Hispanics, as outlined earlier, share a range of sociocultural characteristics, as well as national, experiential, and in some instances genetic make-up, that can impact their health status within the United States. Certain cultural factors, such as a more traditional diet and lower rates of smoking among women impact favorably on their health status, while others, such as low immunization rates linked to low economic status and fear of authority among new immigrants, have negative consequences. Unfortunately acculturation among new immigrants and their children seems to weaken positive health habits and lead to the adoption of negative ones from U.S. culture (such as smoking, alcohol use, and early sexual activity).

For decades when researchers, health professionals, politicians and policy-makers addressed minority health, they were usually referring only to issues and statistics dealing with African-American health profiles and then extrapolating from these to other communities. The major reason for this was that it was not until 1989 that the U.S. National Model Death Certificate collected data on Hispanics. This lack of data prevented the emergence of an authentic Hispanic health profile. As data became more available in the 1990’s, a Hispanic health profile emerged which showed that despite lower income, less education, and less access to health Hispanics have a longer life expectancy than non-Hispanic whites. This ran counter to the prevailing models of health.

v Mortality and Morbidity

In 1985 the Report of the Task Force on Black and Minority Health of the U.S. Department of Health and Human Services, attempted to outline the disparities in health status existing between the non-Hispanic white population and the rest of the population. However, it remained difficult to ascertain the actual differences in health status among "minority" populations due to the fact that although mortality data were available for blacks, Asian/Pacific Islanders, Native Americans and whites, it was still not available for Hispanics. Even today the organization of reliable and accessible data on Hispanic mortality and morbidity lags behind that for other racial and ethnic groups. Nonetheless certain trends and statistical health profiles have become clear, with the mortality rates for Hispanics proving counter-intuitive to the traditional view that the lower economic status and educational attainment of "minorities" dooms them to a higher rate of mortality.

Despite having a lower income, Hispanics live longer than non-Hispanic whites. Hispanics have an average life-expectancy of 75.1 years for men and 82.6 years for women. As a result, for the Hispanic community the issues of morbidity rather than mortality are of greatest concern. These issues include lifestyle and behaviors affecting health, environmental factors such as exposure to pesticides, unclean air and polluted water, and the ongoing need for more effective use of existing health services. Many of these morbidity factors also play a significant role in Hispanic mortality rates.

The top ten leading causes (1998) of death for Hispanics of all age groups are:

1. Heart disease,

2. Malignant neoplasms,

3. Accidents and adverse effects,

4. Cerebrovascular diseases,

5. Diabetes mellitus,

6. Pneumonia and influenza,

7. Homicide and legal intervention,

8. Chronic liver disease and cirrhosis,

9. Chronic obstruction and pulmonary diseases, and,

10. Certain conditions originating in the prenatal period.

The top two leading causes of death are the same for the Hispanic and for the non-Hispanic white population: heart disease and cancer. However, for Hispanics these two causes account for 45% of deaths, whereas they accounted for 55% of all deaths among non-Hispanic whites in 1998.

Of the ten leading causes of death for the Hispanic population, two, "Homicide and legal intervention," and "Certain conditions originating in the prenatal period," also reflect differences in age composition between Hispanics and other groups. The Hispanic community is marked by its youthfulness. Its median age is 26.6 years, compared to 38.6 years for the non-Hispanic white population.

Because the Hispanic population has a greater proportion of young persons, it also has a larger proportion of deaths due to causes that are more prevalent at younger ages, such as male violence. Some key mortality differences are:

• Chronic liver disease is a leading cause of death for Hispanics, but
  not for non-Hispanic whites;

• Diabetes mellitus ranks higher for Hispanic populations as a cause of
  death than for non-Hispanic   whites;

• HIV infection for Hispanics aged 1-4 and 15-24 years is the 9th leading
  cause of death, but is not a leading  cause of death for non-Hispanic
  whites in those age groups; and, 

• Homicide and legal intervention consistently ranks higher for Hispanics
  than for non-Hispanic whites for age groups between 15-24 years
  and 25-44 years.

