In a report from the Institute of Medicine, more than studies were cited to document this disparity. Department of Health and Human Services. Culturally competent care necessitates cross-cultural training, which is increasingly included in medical education, but with the realization that cultural competency is a lifelong learning process rather than an end in itself.
Enlarge Print. Instituting more culturally competent care is likely to improve treatment adherence and health outcomes. Most, although not all, alternative therapies in the Latino community are not harmful and may be combined with conventional care. Patient activation will help motivate the patient to become involved in his or her own care. Latinos have disproportionately higher rates of obesity and diabetes mellitus Table 1. Because of less access to health care, Latinos with diabetes are often diagnosed later and have a greater risk of complications.
Mexican Americans are much less likely to be treated for hypertension than non-Latino whites 35 versus 49 percent. Recent immigrants often feel lonely and can have culture shock, fears of deportation, and financial problems; depressed mood may manifest as headaches and somatic symptoms. Delayed immigration protocols and anti-immigration legislation may contribute to stress.
Neurocysticercosis is the most common cause of seizures in Latino immigrants. Cysticercosis is caused by consumption of contaminated with pork tapeworm Taenia solium eggs. Compared with non-Latino whites, Mexican Americans have up to a three times higher incidence of diabetes mellitus and a three times higher prevalence of obesity, but hypertension-related mortality is only 4 percent higher not a significant difference.
Puerto Ricans have a 14 percent higher rate of hypertension-related mortality than other Latino groups. Low levels of hypertension awareness are a major problem in the Latino community.
Mexican Americans with hypertension are less likely to be treated than non-Latino whites 35 versus 49 percent. Approximately 43 percent of Mexican Americans older than 20 years are obese, compared with 33 percent of non-Latino whites. A high-carbohydrate and high-calorie diet, a more sedentary lifestyle in the United States, and genetic factors may contribute.
Most Latino immigrants have received the BCG vaccine; although past practice has been to interpret skin test results without regard to BCG status, false-positive tests in this population are common. Interferon gamma—release assays are preferred to tuberculin skin testing in immigrants with a history of BCG vaccination.
Approximately Information from references 9 through Many Latino immigrants experience tremendous stress once they are in the United States. Emotional distress often presents with headaches dolor de cabeza or other physical symptoms instead of depressed mood. Neurocysticercosis, a leading cause of seizures in Mexico, and pulmonary tuberculosis are more common in Latino immigrants.
Despite a lack of U. Non-Latino physicians may be perplexed by references to folk healing and illness in Latino patients. Other healing specialties include yerberas herbalists , hueseros bone setters , parteras midwives , and sobradores similar to physical therapists. Information from reference Symptoms are often interpreted differently based on cultural presuppositions.
Abdominal pain may be attributed to empacho, or food stuck in the intestine. Table 3 lists some common Latino folk illnesses, their symptoms, and treatment. Azarcon and greta lead salts and azogue mercury compounds, which are sometimes given for teething or empacho, are contraindicated.
However, it may be more likely to mistakenly suspect child abuse than to actually encounter it in patients who use traditional treatments. Intense but brief release of emotion thought to be caused by family conflict or anger. Childhood condition characterized by irritability and diarrhea thought to be caused by abrupt withdrawal from the mother's breast.
Steam inhalation and herbal treatments, including eucalyptus and mullein gordolobo. Pelvic congestion and decreased libido thought to be caused by insufficient rest after childbirth. A hex cast on children, sometimes unconsciously, that is thought to be caused by the admiring gaze of someone more powerful. The hex can be broken if the person responsible for the hex touches the child, or if a healer passes an egg over the child's body; the egg is then broken into a bowl of water and placed under the child's bed; child may wear charms for protection.
Temporary paralysis of the face or limbs, often thought to be caused by a sudden hot-cold imbalance. Barrida ritual purification ceremony herbs used to sweep patient's body repeated until the patient improves. Herbal therapies play a major role in Latino folk medicine, so knowing the Spanish names of common herbs can be helpful eTable A. A large selection of herbal teas are available from botanicas or yerberas in most Latino neighborhoods. Herbs often have hot or cold properties; hot herbs are used to treat cold conditions, and vice versa.
