substantive discussions. A Structural-Demographic View of Latino Male Health

It seems that nearly every review article about Latino health commences with a restatement about the incredible rate of population growth. There are very good reasons for the redundant emphases: the growth trend has been awe-inspiring, and if it continues as expected until midcentury, 29 percent of the U.S. population will be of Latino origin. Dual demographic imperatives, growth and structural marginality, loom as critical determinants influencing population health status and access and quality of health care for Latino males. But will 261

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current trends continue? There are historical reasons to believe they will. Even assuming a reduction in annual volume of new immigrants arriving into the United States, fertility rates alone will disproportionately increase the Latino portion of the U.S. population. As noted in a recent U.S. population projection for 2005–2050 provided by the Pew Hispanic Center, “The major role of immigration in national growth builds on the pattern of recent decades, during which immigrants and their U.S.-born children and grandchildren accounted for most population increase. Immigration’s importance increased as average number of births to U.S.-born women dropped sharply before leveling.” A tempered forecast is that a downturn in the immigrant flow will occur as U.S. labor markets reach saturation and hostility increases in receiving communities in the United States, causing push-back. Nevertheless, documented and undocumented immigration from Latin America will remain significant, because adjustments in U.S. regional labor market activity will periodically reactivate the search for labor in an aging American population with low overall fertility. The current trend that disproportionately favors Latino males during early adulthood immigrating or sojourning to the United States is likely to continue, and most of these males will likely be derived from the lower strata of educational and income subgroups in Latin America just as they are today. Therefore, assuming that population growth continues at levels anticipated by current U.S. census estimates, and the current socioeconomic stratification patterns remain unchanged—reinforced by low secondary school completion rates and very low college completion rates—structural factors are clearly in place for a continued deterioration in health status in subsequent generations of U.S.-born Latinos. It is clear that the potent mixture of U.S. assimilation and stagnant social mobility appear to weaken personal resilience to lifestyle-caused disease in U.S.-born Latino males. But why does this occur? We suspect that transformations in health behaviors are inevitable with social assimilation, along with changes in family social network composition and structure. These trends are likely to have complex effects on a wide range of health behaviors that increase disease morbidity and mortality. A finer understanding of this process is needed for discrete health outcomes. This underscores the need for research on the nexus between structural factors that regulate upward mobility and the consequences in population health for Latino males who experience intergenerational social and economic stagnation and residential segregation. Among the structural factors are labor market conditions, immigration policies, educational and employment opportunities, segmented assimilation and place effects, discrimination, and a host of other factors, such as the increase of single-parent families, which affect lifestyle options.

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Of course there are other contextual risk factors embedded in poverty and place. The poor are systematically exposed to greater environmental hazards and pollutants, which compound the effects of behavioral risk factors. The pattern that develops is especially pernicious for the impoverished children of immigrants (second generation) and their offspring (third generation) because of their excess behavioral risk factor exposure (e.g., greater obesity, violence exposure, criminal behavior leading to incarceration, smoking, and regular alcohol and drug use) compared to first generation males. This scenario is based on assumptions of the health gradient model—that is, the phenomenon in which people with higher socioeconomic status ultimately exhibit superior health and longevity than people with low socioeconomic status—which is a widely recognized phenomena. Oddly enough, the health gradient effect is mostly undetectable in the Latino population because socioeconomic status is not correlated with mortality due to the current favorable health status of foreign-born males. When it comes to subsequent generational cohorts of Latino males, it seems probable that the health gradient will emerge. Moreover, the lack of a health gradient in the Latino population is potentially masked by existing morbidity and mortality pertaining to Mexican Americans. Relying on this evidence to make inferences to all Latinos ignores intrapopulation heterogeneity—that is, differences in population composition and health behaviors of Cubans, Puerto Ricans, and Central and South Americans. Thus, this health gradient may already be a reality, but our research has simply been inadequate and unable to detect an emerging trend. Indeed, a recent article based on the NHANES III (1988–1994) data, with Latinos in the sample, concluded, “As hypothesized consistent education and income gradients were seen for biological parameters reflecting cardiovascular, metabolic and inflammatory risk: those with lower education and income exhibiting greater prevalence of high-risk values for each of the nine individual biological risk factors” (Seeman et al. 2008). There were no significant differences among ethnic groups in the gradient effect, and income and education were independently and inversely related (after adjustments for confounders) to these cumulative biological risks. In the ensuing decades, we cannot assume that Mexican foreign-born males will continue to maintain the health advantages attributed to them in studies reported over the past three decades. This situation poses a number of research opportunities for medical sociology, public health, health psychology, social epidemiology, and behavioral genetics. One pertinent example is the possibility of examining Latino men’s health by contrasting specific descriptors such as country of origin, skin color phenotype, socioeconomic status and social position, and racial self-identity, as

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recommended by the recent Institute of Medicine report on gene-environment interaction research (Board on Health Sciences Policy 2006). Important information can emerge from future population studies. If public data sets are used they will need to contain sufficiently large subsamples of identifiable Latino subgroup males as well as adequate information about structural factors, biological samples, and geocodes for linkage to census data and other data sets with well-defined area (e.g., neighborhood) indicators. Another possibility may be to conduct a study of the effects of structural factors on intergenerational changes among impoverished young Latino males and the emergence of behavioral risk factors and morbidity phenotypes, along with contrasts with other ethnic group males. Specific gene variants may be more likely to be expressed in second and third generational Latino males, resulting from differential social and environmental exposures than their parents or grandparents during the first quarter of life. Research in this area could examine the importance of structural risk factors and changing social network characteristics experienced by successive generations of low socioeconomic Latino males in the United States. Field surveys used in contemporary population studies are increasingly including biomarkers derived from human fluids to detect biologic signals of chronic stress response in the body. Included are alterations in hormone levels and brain functions. However, the ultimate import of this information is as yet unclear, as most diseases are multifactorial with a strong environmental and social component. It is worth noting that in the United States, most chronic diseases are directly attributable to lifestyle behaviors—which are habitual, avoidable, modifiable, and less commonly acquired or practiced with similar frequency in more affluent sectors of U.S. society. Smoking, overeating, and alcohol abuse are three key examples. These behaviors are socially acquired and are usually a direct product of a supportive social environment in which individuals interact on a daily basis. How can these environments be changed to produce a different outcome? What pragmatic measures are required? What are the implications for the built environment in order to promote healthier lifestyles for Latino males? We have the knowledge base to address such questions, but we have a very fragmented organizational and political base that currently does not have the capacity to reorganize its components to accomplish these important tasks. This is not due to a deficit in health science knowledge, it is a political science dilemma. Is There a Tipping Point Ahead for Latino Male Health and in What Direction Is It Headed?

Latino males are younger and healthier than males in the general U.S. population. What are the prospects that their health status will remain more favorable?

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What would it take? It may be that some of the protective factors, or at least factors that we assume are protective for Latino culture, such as familism, are sufficiently stable across generations, so that the impact of economic stagnation and poverty on health will not be as pernicious for Latino males as experienced in other ethnic subgroups. However, what evidence do we have to support such claims? A positive pattern has been the lower all-cause mortality rates of Latinos, especially in mortality attributable to cancers. A negative pattern has been the higher rates of diabetes across generations of Latino males. Additionally, there are mixed patterns, such as alcohol-related diseases of the liver or drug dependence, which are marked by considerable variability in rates among males in discrete nationality and nativity subgroups. Therefore, future projections are difficult to make but certainly require detailed scrutiny over time to depict changes in subgroups and explanations for them. The normalizing of behavioral risk factors for Latino males, as they assimilate across generations, should be investigated from a life course perspective. This would be especially informative if studied through the years of early development, adolescence, and early adulthood transitions into adult roles. Such roles will include stable relationships, employment, and integration into community life, and ultimately into the final stages of the life course. A life course perspective can account for differences in exposures to early and persistent risk factors, including biologic and environmental ones, the development of risk behaviors, and eventual progression trajectories to disease onset that may be mediated by social position, and other critical factors that are infrequently considered, such as skin color. This type of research, which can only be briefly touched on here, may account for the impact on lifestyles of changing social position and its impact on the health status of Latino men within and across generations. Another needed framework in Latino males’ health research is an examination of health profiles in different historical cohorts of Latinos by subgroups according to country of origin. Is there evidence for positive or negative trends in selection for specific health outcomes? This approach could offer the opportunity to assess how health status has changed over time for Latino males retrospectively, and whether these patterns are similar or differ among subgroups (i.e., Puerto Rican, Cuban, Central American, Mexican American, and Dominican). It could also offer a chance to assess the impact of social and economic conditions, labor conditions, and public policies and programs (including public health programs) on the health of Latino males of different generations, and in different regions of the United States. We know very little about the direct and indirect effects of educational attainment or economic status on Latino men’s health, about what improves and what does not. What increments in education

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and income are needed to significantly improve the health status of U.S.-born Latino males, and for which outcomes, heart disease, diabetes, depression, or drug dependence? Conclusion

The editors hope that this book has answered some questions and raised interest about a variety of issues affecting the health of Latino men. The volume was designed with the goal of stimulating a dialog and the development of an agenda for understanding and responding to the health requirements of all Latino men. This includes securing positive health status by maintaining positive trends, such as lower lung cancer and depression rates, and also addressing the needs of males experiencing specific health disparities in areas as diverse as substance dependence, gastrointestinal cancers, and metabolic syndrome. The focus of this volume has emphasized population health and impacts of structural factors as these play out in the social ecology of male development and lifestyles. We have not given great attention in these pages to the experiences of Latino males in the U.S. health care systems, and we acknowledge that this area is important. Unfortunately, we know very little about this relationship or its effects on Latino health. Indeed, Latino males tend to be younger and they are mostly infrequent users of health care providers. Even after accounting for the barriers to receiving health care, a recent national survey showed that 41 percent of Latino males who reported having no usual source of health care responded that health care was unnecessary for them because they were rarely sick (Livingston and Minushkin 2008). Thus, the value of health care system utilization for improving Latino male population health is, at the very least, ambiguous and difficult to estimate. Yet, while improving our understanding of the value of health care for reducing Latino male morbidity and mortality is a worthwhile goal, it may not be the most high yield solution for bettering Latino health status in U.S. society. It would certainly defy public health science to overcome population health disparities by relying exclusively on increased access and enhanced quality of medical care. Improving our understanding of the pertinent social-structural processes that are putatively causal will require thoughtful inquiry into the social, economic, and political factors that contribute to the health and well-being of Latino males. Although the explanatory framework identified in the introductory chapter of this book is explicitly centered on the health of Latino men in the United States, it is our hope that the model and the analyses presented here have utility and provide insights for the study of health in all males. Health status is an

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outcome of many factors that are not unique to Latinos, and circumscribed explanations that neglect multiple contexts in which all men live cannot provide the comprehensive insights, comparative information, and scientific knowledge needed to respond with viable and equitable solutions. References Board on Health Sciences Policy. 2006. Genes, behavior, and the social environment: Moving beyond the nature/nurture debate. Washington, DC: National Academies Press. Livingston, G., and S. Minushkin. 2008. Hispanics and health care in the United States: Access, information, and knowledge. Washington, DC: Pew Hispanic Center. Seeman, T., S. S. Merkin, E. Crimms, B. Koretz, S. Charette, A. Karlamangla. 2008. Education, income, and ethnic differences in cumulative biological risk profiles in a national sample of U.S. adults: NHANES III (1988–1994). Social Science and Medicine 66: 72–87.

Olivia Carter-Pokras and Mariano Kanamori

Appendix An Overview of Latino Males’ Health Status

This chapter reviews the quality of evidence for evaluating patterns of health status and health care of U.S. Latinos. One of the prerequisites for high quality research and health policy development is the availability of high quality data about Latinos’ health status and health care utilization. The quality of data has been deficient in past decades. Since the information required for comprehensive health indicators requires substantial resources and changing current data collection practices this remains a challenging area. It is inescapable that disparities in health status, health care access, quality of care, and progress toward solutions can only be optimal when structural-demographic, social-cultural, epidemiologic, and utilization variables are available from a range of sources that are comparable with wide geographic and population coverage, timeordered, and updated regularly. Recommendations for future research and policy analysis, including improvements in data collection and policy analyses are summarized herein, along with presentations of basic population health profiles.

Overall Health Status

In 2005, Latino males were less likely to self-report being in fair or poor health than Latina females regardless of their race or ethnicity (table A.1). Latino males were more likely than non-Latino white males, but less likely than nonLatino black males, to self-report being in fair or poor health (12.4 percent, 7.8 percent and 13.8 percent, respectively).