Looking at some of the major health problems facing Hispanics today including HIV/AIDS, diabetes, coronary heart disease, stroke, and depression, it is easy to see how lifestyle and health behaviors can significantly impact on Hispanics’ health status. For example, improper diet, smoking, and excessive alcohol consumption are known to increase the risks for diabetes and cardiovascular disease.

Smoking

The relationship between smoking and various cancers, heart disease, and respiratory disorders has been clearly established. For the past twenty years there has also been a steady decline in the number of Hispanics who smoke tobacco. By 1998 only 18.9% of Hispanics smoked tobacco compared to 26.5% of non-Hispanic blacks and 25.9% of non-Hispanic whites.

While Hispanic adults have the lowest rates of smoking, Hispanic eighth graders now have the highest rates of smoking among all their peers. A recent survey found that 50.6% of Hispanic eighth graders had reported smoking within the previous 30 days compared to 47.9% of non-Hispanic whites and 41.7% of non-Hispanic blacks. In addition, a recent survey in San Francisco found that while only 15% of first-generation immigrant Hispanic women reported smoking, 23% of second-generation Hispanic women smoked. This was consistent with other findings showing that as Hispanic women acculturate to the United States they tend to give up a number of their healthier habits such as not smoking and good nutrition.

Diet

Diet has been shown to affect several cancers, diabetes, and heart disease. The Hispanic diet is high in fiber, relies on vegetable rather than animal proteins, and includes few dairy products and leafy green vegetables. In cattle producing countries however, diets tend to include a greater amount of animal protein. Recent studies also indicate that Mexican American women report a higher intake of vitamins A, C, folic acid, and calcium than do non-Hispanic white women. Again, however, these positive indicators tend to decline with U.S. acculturated second generation Mexican American women whose dietary intake is the same as that for non-Hispanic white women. Reflecting differences among Hispanic sub-groups, there are findings of both positive and negative nutritional indicators for Hispanic children. While the mean iron intake of Cuban American and Puerto Rican children meet the recommended level for iron, Mexican American infants are below the recommended level. The majority of Mexican American children also consume less than the recommended servings of fruits and vegetables, including fruits and vegetables with high vitamin A and C content. Also, after age 5, the majority of Mexican American children consume less than the recommended daily servings of milk.

In terms of mother’s milk, according to 1990 statistics 52% of Hispanic women breast-fed their infants compared to 59% of non-Hispanic white women and 26% of non-Hispanic black women. Although Hispanic women are regarded as coming from a breastfeeding culture, their nursing rates begin to decline as they acculturate to the United States. In addition, bottle-feeding ad campaigns conducted in Puerto Rico and throughout Latin America by corporations that produce baby formula have also led to a steady decline in breast-feeding in these areas.

Cholesterol 

Linked to diet and nutrition, cholesterol levels for Hispanics are similar to those reported for non-Hispanic whites and non-Hispanic blacks. For all Hispanics, cholesterol levels gradually increase with age. Hispanics with high cholesterol levels tend to be less aware of their situation than their non-Hispanic white counterparts. The traditional Hispanic diet includes a carbohydrate staple (such as rice or corn tortillas) with beans, which together provide a balanced source of protein without cholesterol. However, as Hispanic immigrants and other groups adapt to the dominant culture’s diet their serum cholesterol levels begin to rise.

Weight and Exercise

Less than half (42%) of all adults in the United States are at a healthy weight. The rates are lowest for Mexican Americans at 30% compared to 43% of non-Hispanic white and 34% of non-Hispanic black adults. Data for other Hispanic population groups besides Mexican Americans are not currently available.

Despite evidence linking regular physical activity to a range of health benefits, millions of United States adults remain essentially sedentary, a fact which has generated the descriptive title of "TV couch potatoes" (or with the advent of the internet, "mouse potatoes"). Researchers report that men are more likely than women to participate in physical activity. Also Hispanics are less likely to exercise with 41.0% of Hispanic adults reporting no leisure time physical activity compared to 26.7% of non-Hispanic whites. A CDC study of high school students found that adolescent males are about twice as likely 

as adolescent females to report engaging in vigorous physical activity.While many Hispanics work in occupations requiring heavy manual labor, many of these activities do not contribute to aerobic fitness. A heart study conducted in San Antonio, Texas, found that Mexican Americans engaged in aerobic exercise less often than any other group.