A mother might use cooling herbs to treat diaper rash, a hot condition. She might also stop giving her infant vitamins, because they are a hot therapy.
Web-based resources are available to assist physicians in understanding Latino health beliefs Table 4. Eaten to alleviate hypertension and prevent arteriosclerosis; garlic juice is applied to stings and spider bites. Anticoagulant effect at high doses; avoid high doses in patients taking coumadin Warfarin ; high doses can cause heartburn and bad breath; reduces effectiveness of saquinavir Invirase.
For topical and homeopathic use only; avoid internal use except for homeopathic preparations, which are considered safe ; increased gastroenteritis and dyspnea risk with ingestion.
Hepatotoxicity risk from pyrrolizidine alkaloids in leaves with high or prolonged doses. Spice used as antispasmodic and for upper respiratory infections; although promoted as a hypoglycemic agent, recent research is conflicting. Use with caution in patients taking hepatotoxic drugs; safe in usual food quantities.
Tea used for anxiety, stomach cramps, and inflamed gums; more recently popularized for increasing the urinary excretion of heavy metals. No safety concerns, although there have been recalls because of salmonella and pesticide contamination. Eugenol in clove oil may affect blood clotting; toxic if ingested, especially in children. Tea or syrup used as an expectorant, a diuretic, and for constipation, liver problems, and gall stones; also used to induce menstruation.
Tea used for intestinal parasites; herb is added to beans to prevent flatulence. Chenopodium oil is also used as an antihelmintic but may be toxic ascaridole content. Long-term ingestion causes absinthism trembling, vertigo, thirst, delirium ; thujone in the essential oil is neurotoxic and may cause seizures.
Boiled leaves used for asthma in vaporizers; popular in lozenges for sore throat; also sometimes used as topical disinfectant. Ingesting eucalyptus oil may cause vomiting, diarrhea, delirium, and convulsions; avoid using in vaporizers for children younger than six years. Weed leaf used externally for burns, bruises, mouth sores, and hemorrhoids; tea taken orally for respiratory infections. Eaten as part of diet; has antidiabetic, anti-inflammatory, and laxative properties; also used as hangover treatment and for hyperlipidemia.
Romero rosemary. Safe in small quantities in food, but contains monoterpene ketones, which can cause toxicity intestinal irritation, kidney damage, abortion, seizures. Toxic; avoid oral use; may cause renal and hepatic damage; furocoumarins can cause skin photosensitivity.
Yerba buena mints, including spearmint and Clinopodium [Satureja] douglasii. Safe in usual quantities, but spearmint oil is a mucous membrane irritant and potentially toxic when ingested. Safe for topical use; juice is relatively safe; ingestion of aloe resin a purgative may cause diarrhea, hypoglycemia, hypokalemia, and prolonged bleeding; potential interactions with hypoglycemics and cardiac glycosides.
Safe as a food seasoning, toxic alveolitis reported from inhaling lemongrass oil. Use of folk remedies in a Hispanic population. Arch Pediatr Adolesc Med. Herbal Remedies World. Mexican herbs. Accessed December 14, Risks and benefits of commonly used herbal medicines in Mexico. Toxicol Appl Pharmacol. MedFacts natural products.
Accessed April 4, Information from references 28 and Patients should be asked if they use alternative therapies, because it is not likely that such information will be volunteered. Latinos' belief in alternative treatment is affected by many factors, including education, socioeconomic class, and time spent in the United States acculturation. First-generation immigrants are likely to seek out curanderos, whereas their children may scoff at the idea.
Physicians cannot assume that all Latinos share these beliefs; many do not. Hispanics residing in the USA are on average 15 years younger, four times more likely to not have finished high school, twice as likely to live below the poverty line, and 20 times less likely to speak proficient English than non-Hispanic Whites NHW [ 1 , 7 ].
Hispanic women are also a growing demographic group that endure adverse social and health conditions and lack of access to health care [ 8 ]. Risk factors for non-communicable diseases NCDs , coupled with decreased health care access make Hispanics disproportionately vulnerable to disease and death. Hispanics endure major health risks such as obesity, teen pregnancy, and tobacco use, among others. Significant differences in risk factors, morbidity, mortality, and access to health care can also be observed among Hispanics by country of origin [ 4 , 9 , 10 ].