268

6.1

Limited or unable to work

43.8

17.9

10.4

Non-Hodgkin’s lymphoma

Leukemia

8.9

18.1

Urinary bladder

Pancreas

8.0

15.5

Stomach

Oral cavity and pharynx

127.3

Colon and rectum

Prostate

41.3

384.7

Lung and bronchus

All sites

Cancer incidence (rates per 100,000) (2003)

1.9

10.1

Limited in usual activities

Limited in activities of daily living (ADL)

12.4

Self-report fair/poor health status

All ages (%)

Latino male

5.9

13.7

4.0

7.5

9.6

3.4

29.8

20.8

285.3

7.5

2.9

11.1

14.0

Latino female

16.5

24.4

41.6

12.4

9.0

16.0

156.7

57.7

74.6

543.9

8.3

1.3

12.3

7.8

white male

Non-Latino

Health Indicators in the United States by Race (Age Adjusted)

Health indicator

Table A.1 Non-Latino

9.4

17.5

10.3

10.2

4.0

5.9

43.4

53.6

421.8

8.8

1.9

12.1

8.2

white female

12.5

18.3

22.1

16.5

17.7

16.8

237.5

73.2

107.8

634.6

10.9

1.9

14.8

13.8

black male

Non-Latino

Non-Latino

(Continued)

7.6

12.9

7.2

13.6

9.0

6.8

53.0

52.6

390.5

11.3

3.4

14.1

14.7

black female

Continued

Latino male

7.8

Attempted suicide (grades 9–12, 2005)

7.1

Receive special education or early intervention services

10.7

4.7

Have definite or severe difficulties in emotions, concentration, behavior, or ability to get along with others among ages 4–17 (2001–2003)

Made a suicide plan (grades 9–12, 2005)

14.4

Current asthma (grades 9–12, 2005)

26.0

8.5

Physical disabilities or long-term health problems (grades 9–12, 2005)

Felt sad or hopeless (grades 9–12, 2005)

7.8

Self-report fair/poor health (grades 9–12, 2005)

Children and adolescents (⬍18 years) (%)

Health indicator

Table A.1

14.9

18.5

46.7

3.5

2.6

14.1

8.7

12.9

Latino female

Non-Latino

5.2

9.7

18.4

7.9

6.6

13.7

8.1

6.8

white male

Non-Latino

9.3

15.4

33.4

4.1

3.8

14.8

13.5

8.3

white female

5.2

5.5

19.5

8.7

8.3

15.6

7.7

6.0

black male

Non-Latino

Non-Latino

9.8

13.5

36.9

4.0

2.7

15.0

12.3

11.5

black female

65,373

Number of persons living with AIDS at end of 2004

Chronic joint symptoms

Neck pain

Migraines or severe headaches

10.5

17.9

21.2

23.4

9.3

18.8

1.4 19.1

1.6

3.0

6.1

10.2

3.7

7.3

2.0

26.4 (Mexican)

5.2

19.9

17,780

11.1

13.4

14.4

Liver disease

Arthritis

5.4

9.6

1.7

1.9

Chronic bronchitis

Diabetes

Kidney disease

3.5

Ulcers

2.5

Asthma

24.1 (Mexican)

6.6

Stroke

Hypertension (⬎20 years, 2001–2004)

Coronary heart disease

Self-report fair/poor health status

15.7

37.9

AIDS case rates per 100,000 (2004)

Adults (⬎18 years) (%)

18.8

Chlamydia infections among ages 15–24 attending STD clinics (2004)

Adults or adolescents

13.5

9.8

27.5

19.2

1.4

1.6

7.3

7.3

3.1

5.6

2.3

26.8

8.5

10.1

127,385

12.3

13.9

17.7

21.4

29.6

25.4

1.2

1.4

7.5

6.2

5.6

9.4

2.2

28.5

5.1

10.9

17,990

2.1

11.6

10.3

8.6

20.2

15.0

1.4

2.8

5.4

11.2

2.8

5.2

2.8

41.6

5.7

18.7

119,310

99.4

25.7

(Continued)

13.2

18.4

27.0

26.0

1.1

2.6

5.8

11.5

5.5

10.7

4.0

44.7

6.6

20.4

56,449

48.2

18.1

Continued

4.0

Difficult/unable to lift or carry ten pounds

0.1 (Mexican)

3.0 (Mexican)

2.2 (Mexican)

6–19 years

20–59 years

⬎60 years

3.6

3.2 (Mexican)

1–5 years

Prostate-specific antigen ⬎4.0ng/mL (⬎40 years, 2001–2004)

2.1 (Mexican)

⬎1 years

Elevated blood lead levels ⬎10ug/dL (1999–2002)

4.6

Feel hopeless all or most of the time

Difficult/unable to climb up ten steps without resting

2.1

Sad all or most of the time

2.5

2.6

No natural teeth

2.8

8.5

Vision trouble

Nervous all or most of the time

7.7

Hearing trouble

Bed days per person (Mean)

2.6

12.0

Face or jaw pain

24.3

Latino male

Lower back pain

Health indicator

Table A.1

1.6 (Mexican)

0.8 (Mexican)

0.5 (Mexican)

0.7 (Mexican)

0.8 (Mexican)

8.2

7.3

3.8

6.4

4.1

6.0

7.8

11.0

9.6

4.6

30.1

Latino female

Non-Latino

6.2

0.7

1.0

0.2

1.4

0.8

2.5

3.5

3.8

3.4

1.3

2.2

7.2

8.0

23.6

2.9

28.0

white male

Non-Latino

0.1

0.3

0.2

1.3

0.3

5.2

6.3

5.7

5.0

2.1

3.0

7.5

10.2

14.3

6.6

31.0

white female

7.8

7.5

2.3

0.3

2.5

2.2

3.4

5.0

4.8

2.8

2.0

3.8

8.9

8.9

11.1

2.7

22.1

black male

Non-Latino

Non-Latino

0.8

0.5

0.3

3.7

0.7

9.8

11.1

7.2

4.6

2.7

5.8

11.2

12.4

8.6

4.9

28.1

black female

Age 25–44

1.2

65.8

77.9

76.0

Lives with his children under age 19 (age 15–44, 2002)

Contributes child support regularly for child under 19 they do not live with (age 15–44, 2002)

During past month did not check or help with 5- to 18-year-old children’s homework (age 15–44, 2002)

21.2

24.4

Age 30–44

72.4

77.1

80.8

26.7

22.8

26.1

1.8

23.3

0.1

0.9

61.7

5.7

43.9

1.6

0.3

1.59

84.7

1.3

74.5

Age 15–29

Mean age at first child’s birth (age 15–44, 2002)

Age 25–44

Age 15–24

Mean number of biological children (age 15–44, 2002)

35.4

67.6

20.4

55.5

Ever had a biological child (age 15–44, 2002)

Age 15–24

0.6

Any infertility problem (15–44 years, 2002)

Fertility and fatherhood (%)

1.19

74.1

14.1

55.8

71.5

80.4

47.0

25.8

20.7

23.5

1.6

0.2

1.1

70.7

13.1

49.6

(Continued)

1.47

81.0

28.9

63.3

Continued

59.2

52.6

57.9

During past month did not talk with his 5- to 18-year-old children about things that happened during the day (age 15–44, 2002)

Agrees strongly that parental rewards are worth having children (age 15–44, 2002)

Agrees strongly/agrees man earns main living and woman takes care of home and family (age 15–44, 2002)

49.2

53.4

Latino female

Non-Latino

31.1

52.7

37.5

53.7

white male

Non-Latino

30.1

63.0

white female

35.5

46.3

31.9

52.2

black male

Non-Latino

Non-Latino

31.2

49.8

black female

Sources: Adapted from Adams, Dey, and Vickerie 2007; Chandra et al. (2005); CDC 2005, 2006; Kruszon-Morin and McQuillan 2005; Lacher et al. 2006; Martinez et al. 2006; National Center for Health Statistics 2005a, 2005b, 2007; Pleis and Lithbridge-Cekju 2006; and Simpson et al. 2005.

66.6

Latino male

During past month did not eat meals with offspring (age 15–44, 2002)

Health indicator

Table A.1

11.7

11.9

14.3

13.7

45.0

52.5

36.7

2.7

Births to mothers ⬍20 years

Fourth and higher order births

Births to unmarried mothers

Mothers completing twelve or more years of school

Mothers born in the fifty states and D.C.

Mothers who smoked during pregnancy

Source: Adapted from Mathews and MacDorman 2006.

77.4

Prenatal care beginning in the first trimester

Selected maternal characteristics

Preterm births

6.3

6.7

Birth weight ⬍2,500 grams

2.0

36.2

46.4

43.7

14.8

15.3

76.5

1.1

1.2

Birth weight ⬍1,500 grams

1,040

1,041

654,507

4.94

Sex ratio (male live births to 1,000 female live births)

Number of live births

912,331

Female

Selected infant characteristics

6.21

5.06

Male

6.03

7.9

66.6

70.0

59.8

12.2

17.9

81.1

13.8

10.0

2.0

1,043

58,400

7.10

9.22

Rican

Latinos

Mexican

Puerto

All

2.4

47.2

88.4

31.4

4.8

7.9

92.0

11.8

7.0

1.4

1,035

14,867

4.24

4.89

Cuban

1.1

12.1

64.7

46.0

10.4

8.3

79.1

11.4

6.7

1.2

1,043

135,585

4.45

5.60

American

South

Central/

Infant Mortality Rates by Selected Characteristics of Infants and Mothers

Infant mortality rates per 1,000 live births

Table A.2 Other

6.6

73.0

69.8

46.7

11.8

15.9

77.0

12.6

8.1

1.3

1,036

48,972

6.19

7.10

Latinos

and unknown

14.3

94.2

88.3

23.6

8.8

7.5

88.8

11.3

7.1

1.2

1,053

2,321,921

4.99

6.37

white

Non-Latino

8.3

87.6

76.2

68.5

15.3

17.4

75.9

17.8

13.6

3.2

1,036

576,047

12.10

15.05

black

Non-Latino

276

Olivia Carter-Pokras and Mariano Kanamori

Infant and Maternal Health

In 2003, more than 912,300 Latino babies were born, with a sex ratio of 1,041 male babies to 1,000 live birth female babies (table A.2). During that year, the number of Latino live births was less than half the number of non-Latino white live births. The rate of low birth weight (less than 2,500 grams) was lower among Latino infants than non-Latino white and non-Latino black infants. However, the Latino preterm birth rate was higher than the preterm birth rate for non-Latino whites. Puerto Rican babies had higher rates of low birth weight (less than 2,500 grams) and preterm birth compared to non-Latino whites or other Latino subgroups. Among Latino subgroups, Puerto Rican mothers had the highest rates of smoking during pregnancy, births to unmarried women, and teen births (mothers ⬍20 years). Mexican origin women had the lowest rate of prenatal care that begins in the first trimester, as well as the lowest rate of mothers who completed twelve or more years of school. Mexican origin women also had the highest rate of fourth and higher order births. Child, Adolescent, and Adult Health

In 2005, male ninth and twelfth graders were less likely to report being in fair or poor health than females from the same grades, regardless of their race or ethnicity, and Latinos had higher rates of fair/poor health than both non-Latino whites and blacks (table A.1). Adults at least eighteen years of age were more likely to report being in fair or poor health than ninth and tenth graders, regardless of their gender, race, or ethnicity. Latino adults at least eighteen years of age were more likely to report being in fair or poor health than non-Latino whites regardless of their gender. In fact, 15.7 percent of Latino men at least eighteen years of age reported fair or poor health compared to 19.9 percent of Latino women, 10.1 percent of non-Latino white men, and 10.9 percent of non-Latino white women. Mortality

In 2003, the leading causes of death for Latino males were diseases of the heart, cancer, accidents, stroke, diabetes, homicide, chronic liver disease and cirrhosis, suicide, chronic lower respiratory diseases, and Human Immunodeficiency Virus (HIV) (table A.3). The first three causes of death comprised more than half of all deaths among Latino males. Heart disease and cancer represented the first two leading causes of death for both males and females, regardless of their race and ethnicity. In 2003, males had higher age-adjusted mortality rates than females overall and by specific cause of death regardless of their race or ethnicity (table A.4). Compared to non-Latino white males, Latino males had higher mortality rates

Appendix Table A.3

277

Leading Causes of Death for Latino Males Ranked by Ethnicity, Race, and Gender: United States, 20 03

Cause of

Latino

Latino

Non-Latino

Non-Latino

Non-Latino

Non-Latino

male

female

white male

white female

black male

black female

1

1

1

1

1

1

Cancer

2

2

2

2

2

2

Accidents

3

5

3

6

3

6

death

Heart disease

Stroke

4

3

5

3

4

3

Diabetes

5

4

6

8

6

4

Homicide

6

Chronic liver disease

7

Suicide

8

Chronic lower respiratory disease

9

HIV

10

5 10 8 6

4

4

8

7

7

Source: Adapted from National Center for Health Statistics 2006.

for the following specific causes of death: stomach cancer, liver cancer, diabetes, homicide, chronic liver disease and cirrhosis, viral hepatitis, and HIV. Latino males, though, had lower rates of overall mortality than non-Latino white males and lower rates for the following specific causes of death: heart disease, all cancer (including prostate, lung, and colorectal), accidents, stroke, suicide, injury with firearms, chronic lower respiratory disease, and druginduced causes. In 2003, males had higher overall and age-specific mortality rates than females regardless of their race or national origin (table A.5). Latino males below the age of twenty-five years had higher age-specific mortality rates than non-Latino white males of comparable ages. Infant Mortality

In 2003, male infants had a higher risk of dying during the first year of life than female infants, regardless of their race or ethnic origin (table A.2). The infant mortality rate (per 1,000 live births) for all Latino infant males was lower than the rates for both non-Latino white and non-Latino black infant males. Child and Adolescent Mortality

In 2003, accidents and congenital malformations, deformations, chromosomal abnormalities, and malignant neoplasms represented more than half of all deaths

278 Table A.4

Olivia Carter-Pokras and Mariano Kanamori Age-Adjusted Cause of Death by Race, Latino Origin, and Sex: United States, 20 03 Non-Latino Non-Latino

Cause of

Non-Latino

Latino

Latino

Non-Latino

white

black

black

death

male

female

white male

female

male

female

All causes

748.1

515.8

984.0

702.1

1341.1

899.8

Heart disease

206.8

145.8

286.9

187.1

369.2

257.3

All cancer

156.5

105.9

234.6

163.8

314.2

190.8

8.5

5.0

4.7

2.4

11.5

5.5

10.8

5.2

6.3

2.7

10.3

4.0

Stomach cancer Liver cancer

Prostate cancer 20.2

24.6

58.2

Lung cancer

34.5

14.8

73.6

44.3

94.2

40.9

Colorectal cancer

16.8

10.8

22.6

16.0

32.5

23.1

Accidents

44.9

16.3

53.1

25.5

55.0

22.1

Stroke

43.0

38.1

51.9

50.8

81.0

70.9

Diabetes

38.3

32.4

26.1

19.0

51.7

48.3

Homicide

12.1

2.7

3.6

1.8

37.9

6.6

Chronic liver disease and cirrhosis

20.9

9.0

12.4

5.9

12.6

5.3

Viral hepatitis

3.8

2.1

2.2

1.0

3.8

1.8

Suicide

9.7

1.7

21.0

5.0

9.4

1.9

Injury by firearms

13.6

1.6

15.6

2.7

36.8

3.9

Chronic lower respiratory disease

27.1

15.8

55.4

41.8

45.1

22.3

HIV

9.2

2.7

3.4

0.6

32.0

13.1

Drug-induced causes

9.9

3.3

14.1

8.0

14.4

6.6

Source: Adapted from Hoyert et al. 2006.

among 1–4 year-old Latino males (table A.6). Accidents and malignant neoplasms represented more than half of deaths among 5–9 and 10–14 year-old Latino males. Injuries comprised the leading cause of death for 15–19 year-old males and females regardless of their race or ethnicity. Among 15–19 year-old Latino males, accidents represented almost half (45.6 percent) of all deaths, while homicide represented one-quarter (25.5 percent). In addition, 15–19 year-old Latino males had higher mortality rates for injuries overall and for firearm homicide than Latina females and non-Latino white males and females.