Alcohol and Substance Abuse

Another lifestyle issue facing the Hispanic community is excessive alcohol use that can, over time, cause serious medical problems, as well as increase the more immediate risk of accidents and violence. Alcohol appears to be the major drug of use among Hispanics with more than half (58.5%) reporting that they had used alcohol in the past year. Rates of heavy alcohol use (five or more drinks per occasion on five or more days in the past 30 days) are higher among Mexican Americans (6.9%) than among non-Hispanic whites (5.3%) or non-Hispanic blacks (4.7%).

Furthermore, data indicate that rates of alcohol use increase with acculturation among all U.S. Hispanic groups. This trend is particularly evident among Hispanic women. Hispanic males are more likely to have used alcohol in the past year (68.3%) than Hispanic females (48.4%). However, data are now showing that lower rates of drinking among females are not evident among Hispanic youth. Among 12-17 year olds, 18.8% of Hispanic males report alcohol use in the past month compared to 19.1% of Hispanic females.

Overall, 26.6% of Hispanics report ever having used an illicit drug including marijuana in their lifetime, compared to 33.2% of non-Hispanic blacks and 38.2% of non-Hispanic whites. Hispanics are also less likely to report having used illicit drugs during the past year (10.5%), compared to 10.4% of non-Hispanic whites and 13.0% of non-Hispanic blacks. However, the percentage of Hispanics reporting cocaine use within the past month (1.3%) is the same as that of non-Hispanic blacks and almost twice as high as that of non-Hispanic whites (0.5%). Hispanics are less likely to have used crack cocaine in the past year, however (0.7%), than blacks (1.3%) but more likely than whites (0.3%). Inhalants represent a particular threat for Hispanic adolescents: 5.6% of Hispanics age 12-17 report they’ve used inhalants, compared to 7.2% of white youth and 2.1% of black youth.

Violence and Unintentional Injuries

Self-inflicted and unintentional injuries and death as well as violent homicides also have a disproportionate impact on youthful Hispanic groups and individuals.

Studies find that Hispanic high-school students are more likely to have made at least one suicide attempt (12.8%), compared to their non-Hispanic black (7.3%) and non-Hispanic white (6.7%) peers. Even more disturbing, Hispanic female high-school students are significantly more likely to have made at least one suicide attempt in the previous year (18.9%), than their non-Hispanic black (7.5%) or non-Hispanic white (9.0%) peers. Rates for female students are higher than for male students across all racial and ethnic categories. Violence is another increasing challenge to the health and well-being of Hispanic youth. The percentage of deaths from homicide and legal intervention is almost five times greater for Hispanic adolescents and young adults (28.0%) than that of their non-Hispanic white peers (5.8%).

Twenty-two percent of Hispanic high-school students now report they fear physical and violent attacks when going to and from school. Accidents are the third leading cause of death among Hispanics, accounting for 8.3% of all Hispanic deaths, but only the sixth leading cause among non-Hispanic whites at 3.9%. For children accidents and adverse effects are the leading cause of death for all groups. For Hispanic children, the rate of accidental deaths (11.0 per 100,000 persons under the age of 4) is similar to that for non-Hispanic white children (11.4) and lower than that for non-Hispanic black children (21.8). When examining accidental death rates due to motor vehicle accidents, the death rate for Hispanic children is also higher than that for non-Hispanic white children. Two contributing factors that have been noted: Hispanic children are less likely to use seat belts or to be placed in child safety seats than their white counterparts, and Hispanic adults are over-represented in the number of arrests for drunk driving.

Environment

In addition to lifestyle and behaviors, health status is significantly impacted by our surrounding environment. Most of the major environmental laws in place today, the Clean Air Act, Clean Water Act, Community Right to Know Law, etc. have as their objective the protection of our public health and yet very few Hispanics are aware of them. This is unfortunate as Hispanics in the United States face the highest rates of exposure to pollution and toxic substances. Hispanics are the group most likely to live in areas failing to meet air quality standards according to the EPA, with 80% living in areas that fail to meet at least one National Ambient Air Quality Standard (as compared to 65% of blacks and 57% of whites). 18.5% of Hispanics are exposed to the nation’s worst air pollution (as opposed to 9.2% of blacks and 6% of whites).Studies indicate that Puerto Rican children are also more than three times as likely as non-Hispanic white children to suffer from active asthma.