The most recent reports show that the leading causes of disease among Hispanics are heart disease, cancer, and high blood pressure, while the leading causes of death are cancer, heart disease, and unintentional injuries. Health care services in the USA are provided mainly through employer-based health insurance, Medicare, and Medicaid.
Employer-based insurance is usually privately purchased. Medicare insures people 65 years and older or younger than 65 with disabilities , and Medicaid is a social welfare program for low-income population. In , President Obama signed into law the Patient Protection and Affordable Care Act ACA to expand health care protection by increasing insurance coverage, expanding Medicaid, decreasing health care costs, allowing provider choice and improving the quality of care [ 11 ].
Some of them focus on specific age and gender groups or on country of origin, migrant workers, and undocumented populations [ 13 — 21 ], while some others discuss the Latina Birth Outcomes and Hispanic Mortality Paradoxes [ 22 , 23 ]. After a preliminary review of the literature on the topic [ 7 , 11 , 24 ], we identified a lack of a unified framework to assess Hispanic health in the USA, as well as the need to conduct a scoping review of the literature on the main Hispanic health needs and health policies and services—including the Latina Birth Outcomes Paradox and the Hispanic Mortality Paradox—to help inform policy- and decision-making for improving Hispanic health in the USA.
Such is the objective of this review paper. After discussing several conceptual frameworks, and to accomplish our objective, we developed a modified conceptual framework based on the social-ecological model [ 25 ] and the lifespan biopsychosocial model [ 26 ]. This comprehensive framework embodies the complex interactions—with synergistic and antagonistic effects—between social, biological, and psychological constructs of health Fig.
It posits that distal variables pertaining to SDH Fig. They also interact with proximal variables such as risk factors Fig. Components of the framework do not have unidirectional cause-effect temporality but rather compose causality networks and trajectories that influence each other over time in interconnected, multi-directional cycles. For example, social support systems education, labor, sports, food programs, recreation include health services that serve as determinants of health which influence health needs and risks; however, changes in health needs and risks in turn modulate health services Fig.
These causal networks exert more nuanced effects across Hispanic population subgroups by country of origin, foreign-born status, and migrant and undocumented status. The wide-ranging breadth of this framework would be best approached through a comprehensive review and detailed analysis that would be too extensive for this review paper. Identify the research question.
Different from systematic reviews, where research questions are specific and focused on a particular type of study design, scoping studies seek to answer broader questions and collect data from different types of information sources. They also allow iterative rather than linear analytical processes to fine-tune the research focus in a way that the information is useful for decision-making and further research. The research question to pursue in this scoping review is, What are the current priority issues, needs and services germane to the health of Hispanics in the USA?
Identify relevant studies. Guided by our framework, we searched the literature for comprehensive Hispanic health review documents in electronic databases, government websites and agencies, and civil society organizations addressing Hispanic health. The first step was to find out whether there were any recent comprehensive reviews addressing our research question. Figure 2 shows a flowchart of our citation selection process. After eyeballing the references, there were still many tangential to our study questions.
After a more targeted approach Fig. A thorough review of those citations supported our objective to conduct a scoping study using a unified framework of Hispanic health to answer our research question.
Study selection. While conducting this scoping review alerted by peer-reviewers , a special issue on Latino Health was published [ 23 ], which seemed to supplant content in our review; however, the four papers in that issue refer to specific Hispanic health topics: cancer, cardiovascular disease, health promotion, and health issues in general, with no unifying framework.
For this paper, we selected only citations pertinent to each of the components of the conceptual framework of Hispanic health presented in Fig. All retrieved papers were made available online to the authors in a shared Dropbox file for online remote access. Charting the data. A review of the first reference dataset containing 66 citations showed—with much overlap—that there were 26 review papers focusing mainly on social determinants of health and health disparities, 20 on health needs and risk factors, and 20 on health services see Additional file 1 versing on diverse topics.
We were able to retrieve 42 of the initial 66 reviews. All other references were added as authors reviewed and retrieved materials from different information sources PubMed, Internet, books , for each component of the conceptual framework. Collating, summarizing, and reporting results. We reviewed and selected papers, documents, and websites systematically to develop the sections on social determinants of health and health disparities, health risks, morbidity and mortality, health services, and the Hispanic and Latina paradoxes.