592.3

658.9

526.5

707.3

Male

Female

Puerto Rican

36.5

1,146.9

Source: Adapted from Hoyert et al. 2006.

40.7

55.1

1,427.7

Male

Female

24.9

502.5

48.0

30.2

647.2

27.6

29.3

1,290.0

Non-Latino black

Female

Male

576.5

Female

Non-Latino white

733.3

589.4

Male

Central American, South American, Other Hispanic

Female

19.6

27.9

23.8

12.9

18.1

15.6

16.2

18.9

17.6

56.0

176.5

116.6

44.3

105.9

75.8

41.8

108.0

77.6

87.9

32.8

91.8

62.9

34.5

117.8

79.5

35.5

112.9

77.1

years

15–24

Male

10.0

14.0

12.0

12.5

19.5

16.1

12.8

18.4

15.7

years

5–14

59.0

33.1

35.6

26.5

27.1

33.7

30.5

26.3

33.8

30.2

years

1–4

Cuban

Female

664.9

552.4

Female

Mexican

Male

610.1

665.5

Male

1 year

race, and gender

Latino

Under

118.0

266.6

188.9

61.2

129.9

95.8

47.1

121.6

88.0

94.1

72.2

57.4

167.1

108.3

39.7

112.9

80.0

43.0

118.1

83.9

years

25–34

278.4

440.0

354.2

138.0

243.8

190.9

94.4

185.8

139.5

74.7

170.8

125.9

150.8

310.7

226.9

87.7

176.2

135.6

95.5

189.8

144.9

years

35–44

595.7

1,012.8

788.3

293.1

513.2

402.3

185.6

405.2

286.6

211.0

502.5

366.5

365.4

685.6

532.2

210.2

399.0

306.7

219.1

436.4

327.8

years

45–54

1,201.6

2,047.7

1,578.4

705.0

1,110.5

902.4

489.5

904.4

676.0

358.4

945.1

615.1

637.6

1,365.5

950.7

545.2

842.5

693.5

527.9

920.8

714.3

years

55–64

Death Rates by Age, Latino Origin, Race, and Gender: United States, 20 03

Latino origin,

Table A.5

2,531.2

4,041.1

3,158.7

1,807.9

2,738.5

2,237.2

1,116.6

2,049.7

1,475.4

935.4

1,454.7

1,192.2

1,684.7

2,627.6

2,099.3

1,483.5

2,232.9

1,825.0

1,342.9

2,115.7

1,685.6

years

65–74

5,454.6

8,165.7

6,433.0

4,720.5

6,692.2

5,515.4

3,889.0

4,893.4

3,157.0

3,319.6

3,238.1

5,442.5

3,300.2

4,781.0

3,912.1

3,506.4

4,948.5

4,093.5

years

75–84

13,730.3

15,082.2

14,107.7

14,377.2

16,234.4

14,944.8

9,212.9

9,677.3

10,128.1

11,029.2

10,431.5

and over

85 years

Age-

899.8

1,341.1

1,083.2

702.1

984.0

826.1

604.8

958.7

735.9

416.4

607.0

506.3

633.3

939.0

763.2

499.8

726.6

604.0

515.8

748.1

621.2

rate

adjusted

Table A.6

Leading Causes of Death for Latino Males by Age: United States, 20 03 % of total deaths

Latino males, 1–4 years old

Accidents (unintentional injuries)

36.1

Congenital malformations, deformations, and chromosomal abnormalities

10.9

Malignant neoplasms

10.5

Assault (homicide)

6.3

Influenza and pneumonia

4.2

Diseases of heart

3.3

Chronic lower respiratory diseases

1.4

Certain conditions originating in the perinatal period

1.4

Cerebrovascular diseases

1.2

Septicemia

1.1

All other causes (residual)

24.4

Latino males, 5–9 years old

Accidents (unintentional injuries)

43.9

Malignant neoplasms

22.3

Congenital malformations, deformations, and chromosomal abnormalities

4.8

Assault (homicide)

2.2

Diseases of heart

1.6

Influenza and pneumonia

1.6

In situ neoplasm, benign neoplasms, and neoplasms of uncertain or unknown behavior

1.3

Septicemia

1.0

Cerebrovascular diseases

1.0

Chronic lower respiratory diseases

0.6

Certain conditions originating in the perinatal period

0.6

All other causes (residual)

19.1

Latino males, 10–14 years old

Accidents (unintentional injuries)

38.5

Malignant neoplasms

13.5

Intentional self-harm (suicide)

7.9

Assault (homicide)

7.4

Diseases of heart

3.6

Congenital malformations, deformations, and chromosomal abnormalities

3.3

Chronic lower respiratory diseases

2

Influenza and pneumonia

1.8

Cerebrovascular diseases

1.3

In situ neoplasm, benign neoplasms, and neoplasms of uncertain or unknown behavior All other causes (residual)

0.8 19.9 (Continued)

Table A.6

Continued % of total deaths

Latino males, 15–19 years old

Accidents (unintentional injuries)

45.6

Assault (homicide)

25.5

Intentional self-harm (suicide)

9.3

Malignant neoplasms

5.5

Diseases of heart

1.8

Congenital Malformations, deformations and chromosomal abnormalities

1.0

Cerebrovascular diseases

0.4

Chronic lower respiratory diseases

0.4

Influenza and pneumonia

0.4

Nephritis, nephrotic syndrome, and nephrosis

0.4

Legal intervention

0.4

All other causes (residual)

9.3

Latino males, 20–24 years old

Accidents (unintentional injuries)

44.4

Assault (homicide)

27.7

Intentional self-harm (suicide)

10.3

Malignant neoplasms

3.7

Diseases of heart

2.7

Legal intervention

0.9

HIV

0.6

Influenza and pneumonia

0.5

Congenital malformations, deformations, and chromosomal abnormalities

0.5

In situ neoplasm, benign neoplasms, and neoplasms of uncertain or unknown behavior

0.3

Cerebrovascular diseases

0.3

All other causes (residual)

8

Latino males, 25–34 years old

Accidents (unintentional injuries)

38.5

Assault (homicide)

18.0

Intentional self-harm (suicide)

9.2

Malignant neoplasms

5.8

Diseases of heart

5.1

HIV

3.9

Chronic liver disease and cirrhosis

1.7

Cerebrovascular diseases

1.1

Congenital malformations, deformations, and chromosomal abnormalities

0.8

Influenza and pneumonia

0.7

All other causes (residual)

15.3 (Continued)

Table A.6

Continued % of total deaths

Latino males, 35–44 years old

Accidents (unintentional injuries)

25.3

Diseases of heart

11.1

Malignant neoplasms

9.6

HIV

9.3

Assault (homicide)

6.8

Chronic liver disease and cirrhosis

6.5

Intentional self-harm (suicide)

5.8

Cerebrovascular diseases

2.8

Diabetes mellitus

2.1

Viral hepatitis

1.4

All other causes (residual)

19.4

Latino males, 45–64 years old

Malignant neoplasms

18.6

Diseases of heart

18.2

Accidents (unintentional injuries)

11.6

Chronic liver disease and cirrhosis

9.2

HIV

6.0

Diabetes mellitus

4.1

Cerebrovascular diseases

4.1

Intentional self-harm (suicide)

2.6

Viral hepatitis

2.5

Assault (homicide) All other causes (residual)

2.3 20.7

Latino males, 65 years old and over

Diseases of heart

31.5

Malignant neoplasms

23.7

Cerebrovascular diseases

6.5

Diabetes mellitus

5.9

Chronic lower respiratory diseases

4.4

Influenza and pneumonia

3.3

Nephritis, nephrotic syndrome, and nephrosis

2.2

Accidents (unintentional injuries)

2.2

Alzheimer’s disease

2.0

Chronic liver disease and cirrhosis All other causes (residual) Source: Adapted from Heron and Smith 2007.

1.7 16.7

Appendix

283

Adult Mortality

In 2003, accidents comprised the leading cause of death for 20–44 year-old Latino men (table A.6). Among 20–24 year-old Latino men, 44.4 percent of deaths were due to accidents and 27.7 percent were due to homicide. Suicide was the third leading cause of death, representing 10.3 percent of all deaths. Deaths due to HIV represented the seventh leading cause of death for 20–24 year-old Latino men, the sixth among 25–34 year-olds, the fourth among 35–44 year-olds, and the fifth among 45–64 year-olds. Malignant neoplasm was the leading cause of death for Latino males 45–64 years of age. For Latino males at least sixty-five years of age, heart disease was the leading cause of death. Fertility and Fatherhood

In 2002, Latino 15–44 year-old men were more likely than non-Latino white men to report ever having had a biological child and less likely to report problems with infertility (table A.1). Around three-quarters of 25–44 year-old Latino men (74.5 percent) reported having a biological child compared to 61.7 percent of non-Latino white males. Among 25–44 year-old men, Latinos had a higher mean number of biological children (1.8) than non-Latino whites (1.2). Latino males also tended to be younger at their first child’s birth than non-Latino white males. Around 66 percent of 15–44 year-old Latino fathers lived with their children under the age of nineteen compared to 80.8 percent of non-Latino white fathers and 47 percent of non-Latino black fathers. In 2002, Latino 15–44 year-old fathers were as likely as non-Latino white fathers to contribute child support on a regular basis for their children under nineteen that did not live with them (table A.1). However, Latino fathers were the least likely to check or help their 5–18 year-old children with their homework compared to both non-Latino white fathers and non-Latino black fathers, and they were the most likely to not eat meals with their children and to not talk with their 5–18 year-old children about things that happened during the day. Working multiple jobs, lower English language skills, and geographical separation were likely to play a role in these rates. It is important to highlight that 15–44 year-old Latino fathers were just as likely as non-Latino white fathers to strongly agree that parent rewards are worth the hard work and sacrifice. In addition, 15–44 year-old Latino men more likely held beliefs in traditional gender roles than non-Latino white and non-Latino black males and females. In fact, 57.9 percent of Latino men agreed that the man should earn the main living and the woman should take care of the home and the family, compared to 31.1 percent of non-Latino white males, 30.1 percent of non-Latino

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Olivia Carter-Pokras and Mariano Kanamori

white females, 35.5 percent of non-Latino black males, and 31.2 percent of nonLatino black females. Reproductive Health Sexual Abstinence

In 2002, Latino 15–19 year-old males were less likely to report being sexually abstinent before age 15 than Latina females, non-Latino white males and females and non-Latino black females (table A.7). Only 76 percent of Latino 15–17 yearold males reported being sexually abstinent before age 15 compared to 90 percent of Latina females, 91 percent of non-Latino white males, 88 percent of non-Latina females, and 77 percent of non-Latino black females. Non-Latino black men ages 15–19 reported a lower percentage of being sexually abstinent before age 15 than Latino males (71 percent vs. 76 percent respectively). The rates of being sexually abstinent decreased when 15–19 year-old adolescents were asked to report their sexual abstinence without referring to a specific time (table A.7). In fact, 57 percent of Latino 15–17 year-old males reported being sexually abstinent compared to 75 percent of Latina females and non-Latino white males, 70 percent of non-Latina females, 47 percent of non-Latino black males, and 59 percent of non-Latino black females of similar ages. Sexual Activity

Data from 2005 shows that among ninth to twelfth graders, Latino males were more likely than non-Latino white males to report being currently sexually active (table A.7). Latino males had a lower mean age at first intercourse than non-Latino white males (16.5 vs. 17.1 years respectively). Latino male adolescents who were less than 19 years of age were less likely than non-Latino white males to report in 2002 that they wanted their first sexual intercourse at the time. Moreover, more than twice as many Latino male ninth to twelfth graders reported having been forced to have sexual intercourse than nonLatino white males (6.4 percent vs. 3.1 percent respectively). Among 20–44 year-old adults, the percentage reporting that they wanted their first sexual intercourse at the time was similar among Latino males and non-Latino white males (table A.7). Access and Use of Contraceptive Methods

In 2005, the percentage using condoms at last intercourse among ninth to twelfth graders was lower for Latinos than for non-Latino whites and blacks (table A.7). However, the percentage reporting the use of condoms in 2002 was similar among 20–24 year-old Latino and non-Latino white men (table A.8).