In addition, Hispanics are more than two times as likely as blacks or whites to live in areas with either elevated levels of particulate matter or in areas with high levels of lead in the outdoor air. Another source of lead exposure for children is derived from swallowing nonfood items such as chips of paint containing lead, inhaling of lead dust and hand-to-mouth contamination. House renovations, folk medicines, and cosmetics are others sources of environmental lead exposure. Mercury, commonly known as "quicksilver" or azogue (in Spanish) is highly toxic to humans even in minute amounts. Unfortunately, it is sometimes used by Hispanics as a folk medicine or spiritual agent. Azogue is frequently sold in botánicas–small stores that carry religious and cultural products. Believed to possess spiritual power it is sometimes burned as an incense, or in a candle, or sprinkled about the home.

Hispanics are also more likely than other groups to live in EPA non-attainment areas for ozone and carbon monoxide in the air. Indoor air pollution agents include asbestos, carbon monoxide and second-hand or environmental tobacco smoke (ETS). According to the National Health Interview Survey, 44.3% of Hispanic pre-school children have been exposed to tobacco smoke.

The importance of safe drinking water to health can hardly be emphasized enough. Eighty-two percent of public health officials polled rated it the most important or a very important factor in increasing life expectancy and quality of life. Water quality issues are impacted not only by water sources, but also by delivery systems including municipal pipes and household plumbing.

In urban areas low-income Hispanics are more likely to rent older homes and apartments which may contain antiquated lead plumbing (and wall paint). Additionally biological contamination of urban water systems is getting more notice since outbreaks of cryptosporidum were reported in Milwaukee, Washington D.C. and other cities. Both industrial and biological contamination of water is also a persistent problem along the United States–Mexico border particularly in colonias. In six Texas counties there are about 842 colonias (low-income subdivisions outside municipal boundaries) with some 200,000 Mexican and Mexican American residents. Only three colonias (less than 1%) have public sewage disposal systems. As a result water supplies often become contaminated with bacteria and viruses. The EPA reports that "outbreaks of dysentery and hepatitis A are commonplace in the colonias."

Of the billion pounds of pesticides used annually in the United States 80% is used in agriculture. Hispanics are 71% of all seasonal agricultural workers and 95% of all migrant farmworkers. This is cause for great concern among public health professionals serving Hispanic patients and clients. Exposure to agrochemicals has been associated with a variety of cancers, particularly hemopoietic cancers; acute and chronic neurotoxicity; lung damage; chemical burns; infant methemoglobinemia; immunologic abnormalities; and, adverse reproductive and developmental effects. It’s been reported that prolonged exposure to pesticides is responsible for an estimated 1,000 deaths and 313,000 illnesses annually among agricultural workers in the United States. Among young Mexican American farmworkers interviewed in New York state 48% reported working in fields with pesticides, and 36% reported being sprayed with pesticides while working in fields and orchards. Thus health professionals working with Hispanic patients in rural communities should be familiar with the signs, symptoms and long-term impacts of various pesticide and other agro-chemical exposures.

Biological and chemical contamination of water supplies in migrant labor camps is another widely reported, although not well-documented problem. One study found that 43% of water supplies at state-licensed migrant camps in nine Michigan counties contained nitrates. Migrant labor camps in California have also been cited by the EPA for having excessive levels of nitrates and coliform bacteria in their drinking water.

Occupational exposure to chemicals is also widespread in the Hispanic community. Many Hispanics work in settings in which the risk of exposure to a variety of chemicals, gases, and other toxic substances is very high. Hispanics predominate in the migrant and seasonal agricultural workforce, and are also over-represented in the electronics sector as laborers and assemblers, and in the oil and petrochemical industry.

v Key Areas of Concern

Community-based Hispanic health and human services groups throughout the United States and Puerto Rico have come to identify certain key health issues that are having major impacts on Hispanic health such as AIDS and HIV; cancer; coronary heart disease; stroke; hypertension; diabetes; environmental health; mental health; and, tuberculosis. These are areas that could be of particular interest if you are a health care provider working with a Hispanic patient population.