Authors discussed and agreed upon references to be added for each section. Table 1 was prepared to show the main organizations addressing Hispanic health. The following sections present the main components of Hispanic health, as outlined in our conceptual framework: social determinants of health and health inequalities, health risks, morbidity and mortality, health services and the Latina Birth Outcomes and Hispanic Mortality Paradoxes.
Special subpopulations are emphasized where information was deemed important. In this section, we present the major SDH of Hispanic health including demography, socioeconomic status, environment, occupation, and mobility. We additionally discuss the significant contributions of culture, language, poverty, and gender to Hispanic health inequalities.
Hispanics in the USA include people of Mexican The following states had the highest proportion of Hispanic residents: New Mexico Percentage of Hispanic population in Source: [ ].
Life expectancy at birth is longer for Hispanics Living near a major highway is associated with adverse outcomes including acute [ 37 ] and chronic [ 38 , 39 ] respiratory illnesses, cardiovascular diseases [ 40 , 41 ], obstetrical complications [ 42 ], and poor pregnancy outcomes [ 43 ].
Cancer risk pollutants emitted indoors tend to be higher in Hispanic households [ 44 ]. Despite significant improvements in water availability and quality in the USA, some Hispanic communities still face water quality associated health threats including elevated levels of arsenic [ 45 ] and nitrates [ 46 ]. In , Compared to NHWs, Hispanics are more likely to reside in areas with increased industrial pollution [ 48 ].
Residence near hazardous waste sites has been positively related to an increase in hospitalization from diabetes [ 49 ]. The employment rate among Hispanics Hispanics face an increased risk of mortality from some occupational hazards.
Percentage of Hispanic population growth — Source: [ , ]. Hispanics in the USA have a particular social and cultural identity that characterizes them as an ethnic group. These, together with language, are the main manifestations of their culture. First-generation Hispanics meaning they themselves were foreign-born differ from second-generation Hispanics US-born sons or daughters of at least one foreign-born parent in language use, acculturation, diet, and other characteristics which exert differential health effects.
For example, second- and third-generation Hispanics have an increased frequency of overweight and obesity when compared to first-generation Hispanics [ 53 ]. Familism is also an important cultural value among Hispanics [ 54 ] and is a source of emotional and financial support that may exert health risk-mitigating effects [ 17 , 55 ]. Though English proficiency and educational level among Hispanics have increased, educational attainment is still low mainly among foreign-born Hispanics [ 57 ].
Hispanics are underrepresented in Science, Technology, Engineering, and Mathematics STEM careers [ 58 ], and there is a growing shortage of Hispanic health care professionals [ 59 ].
Between and , the poverty rate among Hispanics in the USA increased 5. By , Additionally, the income-to-poverty ratio, a measure of depth of poverty, showed that 9. Poverty is high among the youngest and oldest Hispanics.
In , 6. Health care services both influence health and are influenced by health needs. In the USA, health insurance is a key determinant of access to health care services. Hispanics have lower rates of health insurance enrollment than NHWs [ 63 ], a figure that is higher for recent immigrants [ 64 ].
The gap was higher for persons aged 65 and over: 4. When poverty levels were considered, gaps were higher. Among the Hispanic poor under age 65, Among persons aged 65 and over, 7. Health inequalities are heightened among US women, mostly related to social determinants such as unfair paid labor, schooling, and violence. Lower educational attainment has been shown to protect against morbidity, mortality, and depression, although recent research has shown that, among US-born Mexican-American women, higher educational attainment was associated with diabetes [ 67 ].
Hispanic women tend to be more vulnerable to abuse and mistreatment; Hispanic women may suffer lower self-esteem and higher intimate partner violence IPV , with differential rates by country of origin [ 64 ]. Those who recently immigrated to the US—who work in bars or cantinas—were found to be at higher risks of experiencing intimate partner violence, including increased sexual risk behaviors from their primary or non-primary sexual partners [ 68 ].
The US Hispanic population includes a large number of migrant and temporary workers who are foreign-born. Self-selection of migrant workers may explain some of the apparent health advantages in the US Hispanic population. This is also known as the healthy migrant effect [ 69 ].