24.4 39.0

Used computers ⱖ 3 hours/day

Met currently recommended levels of physical activity

12.5 88.6 46.1

37.4

Rarely or never wear seatbelt

Rarely or never wear bicycle helmet (among bicycle riders in past year)

Rarely or never wear motorcycle helmet (among motorcycle riders in past year)

Rode with driver who had been drinking alcohol

Injury prevention (grades 9–12, 2005)

45.8

Watched television ⱖ 3 hours/day

Physical activity (grades 9–12, 2005) (%)

24.5

20.0 (Mexican)

12–19 years

Ate fruits and vegetables ⱖ 5 times per day (grades 9–12, 2005)

25.6 (Mexican)

6–11 years

Overweight (2001–2004)

Diet/nutrition (%)

male

Latino

34.7

48.3

83.4

8.7

26.5

14.9

45.8

21.8

17.1 (Mexican)

16.6 (Mexican)

female

Latino

26.2

35.6

84.4

11.5

46.9

25.4

30.2

19.7

17.9

16.9

white male

Non-Latino

30.4

30.2

77.9

7.2

30.2

13.7

28.1

17.4

14.6

15.6

white female

Non-Latino

Health Behaviors among Youth by Age, Race, and Gender: United States, 20 01–20 05

Health behavior

Table A.7

24.3

48.0

93.5

17.7

38.2

34.9

63.5

24.3

17.7

17.2

black male

Non-Latino

Non-Latino

(Continued)

24.0

40.7

90.1

9.4

21.3

16.1

64.5

19.9

23.8

24.8

black female

Continued

10.7

Did not go to school because of safety concerns

8.6

Latino

5.6 12.4 6.0

Ever used steroids

Ever used hallucinogenic drugs

Ever used heroin

4.6 12.5

Ever used illegal injection drugs

7.5

Ever used inhalants

28.1

1.2

6.3

2.2

13.5

1.4

4.7

18.0

21.9

28.7

Current cocaine use

44.8

9.1

1.5

19.2

9.7

32.5

7.8

6.4

female

48.9

20.0

Current marijuana use

Drug use (grades 9–12, 2005) (%)

Episodic heavy drinking

Current alcohol use

Alcohol use (grades 9–12, 2005) (%)

Current cigar use

Current smokeless tobacco use

Current cigarette use

24.8

49.5

In a physical fight ⱖ 1 times during past year

Tobacco use (grades 9–12, 2005) (%)

14.6 29.8

Carried a weapon

male

Latino

Drove when drinking alcohol

Health behavior

Table A.7 Non-Latino

2.7

10.8

4.7

12.0

2.5

3.5

21.3

31.8

47.0

21.0

17.6

24.9

3.9

41.2

31.4

12.4

white male

Non-Latino

1.6

8.0

3.6

14.8

1.3

2.8

19.2

28.1

45.9

8.6

2.7

27.0

4.9

24.7

6.0

10.1

white female

2.5

4.9

3.9

7.4

3.1

2.5

22.1

11.9

29.6

12.3

3.0

14.0

8.2

48.9

23.7

6.5

black male

Non-Latino

Non-Latino

0.5

1.0

1.0

6.2

0.3

0.5

18.8

10.4

32.5

8.3

0.4

11.9

9.2

37.7

9.4

3.5

black female

Ever used ecstasy

20–24 years 49.8

12.5

65.3

70.1

5.8

3.5

4.6

75

91

Source: Adapted from CDC 2006; Chandra et al. 2005; Martinez et al. 2006; Mosher et al. 2005.

Condom use at last intercourse (grades 9–12, 2005)

9.1

4.1

5.4

Had sexual contact with a same-sex partner (15–24 years, 2002)

75

5.5

57

Abstinence among adolescents (15–17 years, 2002)

90

7.0

76

Abstinence before age 15 (15–19 years, 2002)

15–19 years

6.4

3.1

68.7 9.4

68.9

Ever forced to have sexual intercourse (grades 9–12, 2005)

20–44 years

72.6

71.8

68.6

71.7

59.9

65.3

Wanted first sexual intercourse at the time (18–44 years, 2002)

17.1

30.6

6.2

6.1

16–19 years

16.5

Mean age at first intercourse (15–44 years, 2002)

33.7

6.5

7.7

⬍16 years

36.3

Currently sexually active (grades 9–12, 2005)

Pregnancy and STD prevention (%)

9.9 12.8

Ever used methamphetamines

55.6

15.8

12.7

14.2

70

88

10.8

33.5

5.3

6.9

75.5

6.3

5.2

5.7

47

71

7.1

61.6

60.8

59.4

15.5

51.3

5.3

2.7

62.1

10.5

9.9

10.2

59

77

11.5

43.8

2.5

0.8

21.3 10.2

45–64 years

⬎65 years

9.4

76.6 (Mexican)

Current drinker (ⱖ20 years, 1999–2002)

2.7 (Mexican) 0.4 2.3

Narcotic drug use (⬎18 years, 1999–2002)

Illicit drug injection (18–44 years, 2002)

Crack cocaine use (18–44 years, 2002)

Substance abuse

4.6 (Mexican) 18.8 (Mexican)

65

Exceeds guidelines for low-risk drinking (⬎21 years of age, 2001–2002)*

Former drinker (⬎20 years, 1999–2002)

8.3

Lifetime abstainer (⬎20 years, 1999–2002)

23.3

52.3

Current regular drinker

Current infrequent drinker

0.8

0.6

3.2 (Mexican)

54.1 (Mexican)

18.1 (Mexican)

27.8 (Mexican)

54

16.0

48.2

5.4

13.2

12.5

23.1

Lifetime abstainer

Alcohol drinking

20.8 24.7

25–34 years

35–44 years

9.7

9.5 (Mexican)

19.8 (Mexican) 21.3

10.6

Latino female

20.1

18–24 years

⬎18 years

Current cigarette smoking (2002–2004)

Latino male

1.5

0.5

2.9

76.6

16.7

6.7

62

9.0

61.9

14.2

9.4

24.3

29.1

29.7

31.8

24.8

white male

Non-Latino

0.5

0.3

5.9

68.9

16.2

14.8

56

15.2

47.5

23.0

8.5

21.3

26.2

26.3

27.5

21.9

white female

Non-Latino

Health Behaviors among Adults by Age, Race, and Gender: United States, 20 05

Health behavior

Table A.8

3.0

0.9

3.3

66.7

21.6

11.6

60

9.0

45.4

28.8

17.2

30.1

26.7

26.5

19.3

25.1

black male

Non-Latino

Non-Latino

0.8

0.3

4.5

51.5

21.9

26.6

53

12.7

25.3

44.9

8.1

22.3

22.2

16.2

14.7

17.8

black female

4.5 6.2

Median number of sexual partners in lifetime (15–44 years, 2002)

Ever had sexual activity with same-sex partner (15–44 years, 2002)

6.5

1.7

5

6.5

5.3

22

10.7 (38,738,000)

27

37

12.6

3.6

10

8.6 (39,498,000)

18

21

29

39

60

32

27.4

17.4

57.6

61.3

5.0

8.3

34

22.0 (6,940,000)

46

42

61

53

33.5

14.2

67.0

65.7

10.6

4.1

9

19.1 (8,250,000)

29

31

30

37

33

35.3

14.8

79.6

76.6

Source: Adapted from Adams and Schoenborn 2006; Anderson, Mosher, and Chandra 2006; Fryar, Hirsch, and Porter 2006; Mosher, Chandra, and Jones 2005; National Center for Health Statistics 2005, 2007; Pleis and Lithbridge-Cekju 2005.

18

Had ⬎15 opposite-sex partners in lifetime (15–44 years, 2002)

11.7 (9,107,000)

13

20 17.6 (10,188,000)

35–44 years

Percent and number of 15–44 year-olds at risk for HIV due to sex, drug risk, or STD treatment in past year (2002)

18

30–34 years

38

31

25–29 years

30

62 47

35

40

48

25

20–24 years

37

28.7

16.0

71.0

52.7

18–19 years

18–44 years

Condom use (2002)

26.9 26.5 (Mexican)

24.9

14.0 (Mexican)

73.0 (Mexican)

81.0

23.6 (Mexican)

16.9 (Mexican)

High serum cholesterol levels (ⱖ20 years, 2001–2004)

Slept ⬍6 hours per night (2002–2004)

74.6 (Mexican)

68.8

Overweight (⬎20 years, 2001–2004)

Diet/nutrition

No vigorous leisure-time physical activity per week lasting ⬎ten minutes

Physical activity

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Olivia Carter-Pokras and Mariano Kanamori

Nonetheless, the use of condoms was lower among Latino men ages 25–29 and 35–44 than for non-Latino white men who were in the same age range (table A.8). Among 15–44 year-old married men, Latinos and non-Latino blacks were less likely to have received a vasectomy than non-Latino whites in 2002 (4.4 percent, 5.1 percent, and 16.2 percent respectively) (table A.9). Unmarried 15–44 year-old Latino men were just as likely as both non-Latino whites and blacks to have gone to a family planning clinic with their female partner in the past year. Latino and non-Latino black unmarried 15–44 year-old men were more likely than non-Latino whites to have received birth control counseling from a family planning clinic in the past year (34 percent, 36 percent, and 29 percent respectively). In addition, non-Latino black men were the most likely to have received advice/counseling from a doctor on birth control in the past year. Sexual Abuse and Domestic Violence

Involvement in domestic violence is another health issue for Latino men. Domestic violence was examined in a national probability study of non-Latino white, non-Latino black, and Latino married and cohabiting couples at least eighteen years of age interviewed in 1995 and again in 2000 (Field and Caetano 2005). Although most couples reporting violence engaged in mutual partner violence, Latinos were nine times more likely to report male to female violence. Health Care Access and Utilization

In 2005, 37.2 percent of Latino men at least eighteen years of age reported not having visited a doctor’s office during the past year compared to 22 percent of non-Latino white and 30.2 percent of non-Latino black men (table A.9). Latino men at least eighteen years of age were more likely to report never having seen a doctor in their lifetime (4.2 percent) than non-Latino white men (0.6 percent) or non-Latino black men (1.2 percent). Approximately one-third (32.5 percent) of Latino men at least eighteen years of age did not have a usual place of care in 2005—much greater than Latina women and non-Latino white and black men and females. Of Latino men at least eighteen years of age who did have a usual source of care, 71.4 percent reported that their usual place of care was a doctor’s office or HMO and 23.4 percent reported a clinic or health center. Only 4 percent of Latino men at least eighteen years of age reported having a hospital emergency room or outpatient department as their usual place of care—a rate that was intermediate between those for non-Latino white and non-Latino black men.

5.6

71.4 23.4 4.0

Doctor’s office or HMO

Clinic or health center

Hospital emergency room or outpatient department

Dental visit in past year (2–17 years, 2000–2003)

71.5 (Puerto Rican) 73.0 (Cuban)

72.1 (Puerto Rican) 65.3 (Cuban)

71.7 (Other)

64.3 67.2 (Central and (Central and South American) South American)

61.3 (Mexican)

58.2 (Mexican)

2.2

20.1

78.3

0.6

22.0

2.0

5.1

81.7

16.7

7.1

6.9

13.2

15.4

64.1

69.4 (Other)

Non-Latino white male

30.0

64.4

19.2

61.5

4.2

Time since last contact with dental health professional

37.2

No office visits in past year

Never

Time since last contact with health care professional (⬎18 years, 2005)

32.5

No usual place of care

Usual place of care (⬎18 years, 2005)

8.9

7.3

Delayed medical care due to cost (all ages, 2005)

At least one overnight hospital stay (all ages, 2005)

9.8

30.7

Latino female

36.5

No health insurance (⬍65 years, 2005)

Latino male

Health Care Access Indicators by Race and Ethnicity: United States, 20 05

Health care access indicator (%)

Table A.9 Non-Latino

78.8

0.4

9.7

0.9

14.7

83.7

8.9

9.4

8.3

11.1

white female

1.2

30.2

6.6

16.6

76.2

20.2

7.7

6.5

20.9

black male

Non-Latino

Non-Latino

(Continued)

0.5

12.8

5.4

18.3

75.8

10.0

9.4

8.2

17.2

black female

Continued

58.9 (Puerto Rican) 63.0 (Cuban)

51.8 (Puerto Rican) 56.3 (Cuban)

4.9 (Puerto Rican)

5.2 (Puerto Rican)

7.0 (Other)

5.8 (Other)

8.0 7.5 (Central and (Central and South American) South American)

8 8.9 (Mexican)

Unmet dental needs due to cost (2–17 years, 2000–2003)

49 3.4

7.9

3.6

65.2 (Other)

8.6 (Mexican)

55.6

Never (⬎18 years, 2005)

52.9 (Other)

52.8 58.8 (Central and (Central and South American) South American)

54 49.3 (Mexican)

43.9

Latino female

38.6 (Mexican)

Latino male

No dental visits in past year (⬎18 years, 2005)

Dental visit in past year (ⱖ18 years, 2000–2003)

Health care access indicator (%)

Table A.9 Non-Latino

5

0.4

37.3

63.4

white male

Non-Latino

6.3

0.2

29.8

70.2

white female

1.3

51

black male

Non-Latino

Non-Latino

1.3

43.4

black female

14.9 (Mexican) 10.5 (Puerto Rican) 6.8 (Cuban)

9.8 (Mexican) 9.5 (Puerto Rican) 4.1 (Cuban)

44.7 15.6

Ever had HIV test, excluding tests done as part of blood donation (15–44 year olds, 2002)

Had HIV test, excluding as part of blood donation, in past twelve months (15–44 year olds, 2002) 32.6

67.2

Testicular exam in past year (15–44 years, 2002)

12.7

Never tested (⬎18 years, 2004)

7.9 (Other)

20.8

56.3

57.3

11.2

12.2 (Other)

8.9 11.6 (Central and (Central and South American) South American)

13.1

9.1

Ever tested (grades 9–12, 2005)

HIV testing

Unmet dental needs due to cost (⬎18 years, 2000–2003)

38.7

12.4

45.8

69.7

8.8

8

12.5

52.5

64.2

11.6

10.3

17.9

50.3

23.7

56.5

54.0

24.1

(Continued)

24.6

65.4

49.4

Continued

Latino male

34 20 4.4 37.2 (Mexican)

Received birth control counseling from a family planning clinic in last twelve months

Received advice/counseling from a doctor on birth control in last 12 months

Married men with vasectomy (15–44 years, 2002)

Overweight 2–19 year-olds told by doctor or health professional they were overweight (1999–2002)

37.3 (Mexican)

Latino female

Non-Latino

37.9

16.2

18

29

20

white male

Non-Latino

31.0

white female

38.4

5.1

36

36

20

black male

Non-Latino

Non-Latino

47.4

black female

Source: Adapted from Adams, Dey, and Vickerie 2005; Anderson, Chandra, and Mosher 2005; National Center for Health Statistics 2007; Pleis and Lithbridge-Cekju 2006; Ogden and Tabak 2005; and Scott and Simile 2005.