AIDS and HIV 

The annual incidence rate of AIDS for Hispanic adult men is 3.2 times that and for Hispanic women 6.1 times that of non-Hispanic white adult men and women.In 1999 

33.5% of the nearly 105,000 reported AIDS cases among Hispanics adults were due to injected drug use. Men having sex with men accounted for more than one-third of all reported cases (39.0%). Men who had sex with men and injected drugs was included at 5.1%. Among Hispanic women reported with AIDS, injected drug use accounted for 43.6%, while 53.1% got infected through heterosexual contact.

Cancer

Malignant neoplasms are the second leading cause of death in the United States among both Hispanics and non-Hispanic whites. The cancer mortality rate for Hispanics is 64.6 per 100,000 persons compared to a rate of 230.1 for non-Hispanic whites and 185.3 for non-Hispanic blacks. Hispanics have a lower incidence and mortality rate for the four most prevalent cancer sites: prostate, breast (female), lung and bronchus, and colon/rectum. However, rates of stomach cancer are higher for Hispanics than for whites. Furthermore, the cervical cancer incidence rate for Hispanics (15.8 per 100,000 women) is higher than that for black women (11.8) and more than twice that for white women (7.1).

Coronary Heart Disease, Stroke, and Hypertension

Diseases of the heart were the leading cause of death among Hispanics in 1998. Still, according to the National Center for Health Statistics the death rate for diseases of the heart is lower for Hispanics (81.3 deaths per 100,000), than for whites (311.7) or blacks (236.7). This lower rate of heart disease is surprising since Hispanics have a higher prevalence of conditions that increase their risk for coronary heart disease, including obesity and diabetes.

Cerebrovascular disease (stroke) is the fourth leading cause of death among Hispanics, accounting for 5.7% of all Hispanic deaths. It is the third leading cause of death among non-Hispanic whites, accounting for 6.9% of all deaths. Since diabetes and obesity are associated risk factors for stroke and related diseases, Hispanics might be expected to face a higher stroke rate than non-Hispanic whites. In fact the opposite is true. If there is some sort of genetic "protective factor" prevalent in Hispanics, future research may be able to isolate and identify this mechanism, and use it to lower rates of cerebrovascular disease for other communities.

Hypertension affects 25.2% of Mexican American males and 22.0% of Mexican American females. Hispanic men are more likely to have undiagnosed, untreated, or uncontrolled hypertension than the national average. Hispanic females are more likely than Hispanic men to be aware of their condition, although fewer receive treatment for it, and very few have it controlled. In a report out of New York City it was found that 10% of Dominicans and 12% of Puerto Ricans sampled were hypertensive. The study also found that 9% of non-Black Hispanics were found to be hypertensive, compared to 12% of Black Hispanics.

Diabetes

Non-insulin dependent diabetes (Type II diabetes) is a major health problem among Hispanics, especially Puerto Ricans and Mexican Americans, who are about twice as likely to be afflicted by it as non-Hispanic whites. Data show the incidence of diabetes to be 26.1% for Puerto Ricans, 23.9% for Mexican Americans, and 15.8% for Cuban Americans, compared to 12% for non-Hispanic whites and 19.3% for non-Hispanic blacks for individuals aged 45-74.

This higher rate of diabetes is correlated with the higher prevalence of obesity among Mexican American women, but overweight Hispanic women are still more likely to have diabetes than overweight non-Hispanic women. Another risk factor was assumed to be genetic as the incidence of non-insulin diabetes appears to be highest in Mexican Americans with substantial Indian heritage. However it is difficult to support this, given the higher prevalence of diabetes affecting Puerto Ricans who do not have this genetic inheritance.

Environmental Health

The environmental health status of Hispanic communities is poor, and is a major source of health problems. Among Hispanics there is a higher risk of exposures to: ambient air pollution; worker exposure to chemicals in industry; indoor pollution; and, pollutants in drinking water. In terms of exposure Hispanics consistently face the worst exposure levels, or levels that represent significant threats to health. Health practitioners should consider environmental sources in diagnosing and treating a variety of conditions affecting Hispanic patients and clients. Both the Agency for Toxic Substances and Disease Registry (ATSDR) and the EPA produce toxicological profiles that can assist you in diagnosing illnesses related to an environmental risk or toxic exposure.