Given the nature of agricultural work, MSFWs face particular occupational health hazards such as pesticide exposure [ 71 , 72 ], heat exposure [ 73 ], musculoskeletal injuries [ 74 ], respiratory illnesses [ 75 ], skin disorders [ 76 ], eye injuries [ 77 ], food insecurity [ 78 ], and depression [ 79 ]. Unauthorized immigration is an important demographic phenomenon in the USA; undocumented immigrant workers play an important role in the US economy. Although declining, by the number of unauthorized immigrants was estimated at Undocumented migrant workers are employed in substandard, high-risk jobs with risky occupational exposures and very limited or no health insurance [ 81 ].
This section presents some of the main risk factors underlying the most important chronic diseases affecting Hispanics in the USA, namely obesity, tobacco smoking, and alcohol intake. The obesity epidemic underlies multiple health issues among Hispanics; it is a common denominator in the development of metabolic syndrome, non-alcoholic fatty liver disease NAFLD , diabetes, and cardiovascular disease CVD.
In addition, obesity increases the risk for several forms of malignancies [ 53 ]. The Hispanic population in the USA is disproportionately affected by obesity, with Additionally, Hispanics have the highest rates of obesity among American youth ages 2—19 years at Previous data showed that Hispanic children born outside of the USA were less likely to be obese than those born in the USA to immigrant parents [ 85 ].
More recent data demonstrate that foreign-born children of Hispanic immigrants are more likely to be overweight than children of more settled Hispanic immigrants and children of US natives [ 86 ]. The prevalence of obesity is heterogeneous among Hispanic subgroups, though across all subgroups females are more likely to be obese than males. Obesity rates vary from Significant differences in the prevalence of obesity have also been noted between US-born Hispanics Higher degrees of acculturation correspond with greater body weight in all migrant groups to the USA [ 88 ], though this effect is particularly pronounced in Mexican-born individuals [ 89 , 90 ].
Obesity increases the risk for multiple associated health conditions. Obesity indirectly increases the risk of CVD and stroke by increasing the risk of hypertension [ 88 ] and diabetes [ 91 ]. The prevalence of diabetes and hypertension has been demonstrated to rise steadily in Hispanics of all ages with an increasingly elevated body mass index BMI [ 92 ].
Obesity also contributes to metabolic syndrome, which is characterized by insulin resistance. In turn, insulin resistance is a major risk factor for the development of diabetes as well as NAFLD [ 93 ], a condition that disproportionately affects Hispanics and can increase the risk of liver malignancies. Finally, the metabolic syndrome directly promotes the development of atherosclerotic CVD [ 94 ]. The high incidence of obesity in US Hispanics is a multifactorial problem.
Food and beverage marketing for Hispanics in the USA promotes the consumption of low-nutrient, calorie-dense foods and beverages, especially among children [ 20 ]. Low-income Hispanic mothers have been found to engage in highly permissive, indulgent feeding patterns that relate directly to child obesity [ 95 ].
Food insecurity when members of a household experience reduced quality, variety, or desirability of food products has been significantly associated with obesity in low-income Mexican-American women living in California [ 96 ].
Other risk factors such as glucose intolerance and gestational diabetes affect Hispanic women and their descendants, as they will be more likely to develop diabetes themselves [ 97 ].
Moreover, health care inequalities contribute to obesity as well. Behavioral factors have a much greater impact on premature death than does health care, making this lack of preventative counseling significant [ 98 ]. The tobacco industry targets Hispanics by utilizing custom advertising and by financially contributing to Hispanic community activities [ 99 , ]. The incidence of tobacco use is highest in Puerto Ricans, with In contrast, the incidence of smoking is lowest in Dominican males In the USA, second-generation Hispanics have a disproportionately high rate of tobacco use, which increases their risk for CVD, diabetes, and cancer [ ].
Many prevalent cancers in Hispanics lung, breast, colorectal, and liver share preventable risk factors, including, tobacco consumption, sedentary lifestyle, alcohol abuse, obesity, and an unhealthy diet. In the future, cancer mortality rates may decrease by avoiding risk factors that are the outcomes of acculturation, culturally insensitive public health approaches, and limited health care access [ ]. Consumption of alcohol constitutes a risk factor for cancer, diabetes, CVD, and metabolic syndrome [ ].