21

Attended family planning clinic with female partner in past twelve months

Unmarried male involvement in pregnancy prevention (15–24 years, 2002)

Health care access indicator (%)

Table A.9

Appendix

295

Access to Health Insurance and Delayed Care

According to the latest National Health Care Disparities Report from the Agency for Healthcare Research and Quality (2006), Latinos are experiencing an increase in barriers to access to healthcare as well as a decline in the quality of the healthcare services. In 2005, 36.5 percent of Latino males below the age of sixty-five did not have health insurance—much higher than any other racial and ethnic group regardless of their gender (table A.9). Among Latino males, 7.3 percent delayed receiving medical care due to cost, and only 5.6 percent reported having at least one overnight hospital stay during the previous year. Access to Oral Health Care

During 2000–2003, 61.5 percent of Latino 2–17 year-old males reported having visited a dentist during the past year compared to 78.3 percent of non-Latino white males (table A.9). Adults 18 years of age and over were less likely to have visited a dentist during the past year than children or adolescents, regardless of their race or national origin. Males were also less likely to visit a dentist than females, regardless of their race, ethnicity, or age. Diabetes and Obesity Obesity

The distribution of poor health behaviors suggests that chronic disease will continue to increase among Latino males. From 1999–2002, the percent of 2–19 year-old children and adolescent males told by a doctor or a health professional that they were overweight was similar among Mexican American males and non-Latino white males (table A.9). However, during 2001–2004, Mexican American 6–19 year-old child and adolescent males had higher rates of obesity than non-Latino white males (table A.7). Among men at least 20 years old, Mexican Americans were more likely to be overweight than both non-Latino whites and blacks during 2001–2004 (table A.8). Diet and Physical Activity

In 2005, the intake of at least five fruits and vegetables per day was higher for Latino ninth to twelfth graders than non-Latino whites (table A.7). However, Latino ninth to twelfth graders were also more likely to watch at least three hours of television per day, and less likely to meet the currently recommended levels of physical activity than non-Latino white males. In addition, Latinos were less likely to participate in vigorous leisure-time physical activity lasting more than ten minutes than non-Latino whites (table A.8). During 2001–2004, Mexican American men at least twenty years of age had higher rates of serum cholesterol levels compared to Mexican American women (table A.8).

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Diabetes and Other Chronic Disease

In 2005, self-reporting of previous physician diagnosis for diabetes was higher for Latino men at least eighteen years old compared to non-Latino white men (table A.1). In fact, 9.6 percent of Latino men at least eighteen years of age reported previous physician diagnosis of diabetes compared to 7.3 percent of non-Latino white men. Cardiovascular Disease

In 2005, the self-reported rate of previous physician diagnosis of coronary heart disease was lower for Latino men at least eighteen years of age than the selfreported rate of non-Latino white men (6.6 percent vs. 8.5 percent respectively) (table A.1). However, once data were properly validated, Mexican Americans had rates of coronary heart disease that were equal to or higher than those for non-Latino whites (Pandey et al. 2001). Cancer

Among Latinos, cancer is the second leading cause of death for adults following heart disease. Cancer accounts for 20 percent of all deaths in Latinos in the United States. It is estimated that 39,940 new cancer cases in men and 42,140 cases in women were diagnosed among Latinos in 2006. Prostate cancer was the most commonly diagnosed cancer in Latino men, while breast cancer was the most common cancer in Latina women. Cancer of the colon and rectum was the second-most commonly diagnosed cancer in both Latino men and women (American Cancer Society 2006). Cancer screening rates were lower for Latino men. According to the American Cancer Society (2006), Latinos fifty years and older were less likely to have had a recent screening test for colorectal cancer than non-Latino whites (29.9 percent vs. 44.3 percent). Latino men were also less likely to have had a PSA test for the early detection of prostate cancer than non-Latino white men (53 percent vs. 58 percent). In 2002, Latino 15–44 year-old males were less likely to have received a testicular exam during the past year than non-Latino white men and non-Latino black men (32.6 percent, 38.7 percent, and 50.3 percent respectively) (table A.9). HIV and AIDS

More than 65,000 Latino male adolescent and adults were living with AIDS at the end of 2004 (table A.1). AIDS case rates per 100,000 for Latino male adolescents and adults were more than three times those for non-Latino white males, and almost four times greater than for Latina females (37.9, 12.3, and

Appendix

297

11.1 respectively). Consistent with the higher rates of HIV/AIDS, in 2002 Latino men were more likely to be at risk for HIV due to sex, drug risk, or STD treatment in the past year than Latina women and non-Latino white men and women (table A.8). During that year, 17.6 percent or 10,188,000 Latino men 15–44 years of age were at risk for HIV due to sex, drug risk, or STD treatment in the past year. This percentage was higher than the rates for Latinas, nonLatino males, and non-Latina females (11.7 percent, 10.7 percent, and 8.6 percent respectively). In 2002, the median number of lifetime sexual partners for 15–44 year-old Latino men was lower than the median number for non-Latino white and black men (4.5, 5.3, and 8.3 respectively). Eighteen percent of 15–44 year-old Latino men reported having at least fifteen opposite-sex partners in their lifetime. Condom Use

In 2002, only 37 percent of 18–44 year-old Latino men reported using condoms at their last intercourse, dropping down to 20 percent of 35–44 year-old Latino males (table A.8). HIV Testing

Among ninth to twelfth graders, 12.7 percent of Latino males reported having been tested for HIV in 2005 compared to 8.8 percent of non-Latino white males (table A.9). Among 15–44 year-old men, 44.7 percent of Latinos and 45.8 percent of non-Latino whites reported having been tested for HIV. Only 15.6 percent of Latino males age 15–44 and 12.4 percent of non-Latino white males reported having been tested during the previous twelve months (excluding tests done as part of blood donation). Chlamydia Infections

In 2004, chlamydia infections among 15–24 year-olds attending STD clinics were more common among Latino males compared to Latina females, nonLatino white males and females, and non-Latino black females (table A.1). Mental Health

Poor mental health of Latino males is a concern. In 2005, Latino male ninth to twelfth graders were more likely than non-Latino white males to report feeling sad or hopeless, make a suicide plan, or attempt suicide (table A.1). Despite lower rates of suicide attempts for Latino male ninth to twelfth graders compared to Latina females (7.8 percent vs. 14.9 percent respectively), Latino males had considerably higher suicide mortality rates than Latina females

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(9.7 percent vs. 1.7 percent) (tables A.1 and A.4). Among children and adolescents, males were more likely than females to receive special education or early intervention services regardless of their race or ethnicity (table A.1). Latino 4–17 year-old males were less likely than non-Latino white males to have definite or severe difficulties in emotions, concentration, behavior, or ability to get along with others (4.7 percent vs. 6.6 percent). Latino men at least 18 years old were also less likely than non-Latino white males to report feeling nervous all or most of the time, but they were more likely to report feeling sad or hopeless all or most of the time (table A.1). Environmental Health

Environmental health is another concern for Latino males. Data from 1999 to 2002 show that among 1–5 year-old children, elevated blood lead levels at least 10 ug/dl were more likely to be found among Mexican American boys than non-Latino white boys (table A.1). For example, 3.2 percent of 1–5 year-old Mexican American boys had elevated blood lead compared to 0.7 percent of Mexican American girls and 1.4 percent of non-Latino white boys. In general, boys were more likely to have elevated blood lead than girls regardless of age, race, and ethnicity. Elevated blood lead levels were also more common among Mexican immigrant adult men. Three percent of 20–59 year-old Mexican American men had elevated blood lead compared to 0.8 percent of Mexican American women, 1.0 percent of non-Latino white males, and 0.3 percent of non-Latino white females. Among adults at least 60 years of age, 2.2 percent of Mexican American men had elevated blood lead compared to 1.6 percent of Mexican American women, 0.7 percent of non-Latino white males, and 0.1 percent of non-Latino white females. Injury prevention behaviors also tend to be less common among Latino adolescents. In 2005, Latino ninth to twelfth graders were more likely than nonLatino whites to rarely or never wear a seatbelt, to rarely or never wear bicycle helmets (among bicycle riders), to rarely or never wear motorcycle helmets, or to ride with a driver who had been drinking alcohol (table A.7). Regardless of race or ethnicity, males were more likely than females to drive when drinking alcohol, to carry a weapon, or to be in a physical fight during the past year. Approximately 10 percent of Latino adolescents did not go to school because of safety concerns—much higher than the rate for non-Latino whites. Tobacco Use

The 2005 rates of current cigarette use and current cigar use were similar for Latino and non-Latino white male ninth to twelfth graders, although the rate of

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current smokeless tobacco use was much lower for Latino males than for nonLatino white males. Rates of current cigarette use, current smokeless tobacco use, and current cigar use was much higher for Latino ninth to twelfth grade males than Latina females (table A.7). Approximately one out of five Latino and Mexican American men at least 18 years of age currently smoke cigarettes, compared to one out of four non-Latino white and non-Latino black men (table A.8). Mexican American and Latino men were twice as likely as Mexican American and Latina women to smoke cigarettes. Among Latino males, there are differences by age. While around one out of five Latino men ages 18–64 smoked cigarettes, only one out of ten Latino men at least 65 years of age smoked cigarettes. Alcohol Use

In 2005, the rate of current alcohol use among ninth to twelfth graders was slightly greater for Latino males than for Latina females (48.9 percent vs. 44.8 percent respectively) (table A.7). Compared to non-Latino white ninth to twelfth graders, the rates of episodic heavy drinking were slightly lower for Latinos regardless of their gender. Among Latino men at least eighteen years of age, 52.3 percent were current regular drinkers and 8.3 percent were current infrequent drinkers (table A.8). Regardless of their race or ethnicity, adult men were more likely than adult women to be current regular drinkers and to exceed guidelines for low-risk drinking. However, regardless of their race or ethnicity, adult females were more likely than men to be current infrequent drinkers. Slightly less than one out of four Latino men has abstained from alcohol their entire life. Although lifetime abstention rates were higher among Latino men than non-Latino white men, Latino men at least twenty-one years of age who drink were as likely as non-Latino white males to exceed guidelines for low-risk drinking. Other Drug Use

In 2005, adolescent male ninth to twelfth graders were more likely than gradematched women to report drug use regardless of their race or ethnicity (table A.7). Among ninth to twelfth graders, Latino males were more likely than non-Latino white males to report current use of marijuana use or cocaine or to have ever used illegal injection drugs, inhalants, steroids, hallucinogenic drugs, heroin, methamphetamines, or ecstasy. Latino and non-Latino female ninth to twelfth graders were more likely than Latino and non-Latino male adolescents to report ever having used inhalants. Drugs that Latino male ninth to twelfth graders used the most were marijuana (28.1 percent), ecstasy (12.8 percent), inhalants (12.5 percent), and hallucinogenic drugs (12.4 percent).

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Among adults, data from 1999–2002 show that Mexican American males and non-Latino white males at least 18 years of age had similar rates of narcotic drug use (table A.8). In fact, 2.7 percent of Mexican American men at least 18 years of age reported narcotic drug use compared to 2.9 percent of non-Latino white men. In 2002, Latino and non-Latino white men 18–44 years of age had similar rates of illicit drug injection use (0.4 percent and 0.5 percent respectively). The 2002 rate of crack cocaine use among 18–44 year-old Latino men was greater than the rate for non-Latino white men and almost three times the rate for Latina women (2.3 percent, 1.5 percent, and 0.8 percent respectively). Functional Limitations

In 2005, more Latino male ninth to twelfth graders than non-Latino white males reported having fair or poor health (7.8 percent and 6.8 percent) (table A.1). Also, Latino male ninth to twelfth graders had similar rates for physical disabilities or long-term health problems compared to Latina females and nonLatino white males (8.5 percent, 8.7 percent, and 8.1 percent respectively). In 2005, more Latino males at least eighteen years old than non-Latino white males reported having fair or poor health (15.7 percent vs. 10.1 percent) (table A.1). Latino males were less likely than both non-Latino white and black males to report that they were limited in their usual activity and limited or unable to work. Latino and non-Latino black males were more likely than nonLatino white males to report limitations in activities of daily living. Although Latino men at least eighteen years old spent fewer days in bed than non-Latino white men, they were more likely to report difficulty or an inability to climb up ten steps without resting and to lift or carry ten pounds. Among Latino males at least eighteen years of age, 12.0 percent reported having hearing trouble and 7.7 percent reported having vision problems in 2005 (table A.1). Mexican American men were more likely to have hearing problems (OR ⫽ 1.9) than Mexican American women. Men Who Have Sex with Men

Among 15–19 year-old males, Latinos were more likely to report having sexual contact with a same-sex partner than non-Latino whites in 2002 (7.0 percent vs. 3.5 percent) (table A.7). However, among 20–24 year-old men, more non-Latino whites than Latinos reported having sexual contact with a same-sex partner (5.8 percent vs. 4.1 percent). Among 15–24 year-olds, Latina females and nonLatina females were more likely to report having sexual contact with a samesex partner than Latino males.