Mental Health

Hispanics have the highest rates of depression. Additionally, Hispanics are identified as a high-risk group for anxiety and substance abuse. Of course people in transition often experience feelings of irritability, anxiety, helplessness, and despair. They may mourn the loss of family, friends, language, and culturally determined values and attitudes. These reactions are not signs of individual pathology, but rather normal responses to the often disruptive process of change. Sources of stress include: life in a society that does not support their culture and way of life; having to cope with low-incomes and poor housing; experiencing suspicion and distrust regarding their legal status; and, experiencing exploitation and mistreatment from both individuals and institutions in the workplace and other settings.

Such stress had been assumed to increase the risk for somatic and functional illness, depression, organic disease, and interpersonal problems. In September of 1998 the Archives of Psychiatry published an article (Vega, et al) which provided compelling data that Mexico-born U.S. residents had less mental illness than Mexican Americans. This was contrary to the years of myth that Hispanic immigrants would suffer more mental illness than Hispanics born in the U.S. as a result of post-traumatic stress disorders resulting from wars and other violent events in their countries of origin, and hostile attitudes towards Hispanic immigrants.

The evidence indicates that higher levels of acculturation and birth in the United States are associated with higher incidence of phobia, alcohol abuse, drug dependence, and anti-social behavior such as gang membership. Sociologist Herbert Gans argues that immigrant children who hold fast to their parents’ ethnic communities may do better than those who assimilate rapidly and adopt the American culture that they see all around them, including cynical attitudes towards school and rejection of low-wage employment opportunities.

Johns Hopkins University professor Alejandro Pertes finds that the chances for downward mobility and anti-social behavior are greatest for second generation immigrant youth living in close proximity to other American minorities who are poor to start with, and who are themselves victims of racial and ethnic discrimination.

Severe psychiatric disorders among Hispanics are sometimes diagnosed incorrectly, when practitioners are unaware of prevalent cultural beliefs and practices, and when they use psychological tests that have not been standardized for bilingual populations.

Tuberculosis

Approximately 10 to 15 million Americans are infected with mycobacterial tuberculosis (TB). In the United States the number of cases of active TB increased over 20% between 1985 and 1992 with a disproportionate rise among racial and ethnic minorities. In 1998, the rate of new tuberculosis cases per 100,000 persons was 13.6 for Hispanics compared to 2.3 for non-Hispanic whites and 17.8 for non-Hispanic blacks. The risk of contracting TB among Hispanics is approximately six times the risk among non-Hispanic whites. Among Hispanics TB is most prevalent in young adults, ages 25-44. Evidence suggests that the HIV epidemic is in part responsible for the recent increases in tuberculosis among Hispanics in this age group. TB may also be a particularly significant problem for migrant workers. Screening of 214 Hispanic migrant workers in Virginia in the 1980s found that over a quarter had tuberculosis infection, and were at significant risk of developing the clinically active disease.

Much of what we know about Hispanic health is not only new but contrary to existing models of health. Consequently, it is crucial to determine the specific needs of each Hispanic population you are serving before developing educational or clinical approaches to treatment. It is also very important to re-evaluate approaches at regular intervals to assure quality of care.



Copyright The National Alliance for Hispanic Health 
Reprinted with permission.

• Health is generally viewed as: being and looking clean; being able to
  rest and sleep well; feeling good and happy; having the ability to
  perform in one’s expected role as mother/father, worker, etc.In
  Puerto Rico, the phrase llenitos y limpios (clean and not too thin) is
  used.

• A person’s sense of bienestar (well-being) is thought to depend upon
  a balance in emotional, physical, and social arenas. Imbalance may
  produce disease or illness. Some attribute physical illness to "los
  nervios," believing illness results from having experienced a strong
  emotional state. Thus, they try to prevent illness by avoiding intense
  rage, sadness, and other emotions. Depression is not talked about
  openly; a person may say, "I am sad" (triste).