In the USA, Hispanics are less likely to binge-drink defined as having a blood alcohol concentration greater or equal to 0.
However, alcohol consumption among Hispanics who already drink is higher than among NHWs. In , the rate of alcohol dependence by country of origin was as follows: Puerto Rico 5. Binge drinking contributes to the development of fatty liver disease [ , ].
Social, environmental, and biological forces have modified the epidemiologic profile of Hispanics in the USA, with cancer being the leading cause of mortality, followed by cardiovascular diseases, liver disease, and unintentional injuries. CVD and diabetes share a host of common risk factors. Most specifically, these take the form of the metabolic syndrome, which is diagnosed when an individual meets any three of the following five criteria: elevated waist circumference central obesity , elevated triglycerides, reduced high-density lipoprotein-C, elevated blood pressure, or elevated fasting glucose [ 94 ].
Significant risk factors for CVD include hyperlipidemia, tobacco use, diabetes, obesity, and hypertension [ 87 ]. This seemingly paradoxical finding may be explained by the relatively low median age of Hispanics residing in the USA, or it may represent an extension of the Hispanic Mortality Paradox, as supported by recent publications [ 7 , , ]. In , it was estimated that 29 million Americans had diabetes [ 97 ].
The incidence of diabetes increased until and then decelerated between and As shown in Fig. The incidence of diabetes in Hispanics has been increasing when compared to NHWs [ ]. The prevalence of diabetes varies among Hispanic subgroups: in , the age-adjusted rate of diagnosed diabetes was Percentage of diagnosed diabetes by ethnicity in people aged 20 years or older for the period — Source: [ 97 ]. Percentage of diagnosed diabetes by Hispanic subgroups — Hispanics with diabetes in the USA are affected by related comorbidities such as CVD, diabetic retinopathy, chronic renal disease, and diabetic neuropathy.
These diseases generate additional medical expenses that especially affect uninsured Hispanics [ 97 ]. In the USA, the total diabetes expenditure for the year was billion US dollars: billion expended in direct medical costs comorbidities, medications, medical supplies, hospitalization and 69 billion in indirect costs loss of employment, permanent disability, low healthy life expectancy [ 97 ]. The medical expenses of Americans with diabetes were 2. In the USA, diabetes mortality disproportionately affects Hispanics.
In , diabetes was one of the top ten causes of mortality in the country with 69, deaths [ 97 ]. The death rates from diabetes were significantly different for Hispanics Among Hispanic males, diabetes death rates were higher For Hispanic women, diabetes death rates were also higher Consistent with decreasing trends in cancer mortality among NHWs, cancer mortality has also decreased among Hispanic men 1.
The incidence of gastric cancer is increasing in young Hispanic men [ , ]. Cancer morbidity and mortality rates differ by country of origin and ethnicity. Compared to NHWs, Hispanics are more likely to be diagnosed with infection-related cancers such as gastric, hepatic, and cervical but are less likely to be diagnosed with prostate, breast, lung, and colorectal cancer.
US-born male Hispanics are twice as likely to develop hepatocellular carcinoma than foreign-born Hispanics [ ]. Skip directly to site content Skip directly to page options Skip directly to A-Z link. Vital Signs. Section Navigation. Facebook Twitter LinkedIn Syndicate. Minus Related Pages. On This Page. Doctors and other healthcare professionals can: Work with interpreters to eliminate language barriers, when patient prefers to speak Spanish.
Counsel patients on weight control and diet if they have or are at high risk for high blood pressure, diabetes, or cancer. Ask patients if they smoke and if they do, help them quit. Engage community health workers promotores de salud to educate and link people to free or low-cost services.
Health risks differ among Hispanics. Hispanics have different degrees of illness or health risks than whites. Mexicans and Puerto Ricans are about twice as likely to die from diabetes as whites. Skip to main content. Abstract Culture impacts the ways people evaluate and respond to health and illness. Files over 3MB may be slow to open. For best results, right-click and select "save as Included in Communication Commons.
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