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Summary

Despite dramatic improvements in availability of data that document the nature and extent of health disparities experienced by Latino men, it is crucial to improve data collection, analysis, and dissemination. Reports from national data systems often do not present cross-tabulated data by race/ethnicity, gender and age. Subgroup details are also frequently lacking. In addition, Latinos may be underrepresented in survey samples, especially when the surveys are conducted only in English and/or by telephone. Reliance on state telephone surveys such as the Behavioral Risk Factor Surveillance System to provide the bulk of the information on the health status of state populations is problematic due to differential coverage of Latinos and other underserved populations, and the general increase in the use of caller ID, answering machines, cellular telephones, multiple telephone numbers, and unlisted numbers. Unfortunately, budget challenges to support existing national data systems, as well as to support new data collection efforts, have worsened. Chronic disease patterns in middle to late adulthood for Latinos are particularly understudied, and limited longitudinal data exist for Latino subgroups. The new multisite Hispanic Community Health Study has the potential to contribute significantly to filling the knowledge gap about chronic disease in the years ahead. Another shortfall is the minimal information about how community-neighborhood characteristics affect Latino health, exploring issues such as compositional and segmented assimilation effects on health behaviors and health services use. New approaches to address the nationwide increase in survey nonresponse due to increasing refusals, declining contact rates, and/or inability to participate are necessary. These approaches should include outreach to communitybased organizations to inform community members of the study, to participate in recruitment, and to help reduce the community’s fear and mistrust of the outsiders. Interviewers should be bilingual, bicultural, and familiar with the community. It is also important to address other recruitment barriers, such as lack of transportation and/or childcare, costs related to lost time at work, family responsibilities including childcare and care giving, and lack of appropriate language services. Studies that require the matching of death or other records should retrieve the participant’s name as it would appear on legal documents (e.g., driver’s license), the father’s last name (first last name), and the mother’s surname (second last name), as well as any name change due to marriage. Researchers should also describe their methods for determining race or ethnicity and their assumptions of the variables to the mean. In addition, researchers should try to move beyond simple comparisons to consider potential confounders, mediators, or effect modifiers, such as socioeconomic status,

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comorbidity, and severity of illness, as well as birthplace or generation, time in the United States, reasons or age at migration, language usage, and other indicators. Within this chapter, important health problems experienced by Latino males in the United States were identified using available data from national data systems and the peer-reviewed literature. Latino infants are at higher risk of low birth weight and death during the first year of life than non-Latino white and non-Latino black infants. Latino males have higher age-specific death rates from 0–24 years compared to non-Latino white males. Overall, Latino men are at higher risk of death due to stomach cancer, liver cancer, diabetes, homicide, chronic liver disease and cirrhosis, viral hepatitis, HIV, and drug-induced causes compared to non-Latino white males. Homicide, chronic liver disease, and HIV rank in the top ten leading causes of death for Latino males but are not even listed in the top ten for non-Latino white males. Latino adolescent males 15–19 years of age have higher death rates than non-Latino white males due to all causes, and injuries, firearm-related mortality, and firearm homicide in particular. National health interview and examination data suggest that Latino adolescent and adult men have poorer health status overall. Rates of current asthma are higher for Latino adolescent males compared to non-Latino white males. Despite fewer bed days per person, Latino men find it more difficult to climb up ten steps without resting and to lift or carry ten pounds compared to non-Latino white males. Poor cardiovascular health is suggested by the fact that one out of every four Mexican American adult men has hypertension. Latino male children and adolescents are also more likely to be overweight, watch television at least three hours per day, and not meet the recommended levels of physical activity compared to non-Latino white males. One of every four Mexican American 6–11 year-old males, and one of every five Mexican American 12–19 year-old males is overweight. Also, three out of every five Latino males in the ninth to twelfth grade do not exercise in their leisure time. Available data on infectious disease paints a picture of future chronic disease burden. Latino male rates of HIV, AIDS, and chlamydia are higher than the rates for non-Latino white males. Concerning the topic of Latinos’ fertility and fatherhood, Latino men have more children and start becoming sexually active and experience fatherhood earlier than non-Latino white men. They are just as likely as non-Latino white males to contribute regular child support to children, to not live with them, and to agree strongly that parental rewards make children worth having. However, Latino men may not participate as much in their children’s lives due to multiple jobs, geographic separation of families, and English language barriers.

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Mental health and drug use are also two important problems for Latino males. In fact, Latino adolescent and adult males have higher rates of feeling sad or hopeless than non-Latino whites. Latino male adolescents also are more likely to make a suicide plan and attempt suicide than non-Latino whites. Tobacco and alcohol use are similar for Latino male adolescents and non-Latino whites; however, use of other drugs (e.g., marijuana, cocaine, illegal injection drugs, steroids, hallucinogenic drugs, heroin, methamphetamines, and ecstasy) are higher for Latino male adolescents. Compared to non-Latino whites, Latino adults have similar rates of alcohol consumption that exceed the guidelines for low-risk drinking. However, Latino rates of smoking are lower. Rates of crack cocaine are higher for Latino men than non-Latino whites. There are some sexual health related topics that affect Latino adolescent males that should be addressed. Compared to non-Latino whites, Latino males are less likely to report wanting sexual intercourse at the time of their first sexual intercourse. Latino adolescents are also more likely to report being forced to have sexual intercourse. Among 15–19 year-old adolescent males, Latinos are twice as likely as non-Latino white males to report having sexual contact with a same sex partner. Condom usage is lower for Latino adolescent males than non-Latino white males. Latino 15–44 year-olds are more likely to be at risk for HIV due to sex, drug risk, or STD treatment than non-Latino whites. Safety is another concern for Latino male adolescents. In fact, Latino adolescent males are less likely to use seat belts, bicycle or motorcycle helmets, and are more likely to drive when they have been drinking alcohol or to drive with a driver who has been drinking alcohol compared to non-Latino whites. Latino males are also more likely than non-Latino white males to have been in a physical fight and to have missed school because of safety concerns. Concerning access to health services and health insurance, Latino males are three times as likely to lack health insurance as non-Latino white men, and they are more likely to have delayed medical or dental care due to cost. In addition, Latino men are twice as likely to lack a usual source of care. More than one-third of Latino men have not visited a doctor in the past year. Latino males are less likely to see a dentist and more likely to have no natural teeth than nonLatino white males. Among married 15–44 year-old men, Latinos have onequarter the rate of vasectomies as non-Latino whites. Despite lower health insurance coverage, Latino males are more likely to have been tested for HIV in the previous year, and as adolescents, than non-Latino white males. Unmarried 15–24 year-old Latino males are as likely as or more likely than non-Latino whites to have received birth control counseling.

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To date, the peer-reviewed literature has presented an uneven picture of the health of Latino males, mainly focusing on HIV, AIDS, sexually transmitted infections, drug use, and domestic violence. The findings presented in this chapter can provide guidance for future interventions and research to better understand how to reduce and eliminate the disparities experienced by Latino male children, adolescents, and adults. References Adams, P. F., A. N. Dey, J. L. Vickerie. 2007. Summary health statistics for the U.S. population. National Health Interview Survey, 2004. Vital and Health Statistics 10: 233. Adams, P. F., and C. A. Schoenborn. 2006. Health behaviors of adults: United States, 2002–04. Vital and Health Statistics 10: 230. Agency for Healthcare Research and Quality (AHRQ). 2006. National healthcare disparities report. http://www.ahrq.gov/qual/nhdr06/nhdr06.htm. American Cancer Society. 2006. American Cancer Society report describes unique cancer profile of Hispanic/Latino Americans. http://www.cancer.org/downloads/STT/ CAFF2006HispPWsecured.pdf. Anderson, J. E., A. Chandra, W. Mosher. 2005. HIV testing in the United States. Advance data from Vital and Health Statistics. No. 363. Hyattsville, MD: National Center for Health Statistics. Anderson, J. E., W. D. Mosher, and A. Chandra. 2006. Measuring HIV risk in the U.S. population aged 15–44: Results from Cycle 6 (2002) of the National Survey of Family Growth. Advance data from Vital and Health Statistics. No. 377. Hyattsville, MD: National Center for Health Statistics. Centers for Disease Control and Prevention (CDC). 2005a. Blood lead levels—United States, 1999–2002. Morbidity and Mortality Weekly Report 54 (20): 513–516. ———. 2005b. HIV/AIDS Surveillance Report, 2004. Vol. 16. Atlanta: U.S. Department of Health and Human Services. ———. 2005c. Sexually Transmitted Disease Surveillance, 2004. Atlanta: U.S. Department of Health and Human Services. Chandra, A., G. M. Martinez, W. D. Mosher, J. C. Abma, J. Jones. 2005. Fertility, family planning, and reproductive health of U.S. women: Data from the 2002 National Survey of Family Growth. Vital Health Statistics 23 (25): 1–160. Eaton, D. K., L. Kann, S. Kinchen, J. Ross, J. Hawkins, W. A. Harris, R. Lowry, T. McManus, D. Chyen, S. Shanklin, C. Lim, J. A. Grunbaum, and H. Wechsler. 2006. Youth risk behavior surveillance—United States, 2005. Journal of School Health 76 (7): 353–372. Field, C. A., and R. Caetano. 2005. Longitudinal model predicting mutual partner violence among white, black and Hispanic couples in the United States general population. Violence and Victims 20 (5): 499–511. Fryar, C. D., R. Hirsch, K. S. Porter, et al. 2006. Smoking and alcohol behaviors reported by adults, United States, 1999–2002. Advance data from Vital and Health Statistics. No. 378. Hyattsville, MD: National Center for Health Statistics. Heron, M. P., and B. L. Smith. 2007. Deaths: Leading causes for 2003. National Vital Statistics Reports 55 (10): 1–92. Hoyert, D. L., M. P. Heron, S. L. Murphy, and H. Kung. 2006. Deaths: Final data for 2003. National Vital Statistics Reports 54 (13): 120.

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Kruszon-Morin, D., and G. M. McQuillan. 2005. Seroprevalence of six infectious diseases among adults in the United States by race/ ethnicity: Data from the third National Health and Nutrition Examination Survey, 1988–94. Advance data from Vital and Health Statistics. No. 352. Hyattsville, MD: National Center for Health Statistics. Lacher, D. A., T. D. Thompson, J. P. Hughes, and M. Saraiya. 2006. Total, free, and percent free prostate-specific antigen levels among U.S. men, 2001–04. Advance data from Vital and Health Statistics. No. 379. Hyattsville, MD: National Center for Health Statistics. Martinez, G. M., A. Chandra, J. C. Abma, J. Jones, and W. D. Mosher. 2006. Fertility, contraception and fatherhood. Data on men and women from Cycle 6 (2002) of the National Survey of Family Growth. Vital Health and Statistics 23: 26. Mathews, T. J., and M. F. MacDorman. 2006. Infant mortality statistics from the 2003 period linked birth/infant death data set. National Vital Statistics Reports 54 (16): 1–29. Mosher, W. D., A. Chandra, and J. Jones. 2005. Sexual behavior and selected health measures: Men and women 15–44 years of age, United States, 2002 . Advance data from Vital and Health Statistics. No. 362. Hyattsville, MD: National Center for Health Statistics. National Center for Health Statistics. 2006. Health, United States, 2006 with chartbook on trends in the health of Americans. Hyattsville, MD: National Center for Health Statistics. ———. 2005a. Blood lead levels—United States, 1999–2002. Vital and Health Statistics 23: 25. ———. 2005b. Quickstats: Percentage of persons aged ⱖ 20 years with hypertension, by race/ethnicity—United States, 1999–2002. Morbidity and Mortality Weekly Report 54 (33): 826. ———. 2004. Health, United States, 2004 with chartbook on trends in the health of Americans. Hyattsville, MD: National Center for Health Statistics. Ogden, C. L., and C. J. Tabak. 2005. Children and teens told by doctors that they were overweight—United States, 1999–2002. Morbidity and Mortality Weekly Report 54 (34): 848–849. Pandey, D. K., D. R. Labarthe, D. C. Goff, W. Chan, M. Z. Nichaman. 2001. Communitywide coronary heart disease mortality in Mexican Americans equals or exceeds that in non-Hispanic whites: The Corpus Christi Heart Project. American Journal of Medicine 110 (2): 81–87. Pleis, J. R., and M. Lithbridge-Cekju. 2006. Summary health statistics for U.S. adults. National Health Interview Survey, 2005. Vital and Health Statistics 10: 232. Scott, G., and C. Simile. 2005. Access to dental care among Hispanic or Latino subgroups: United States, 2000–03. Advance data from Vital and Health Statistics. No. 354. Hyattsville, MD: National Center for Health Statistics. Simpson, G. A., B. Bloom, R. A. Cohen, S. Blumberg, K. H. Bourdon. 2005. U.S. Children with emotional and behavioral difficulties: Data from the 2001, 2002, and 2003. National Health Interview Surveys. Advance data from Vital and Health Statistics. No. 360. Hyattsville, MD: National Center for Health Statistics.