• Eating well and drinking fruit juices are common health promotion
  practices. Exercise is often not perceived as a health promotion
  practice and is discouraged during illness. As with other issues, this
  will vary by educational level.

• Individuals may not seek help until they are very sick.

• Hispanic cultures view illnesses, treatments, and foods as having
  "hot" or "cold" properties, although how these are ascribed may vary
  by country. Some consider health as the product of balance among
  four body humors (blood and yellow bile are "hot," phlegm and black
  bile are "cold.").One would balance a hot illness with cold medications
  and foods, etc. This might result in not  following a doctor’s advice to
  drink lots of fluids for a common cold, if one believes such drinks add
  more coldness to body. Instead, hot liquids (teas, soups, broth) could
  be recom- mended. Colombians often use meat broth instead of
  chicken soup when sick; also drink agua de panela (unprocessed
  sugar and water) for respiratory/flu symptoms.

• Prevention strategies could build on this concern for balance – e.g.,
  adopt a balanced diet to prevent diabetes and other diseases
  associated with overweight.

Potential Culture-Related Health Concerns Among Hispanic Populations

Persons from some Hispanic cultures may have a tendency toward certain health concerns because of cultural factors.

Specific concerns include:

1. High incidence of teenage pregnancy among Mexican and
    Puerto Rican populations, due to a large percentage of
    women of childbearing age.

2. Low incidence of breast-feeding, especially in the Puerto
    Rican population.

3. Where breast-feeding is practiced, a tendency to do so
    for a short period and to introduce solid foods earlier
    than recommended in current pediatric guidelines.

4. Very low intake of vitamin A.

5. Alcohol abuse, especially by young Mexican males
   (abetted by cultural taboos against female disclosure of
   alcohol use).

6. Drug use at levels higher than among non-Hispanic
   whites.

7. High prevalence of undetected non-insulin-dependent
   diabetes (especially among Mexicans with Pima Indian
   blood).

8. High incidence of tuberculosis (the National Coalition of
   Hispanic Health and Human Service Organizations
   [COSSMOS] recommends aggressive screening 
   with Mantough tuberculin skin test and, if the test if
   positive, use of the NIH’s preventive therapy, because of
   the high use of BCG in Latin America.

9. High risk for mental health problems such as depression,
    anxiety, and substance abuse.

10. Dietary concerns due to:

- high consumption of fats (often lard, especially for
   low-income people) and fried food;

- traditional diet high in carbohydrates from beans and rice
  (Puerto Rico, Cuba, and the Caribbean islands) or corn
  tortilla (Mexico);

- low intake of green or leafy vegetables and/or milk and
  eggs, especially in conjunction with increased consumption
  of meat and fast foods as acculturation occurs.

12. Lack of sunshine (primarily for immigrants to northern cities).

13. Little tradition for "recreational" physical exercise outside the
     context of field or other physical labor.

14. Excessive reliance on Azarcon (also called "Greta" or "Alarcon"),
     which is about 90 percent lead, as a home remedy for
     gastrointestinal/intestinal complaints.

15. Sharing, with family and friends, of hypodermic needles and
     syringes, which in Mexico are often used to administer vitamins,
     medications, and contraceptives. 

Health Promotion, Prevention, and Treatment

• Preventative medicine is not a norm for most Hispanics. This behavior
  may be related to the Hispanic "here and now" orientation, as opposed
  to a future-planning orientation.

• Some commonly known Hispanic sayings suggest that events in one’s
  life result from luck, fate, or other powers beyond an individual’s
  control.

Que será, será (What will be will be);

Que sea lo que Dios quiera (It’s in God’s hands);

Esta enfermedad es una prueba de Dios (This illness is a test of God);

De algo se tiene que morir uno (You have to die of something).

• Persons with acute or chronic illness may regard themselves as
  innocent victims of malevolent forces. Severe illness may be attributed
  to God’s design or bad behavior or punishment. Genetic defects in
  child may be attributed to parents’ actions.

• Family and friends may indulge patients, allowing them to be passive
  – a stance that may conflict with the view that active participation is
  required to prevent or heal much disease.