Contributors

Marilyn Aguirre-Molina is a professor of public health at the City University of New York and the founding director of the CUNY Institute for Health Equity. She has published extensively on the issue of underserved populations, editing several other books and a policy monograph on Latinos’ Barriers to Primary and Preventive Services. Her international research includes the study of AIDS, poverty, and gender inequality in Latin America and the Caribbean.

is a professor at the Harvard Medical School and the director of the Center for Multicultural Mental Health Research. She and her staff at the Center for Multicultural Mental Health Research are the recipients of a prestigious five-year grant for an Advanced Center for Latino and Mental Health Systems Research, awarded by the National Institute of Mental Health. The Advanced Center will focus on research that addresses pervasive ethnic and racial disparities in mental health service utilization and in mental health status.

Margarita Alegría

is an assistant professor and a program director for the John Harford Center of Excellence in Geriatrics at the University of Texas Health Science Center at San Antonio. Her research interests include educational effectiveness and healthcare for the elderly.

Cynthia Alford

is the director of the Institute on Urban Health Research and a distinguished professor at Northeastern University. Her research focuses on public health epidemiology, prevention, and intervention in the areas of substance abuse, HIV/AIDS, mental illness, and interpersonal violence. Recently, she has expanded her work to young incarcerated males and college students.

Hortensia Amaro

Sandra P. Arévalo is a program manager at the Institute on Urban Health at Northeastern University. Her research focuses on substance abuse and the treatment of Latina women.

is a research public health analyst at RTI International in San Francisco. He previously served as director of the Institute for Gay Men’s Health, a collaboration between APLA and Gay Men’s Health Crisis in New York City. Ayala has nearly twenty years of experience in HIV/AIDS prevention education, with a focus on working with youth, people of color, and gay communities.

George Ayala

is a doctoral candidate at University College London. She completed an MPH at Boston University School of Public Health and worked at Northeastern University evaluating substance abuse treatment programs for Latina women in Boston.

Laia Bécares

307

308

Contributors

is research associate for Planned Parenthood of New York City. She has worked extensively with at-risk youth in numerous capacities and as a researcher at the Mount Sinai Hospital Adolescent Health Center in New York City.

Gabriela Betancourt

serves as project director at the Bixby Center for Global Reproductive Health at the University of California, San Francisco. She also directs the evaluation of California’s publicly funded family planning program (Family PACT) and a study of Latino adolescent reproductive health, funded by the Annie E. Casey Foundation.

M. Antonia Biggs

Luisa N. Borrell is an associate professor in the department of health sciences, Lehman College, City University of New York. Her research interest is race, ethnicity, socioeconomic position, and neighborhood effects as social determinants of health. She has published extensively in the areas of race/ethnicity, socioeconomic position, and neighborhood effects on health outcomes and mortality. Claire D. Brindis is a professor in the Division of Adolescent Medicine, Department of Pediatrics, and the Institute for Health Policy Studies at the University of California, San Francisco. She is executive director of the National Adolescent Health Information Center and associate director of the Information and Analysis Center for Middle Childhood and Adolescence. Olveen Carrasquillo is associate professor of medicine at University of Miami Miller School of Medicine. He is the principal investigator of the Columbia Center for the Health of Urban Minorities, director of the Community Liaison core of the Columbia Center for the Active Life of Minority Elders, and co-director of the General Medicine Fellowship Program. Olivia Carter-Pokras is an associate professor in the Department of Epidemiology and Biostatistics, College of Health and Human Performance, University of Maryland College Park. She has conducted health disparities research in the federal government and academia. Her research focuses on the intersection of epidemiology and health policy to address Latinos’ health and children’s environmental health.

is the director of the Center for Integrative Approaches to Health Disparities and the associate director of the Center for Social Epidemiology and Population Health at the University of Michigan at Ann Arbor. She is also a professor of epidemiology at the University of Michigan. Her research interests include social epidemiology, neighborhood effects, cardiovascular disease epidemiology, and race/ethnic health disparities.

Ana Diez-Roux

is a research fellow at the University of Medicine and Dentistry in New Jersey. As a social epidemiologist, she is interested in examining the effect of neighborhood conditions on health and how social conditions contribute to and modify racial/ethnic disparities.

Sandra Echeverria

Contributors

309

is an associate professor at the University of Texas Health Science Center in San Antonio. His research interests include issues affecting Hispanic elders and Alzheimer’s research.

David Espino

is a sophomore undergraduate student at the University of Maryland at College Park. As a research assistant with Dr. Olivia Carter-Pokras,

Alexander H. Fischer

he is currently developing discussion guides for medical and other health professional students to accompany a national television series on upstream factors for health disparities. Andres Gil has served as the director of the South Florida Youth Development Project at the University of Miami; a research scientist at the Western Consortium for Public Health at the University of California, Berkley; and as assistant professor of human development and family relations at the University of Connecticut. He was recruited as an assistant professor of social work and also serves as an advisor to the Mental Health Services Administration and the National Institute of Mental Health on issues pertaining to at-risk youth. Nancy Harada is associate professor with a joint appointment in the University of California Schools of Public Health and Medicine in Los Angeles. She is associate director of health services research at the Geriatric Research, Education and Clinical Center of the VA Greater Los Angeles Health Care System and senior researcher at the University of California Center for Health Policy Research. Her research interests include racial/ethnic disparities in the access and utilization of health care services.

received her BA in sociology from Princeton University and has worked as a private market research analyst. She is currently at home raising her twin boys.

Patricia A. Homan

received his medical degree from Columbia University College of Physicians and Surgeons. He is currently completing a residency in pediatric medicine at the University of Florida in Gainesville.

Russell Homan

Anh-Luu Huynh-Hohnbaum is an assistant professor of social work at California State University, Los Angeles. Her research interest is in the social implications of race and multiracial status and its mental health consequences. Mariano Kanamori

is a research assistant at the University of Maryland,

College Park. Miguel Muñoz-Laboy is researching the cultural and structural dimensions of HIV and sexual health-related risks among a number of different ethnic and sexual minority urban populations in the United States and internationally. His areas of research and program design include sexual health, bisexuality, masculinity, street culture, sexual cultures, and examining the impact of the intersections of gender, race/ethnicity, and class power inequalities in young men’s health.

310

Contributors

is an assistant professor of psychology at DePaul University. His research interests include treatment of youth depression and the delivery of evidence-based interventions into community settings such as schools and mental health clinics, as well as etiology and correlates of mental health problems across cultural groups in the United States, including Latino and immigrant groups.

Antonio Polo

is a research associate at the Bixby Center for Reproductive Health Research and Policy at the University of California at San Francisco.

Lauren Ralph

Clara Rodríguez is a professor of sociology at Fordham University’s College at Lincoln Center. Her research focuses on race and ethnicity, media studies, Latino studies, labor markets, migration, and urban and regional studies. She is the author of ten books and the recipient of numerous research and teaching awards.

is a professor in the Department of Sociology at the University of California at Irvine. His research includes international migration, the “1.5” generation, comparative race and ethnic relations, structural inequality, identity, and physical and mental health.

Rubén G. Rumbaut

is a pediatrician and adolescent medicine specialist who recently joined the School of Public Health at Columbia University. He has conducted research on HIV/STD risk behaviors, programs to prevent STD/HIV/unintended pregnancy among adolescents and women, school-based health centers, clinical preventive services, and research ethics.

John Santelli

is provost professor at the University of Southern California. He has conducted field and clinical research projects on health, mental health, and substance abuse in various regions of the United States and Latin America. He has published over 160 articles and chapters on these topics, in addition to several books.

William Vega

is adjunct assistant professor with the University of California, Los Angeles, School of Public Health, Department of Community Health Sciences, and senior research scientist with the UCLA Center for Health Policy Research. Villa’s research has focused on minority aging and the investigation of health disparities across Latinos, Koreans, African Americans, and non-Hispanic whites.

Valentine V. Villa

Index

absenteeism, 79 abstinence, 284 academic success, 96 access to care, 229 acculturation, 59, 85, 173, 254 acculturative stress, 189 addiction, 101, 127 adolescents, 89, 276, 298–299, 302–303; male, 296, 299, 303 Afghanistan, 132 African Americans, 34–35, 44, 75, 90, 124, 127, 129–130, 143, 171, 221. See also blacks ageism, 256 age structures, 20 aging populations, 25, 29, 249 agriculture, 77 AHRQ (Agency for Healthcare Research and Quality), 229 AIDS, 212, 216. See also HIV; HIV/AIDS alcohol: abuse, 118; use, 73, 103–104, 142, 299, 303 Alzheimer’s disease, 249 American Indians, 34 analgesics, 119 anger, 130 annual household income, 202 antiwar sentiment, 126 anxiety, 131, 183, 193, 200, 209, 218 armor, 133, 135 artillery, 133 asbestos, 77 Asians, 34 assimilation, 101, 114, 262 asthma, 72 baby killers, 130 barriers: to health care, 4, 85; to health coverage, 235; to recruitment, 60 behavior problems, 103 behaviors: health-related, 174; healthy, 44; risk, 131, 265; unhealthy, 131

bicultural, 258 bio-psychosocial process, 10 birth control, 88, 91 birth rates, 20; high teen, 88; Latina teen, 83 birth weight, low, 276 blacks, 39, 42–43, 45, 129, 229, 236. See also African Americans bombs: dirty, 135; suicide, 133, 135 bonding, 114, 119; low, 111 BRFSS (Behavioral Risk Factor Surveillance System), 301 Cambodians, 28 cancer data on Latinos, 159 cancers, 296; colorectal, 167, 296; gallbladder, 168; prostate, 167, 296; stomach, 168, 302 cancer screening, colon, 243 capital: cultural, 9; human, 18–19, 33, 116; social, 9 cardiovascular disease, 41, 164, 296 Caribbean Hispanics, 43 causal model, 175 census data, 34, 58, 119, 264 Central Americans, 26, 44 Central and South Americans, 26–27 Chicano, 37 childbearing, 89; early, 19 child health, 69 child health indicators, 69 childhood obesity, 72 children, low income, 239 chlamydia infections, 297 chronic conditions, 70, 72, 158 chronic disease, 141, 153, 158, 168, 171–174, 264, 295, 301; epidemiology, 169; outcomes, 158, 169, 174–175 chronic illness, 3, 5, 256 CIDI (Composite International Diagnostic Interview), 119 cigarette use, 298–299

311

312

cigar use, 298–299 cirrhosis, 302 citizenship status, 234 classification, ethnic, 58 cocaine, 144, 299; abuse, 118; dependence, 109, 111 cognitive decline, 259 cognitive impairment, 250 cohort, generational, 26–27 college credentials, 18 colonialist regimes, 33 colonoscopy, 243 colorism, 33–34 combat, 132 communities, 8 community factors, 72, 251, 254 community health centers, 241 conceptual model, 10, 158, 169, 171 concurrent partnerships, 221 condoms, 89, 91–92, 284, 290, 297 confidentiality, 61 conflicts with parents, 103 contraception, 90, 94; effective, 85 contraceptive methods, 89 coronary heart disease, prevalence of, 164 correctional health data, limitations of, 141 correctional health services, 154 CPES (Collaborative Psychiatric Epidemiology Surveys), 184 CPS (Current Population Survey), 230 Cubans, 19, 26–27, 34, 41 cultural factors, 171, 173 cumulative adversity, 46 data: ethnic, 55–56; health services utilization, 3 data artifact effect, 57–58, 165 data systems, national, 301 death certificates, 160 death rates, 54, 58, 168; age-adjusted, 163 death risk, 251 dementia, 249–250 dentist, 295, 303 deployment, 135 depression, 103, 131, 250; late-life, 250, 254, 259; major, 189; rates, 251; treatment, 251

Index

depressive disorders, 10, 193, 200 descent, 34 determinants, 3–4, 6, 37, 84, 115, 171 diabetes, 41, 71, 296, 302; diagnosed, 161, 163–164; prevalence of, 159, 163; undiagnosed, 163 diabetes-related morbidity, 161 diet, 46, 173, 295 discrimination, 6, 39, 126, 128, 131, 135, 189, 220; ethnic, 217, 256; housing, 43; perceived, 42, 206; racial, 42–43; social, 218, 220 discriminatory policies, 10 disorders, past-year, 193, 200, 202 disparities, 3, 6, 11, 67, 139, 168, 210, 220, 229–230, 238, 243–245, 268 DOD Hispanic initiatives, 124 domains, 6, 176 domestic violence, 73, 290 Dominicans, 27 drinkers, regular, 299 drug abuse/dependence, 99, 107, 109, 111, 119. See also substance abuse drug addiction, 103, 116 drugs: crack, 144; crystal methamphetamine, 218; hallucinogenic, 299; illicit, 99; methamphetamines, 299 drug use, 108, 299; adolescent, 102; daily, 145; illicit, 99, 101, 105; narcotic, 300. See also polydrug use DSM-IV disorders, 107, 109, 111, 114 early adolescence/adulthood, 109 economic: disenfranchisement, 217; hardship, 119; opportunities, 133–135 ecstasy, 299 education, 256; low levels of, 18–19; public, 115; quality of, 6; special, 75, 298 educational: attainment, 19, 84, 88, 90; hierarchy, 25–26; investments, 29–30 educational attainment, low, 27, 36, 90–91, 114–115 emergency room, 242, 290 employment: conditions, 171; marginal, 5; opportunities, 79, 83, 115–116, 174, 233, 238, 245, 262 enemy, 130

Index

EPESE (Established Populations for Epidemiologic Studies of the Elderly), 251 equity, 17 eras, genomic, 35 ethnic groups, 83 ethnicity, 37, 55 exposures, unhealthy, 174 families, 61, 77, 90, 189, 221–223, 250; two-income, 18 familism, 265 familismo, 255 family: caregivers, 255; factors, 111; income, 234; poverty, 109; stability, 102; structure, 91, 116, 119, 255 family planning clinic, 290 family planning/reproductive health care, 95 father bonding, 114 federal agencies, 53, 55 femininity, 8–9 fertility, 283; high, 83; rates, 262 Fragile Families and Child Well-Being Study, 71 GAD (generalized anxiety disorder), 189 gang: activity, 78; involvement, 78; members, 78 gay, 212, 219 gender, 25; differences, 107; ideologies, 9; norms, 9 generations: immigrant, 84–85; third, 27 genocide, 74 geographic accessibility, 258 GPA (grade point average), 109, 119 grades, low, 109 GRIDS (gay-related immunodeficiency syndrome), 212 Guatemalans, 20, 28 hazards: environmental, 131, 134–135, 263; occupational, 249 health, 9; environmental, 298; expenditures, 230, 246; experience, 47; fair/poor, 70; inequalities, 35; protection, 172; providers, 257; screenings, 230; services, 95, 151, 303; sexual/reproductive, 84; statistics, 56

313

health advantage, 44, 57, 166 health care: access and transportation, 258; male-friendly, 95; substandard, 249 health center, 290 health complaints, physical, 131 health conditions: chronic, 79, 158; physical, 148 health consequences, 172; negative, 45 health disparities, 4, 44–45, 79, 140 health-enhancing features, 172 health evaluations, yearly, 242 health gradient model, 263 healthier lifestyles, 264 health indicators, 57; comprehensive, 268 health insurance, 5, 171, 245, 295; comprehensive high quality, 238; employer-sponsored, 235; guarantee, 231; lack of, 69, 238, 303; national, 231; public, 237; status, 172, 241 health insurance coverage, 92, 230, 232; continuous health, 91; data, 230; government, 239, 246; public, 245; rates of, 240; supplementary, 239 health literacy, low, 259 health outcomes, 45–46, 59; effective, 6; mental, 210; negative, 4, 67, 69, 217; negative reproductive, 89; oral, 70; reproductive, 88, 90–91, 94; worse, 39, 43, 83, 207 health problems, 69; chronic, 125; long-term, 300; public, 151–152 health profile of Latino boys, 70 health-promoting behaviors, 220 health reform proposal, 246 health research: applied, 96; mental, 42 health risk factors, 56 health risks, 9, 70; elevated, 43 health science knowledge, 264 health status of Latinos, 159 hepatitis, 148, 302 heroin/opiates, 144, 299 heterosexism, 217, 220, 223 HHANES (Hispanic Health and Nutrition Examination Survey), 56, 59, 63, 159, 163, 177, 179–181 high school diploma, 27–28, 91–92 high school dropouts, 27–28, 75, 111

314

Index

Hispanic: blacks, 39, 42–43; elders, 256; health data, 62; identifier, 34; immigrants, 29; mortality advantage, 57; mortality data, 53; paradox, 46, 249; population, 19, 20, 29; skin color, 41 Hispanic Community Health Study, 59, 61, 161, 301 Hispanic Heritage Month, 124 Hispanic origin, 53–54; persons of, 53, 55; underreporting of, 54 history, criminal, 142 HIV, 212, 297, 302; infection, 213, 218, 223; prevention, 213; prevention research, 221; risk, 212; risk behavior, 218–219; seroprevalence, 151–152; sero-status, 219–220, 222 HIV/AIDS, 83, 88, 297; epidemic, 216; stigma, 213, 218, 221–222 homelessness, 154 homicide, 283, 302 homophobia, 222 housing conditions, 69, 77, 79; poor, 77 hypertension, 41–42 immigrant flow, 262 immigrant Latinos, resiliency of young, 200, 207 immigrants, 25, 28, 57, 74, 104, 107, 111, 114, 150 immigration history, 171–172 immigration status, 171–172 imprisonment, mass, 18 incarceration, 18–19, 27, 144; rates, 28 incentives, 60, 115 inclusion, social, 256, 258 inequality: economic, 3, 223; rising, 17; stratified, 102; structured, 4, 34, 116 infant mortality, 54, 58, 277 initiatives, community level, 240 injuries, 75, 132, 135, 148, 277, 302; blast, 133; unintentional, 70, 76 inmates: black, 141; male, 140 intergenerational disparity, 258 intergenerational social mobility, 27 interventions, programmatic, 11, 47 Iraq, 132 IRCA (Immigration Reform and Control Act), 37

jails, local, 18, 28, 139, 143, 150–151 jerarquismo, 255 jobless, 26 jungle, 127 key informants, 69 kinships, 8 labor, low-wage, 26 labor force participation, 26, 234 labor market conditions, 33 labor markets, 18 land mines, 133 language-based indicators, 114 Laotians, 28 Latino: AIDS cases, 216; communities, 1; culture, 6, 61, 171, 257; elders, 258; ethnicity, 159, 164–165, 175, 230, 250; health research, 62; incarceration rates, 140; infants, 70, 276, 302; inmates, 140–142, 150; institutionalized, 47; insured, 241, 243; life expectancy, 3; men’s health, 10; migrant farmworkers, 160; military participation, 124; military recruitment, 124; mortality rates, 58; noncitizen, 233; population, 1, 88, 90, 117, 123, 134, 159, 161, 172, 183, 231, 240, 263; preterm birth rate, 276; undocumented, 232–233; uninsured, 232, 242; veterans, 123; young, 88, 91, 94 laws, antidiscrimination, 135 lead, elevated blood, 298 life expectancy, 3 life stress, 249 limitation in Medicaid, 240 linguistically competent, 95 liver cancer, 168, 277, 302 liver disease, chronic, 276, 302 lung cancer, 167 machismo, 6, 173, 255 malignant neoplasms, 250, 283 marijuana, 73, 109, 144; abuse, 107, 109, 111, 118; use, 299 Marines, 133 masculinity, 8–9 Medicaid, 233 medical: conditions, 152; history, 150; problems, 148; records, 160

Index

Medicare, 232, 258 melanin, 46 mental health, 42, 69, 73, 118, 125, 131, 134, 140, 183, 208, 249, 257, 297, 303; check-ups, 150; illness, 151; issues, 132, 218, 258; problems, 183, 193, 208, 259; professionals, 134; profiles, 183, 207; service delivery, 210; service inequalities, 208; services, 73, 148; service usage, 183, 202; status, 126–127; treatment, 153 mental illness, 41, 184 men who have sex with men, 212 MEPS (Medical Expenditure Panel Survey), 231 Mexican Americans, 41 Mexican-origin persons, 57, 59 Mexicans, 20, 26, 28, 34, 44 Mexican women, 58 migrant effect, healthy, 44, 57, 165, 167. See also paradox migrant workers, 77 military service, 123–125, 133–134 misclassification of ethnicity, 160, 165 MMSE (Mini Mental Status Exam), 254 monolingualism, 256 mortality, 3, 41, 276 mortality advantage, 57–58 mortality rates, 58 mortar fire, 133 MRFIT (Multiple Risk Factor Intervention Trial), 167 MTF (Monitoring the Future Surveys), 104 National Comorbidity Survey, 140–141 national health surveys, 53 National Institutes of Health, 59 National Longitudinal Study of Adolescent Health, 85 National Research Council, 29 NCS (National Chicano Survey), 39 NDI (National Death Index), 58, 61, 167 NDIC (National Diabetes Information Clearinghouse), 159 neighborhood characteristics, 172 neighborhoods, 254 newcomers, 17 NHANES (National Health and Nutrition Examination Survey), 159

315

NHDR (National Health Disparities Report), 229 NHIS (National Health Interview Survey), 37, 231 nightmares, 128 NLAAS (National Latino and Asian American Study), 183 NLMS (National Longitudinal Mortality Survey), 54, 58 North American Association of Central Cancer Registries, 56 NSCH (National Survey of Children’s Health), 67, 70 NSDUH (National Survey on Drug Use and Health), 104–105 NSFG (National Survey of Family Growth), 88 NSKC (National SAFE Kids Campaign), 76 obesity, 70–71, 161, 263, 295 occupational prestige scores, 37 OEF (Operation Enduring Freedom), 132 OIF (Operation Iraqi Freedom), 132 outpatient departments, 241, 290 Pacific Islanders, 34 panethnic, 26 panic disorder, 189 paradox, 43, 47, 59, 104; epidemiologic, 57; health advantage, 44; Latino health, 165–166, 207 paternalism, 256 pathophysiology of disease, 4 pesticides, 77 phenotype, 33, 39, 45 physical activity, 71, 295 physical disabilities, 300 playground equipment, poor, 76 policy analyses, 268 policy interventions, 208 policy recommendations, 44, 94, 116–117, 175 political science dilemma, 264 polydrug use, 109, 218 population: growth, 19; health disparities, 266; immigrant-stock, 17; nonincarcerated, 141; projections, 262; underserved, 301; uninsured, 232, 237; veteran, 125, 134

316

Index

poverty, 4, 67, 69, 73, 75, 77, 79, 84, 90, 100, 104, 109, 111, 119, 124, 207–208; extreme, 74; level, 36; neighborhood, 114, 119; rates, 5, 27; ratio, 184 pregnancy: desire, 89; teen, 83; unintended, 83–84 prejudice, 128–129 prevention programs, 94, 153 preventive health care measures, 242 prisoners, 18–19, 139, 141, 150, 153 prison records, 18–19 prisons, 28; federal, 151; state, 148 privacy, 61 protective effects, 103–104, 165, 200, 259 protective factors, 58, 100, 115, 265 providers, male Latino peer, 95 psychiatric disorders, 126, 183, 200, 206–207; past-year, 189; rates of, 209 psychiatric illness, 209 PTSD (post-traumatic stress disorder), 125, 131, 134 public health analyses, 8 public health interventions, 53, 153 Puerto Ricans, 26, 32, 34, 37; dark-skinned, 41 PUMS (Public Use Microdata Samples), 28, 36 pyramidal class structure, 33 race, 9, 32–33, 35, 37, 39, 42, 45, 55, 124, 223; categories, 35; effect, 35; groups, 46; role of, 41; traditional categories, 35; traditional markers, 46 racial/ethnic: differences, 145, 150; identity, 42, 160 racism, 6, 32, 34, 45, 126, 128, 131, 134–135, 217, 221, 256 relationship, impaired, 257 religiosity, 256 reproductive health, 83, 95 resiliency, 6, 10, 262 retirement age, 29 return migration effect, 57 risk factors, 103 role models, 6 rural areas, 76

Sacramento Area Latino Study on Aging, 251 salmon bias, 57, 166 Salvadorans, 20, 28 same-sex partner, 300 SCHIP (States Children’s Health Insurance Program), 232, 245, 247 school disengagement, 79 school environment, 75–76 school years, 74 second generation, 27 sedatives, 119 SEER (Surveillance, Epidemiology, and End Results), 179 segregation, 6, 39, 43 service members, 133 sexual activity: contact, 300, 303; current, 88; first intercourse, 73, 88–92, 284; intercourse, 89, 284, 303; number of partners, 88. See also abstinence sexual behaviors, 84–85, 90; risky, 88; significant predictors of, 94 sexual health, 213, 303; behaviors, 88–89; outcomes, 90, 92, 96; programs, 84 sexually active, 302 SILJ (Survey of Inmates in Local Jails), 141 skin color, 33, 36, 41–42, 45, 265 slavery, 32–33 smokeless tobacco use, 299 social buffering effect, 57–58 social characteristics, 69, 172 social class, 171; inequalities, 99, 134; position, 3, 101; stagnant mobility, 262 social cohesion, 9 social construction of masculinity, 6 social contract, 17 social determinants, 115 social networks, 6, 8–9, 44, 58, 100, 207, 209 social phobia, 189 socioeconomic outcomes, 32–33 socioeconomic status, 39, 55, 67, 171, 206, 220, 263; low, 4–5, 46, 57–59, 139, 207; outcomes, 37 soldiers, 132–133, 135 source of care, 241; usual, 230 Spanish monolingual, 259

Index

Spanish surnames, 160 spirituality, 256 statistics, vital, 57–58 STD treatment, 297, 303 stigma, 55, 220, 259; antigay, 221 STIs (sexually transmitted infections), 83 stress, 5, 77, 250 stressors, 184, 189, 206, 257 structural barriers to economic mobility, 154, 233, 238, 240 structural conditions for life opportunities, 169, 170, 171–173 structural determinants, 183, 212, 218; factors, 5, 8, 11, 47, 53, 62, 84, 88, 99–100, 105, 107, 109, 124, 208–209, 249–250, 261–262; unemployment, 201 substance abuse, 131, 218; treatment, 142, 145, 148, 151–153 substance use: disorders, 105, 111, 183, 193; patterns, 105, 107 suicidal ideation, 103 suicide, 103, 283 TB (tuberculosis), 148, 150, 153 terrorism, 126 toddlers, 77 toxins: chemical, 135; industry, 77 tranquilizers, 119

317

translators, 257 transportation, public, 258 trauma, 74, 127; psychological, 125, 127, 131 tuberculosis. See TB UAI (unprotected anal intercourse), 219 underreporting of deaths, 58 unemployment, 184. See also employment unequal distribution of wealth, 100 uninsured, 67, 73, 206, 230, 241. See also health insurance urbanization, 254 U.S. Army, 133 utilization of health service, 236, 241, 244 veterans, 123; Vietnam-era, 125–126, 132 Veterans Administration, 134–135 violent offenses, 143 VIP (Veteran Identity Program), 126 wages, hourly, 36 war, civil, 74 war cohorts, 125, 129 warfare, guerilla mode of, 126–127, 132 white ethnocentrism, 256–257 YRBSS (Youth Risk Behaviors Surveillance System), 72

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