• Other Hispanic sayings support health promotion, and illustrate the
  considerable status given to health and prevention:

La salud es todo o casi todo (Health is everything, or almost everything);

Es mejor prevenir que curar (An ounce of prevention is worth a pound of cure);

Ayúdate que Dios te ayudará (Help yourself and God will help you).

· "Helping yourself" may lead to placing responsibility for cure with the
  entire family. The challenge for health professionals is to assess the
  amount of control patients believe they have over their health and to
  design interventions that build on traditional support systems.

· Vaccination is very important and adhered to for children.

· Western medicine is expected and preferred in case of severe illness,
  but some Hispanics may also use native healers. Curanderos utilize
  prayers, massage, and herbs to treat physical, spiritual, and emotional
  ailments. Espiritistas are believed to have spiritual or psychic powers
  to cure illness by communicating with dead souls.

· A "botanica" is a resource store for herbs and other traditional remedies.
  Some Hispanics may go there before going to a physician or clinic. In many
  Latin American countries, pharmacists prescribe medications, and a wider
  range of medications is available over the counter. People may share
  medicines, or write home for relatives to send them medications. Individuals
  may discontinue medication if it doesn’t immediately alleviate symptoms, or
  after their symptoms abate. Many believe taking too much medicine is
  harmful.

Diseases may be divided into Anglo and traditional diseases, and traditional diseases may be either natural or unnatural. Many people mix and match "modern" medicine and traditional care, consulting modern health providers for Anglo and natural diseases, and folk healers for traditional and unnatural diseases. 

Major Folk Illnesses Among Hispanic Populations

Ataque. A culturally condoned emotional response to a great shock or bad news, characterized by hyperventilation, bizarre behavior, violence, and/or mutism.

Bilis. An illness believed to be caused by strong emotions that result in an imbalance of bile, which "boils over" into the bloodstream. Symptoms include vomiting, diarrhea, headaches, dizziness, and/or migraine headaches.

Empacho. Lack of appetite, stomachache, diarrhea, vomiting, caused by poorly digested or uncooked food. Treated by massaging the stomach and drinking purgative tea, or by azarcon or greta, medicine that has been implicated in some cases of lead poisoning.

Pasmo. Tonic spasm of voluntary muscle; chronic cough or stomach pain; arrest of child’s growth and development, all brought by exposure to cold air when body is overheated.

Diseases of hot/cold imbalance. The hot/cold theory of disease traces its roots to the Aristotelian system of humors, which were either hot or cold, wet or dry. The hot/cold portion of the theory survives in many Hispanics of Mexican and Puerto Rican origin. Body organs, diseases, foods, and liquids may be "hot" or "cold," and good health depends on maintaining a balance of hot and cold. A "hot" ailment calls for "cold" herbs and foods to restore the balance, and vice versa.

Note that temperature is not the key factor in the classification scheme; ice is "hot" because it can burn, and Linden tea, though served hot, is "cold" and is often used by Mexicans to treat "hot" ailments. Penicillin, neutral in temperature, is considered "hot" because it may cause hot symptoms, such as diarrhea or rash.

Acceptance of the hot/cold system can affect compliance with treatment. For instance, a patient suffering from a high fever may resist cold compresses, reacting against the treatment of a "hot" ailment (fever) with a "hot" treatment (ice).

Indirect questions can help a provider determine whether a patient subscribes to the hot/cold belief system. If the patient does, the provider should try to work within the hot/cold framework to increase patient trust and maximize compliance.

Mollera cerrado or cerrado de mollera (fallen fontanel). Said to exist when an infant’s anterior fontanel is either visibly depressed or believed to have been depressed as the result of trauma. Symptoms are excessive crying, lack of desire or ability to feed, diarrhea, vomiting, restlessness, and irritability. Whether real or imagined, this problem warrants attention because the family may believe it to be fatal if not treated.

Embrujado (bewitchment). A socially accepted psychological disease (in contrast to being considered "mad"), embrujado may be manifested through physical or psychological illness, depending on the intent of the bewitcher (who is always female). Some researchers have suggested that embrujado may be a culturally accepted behavior for males who cannot cope with the Anglo world.

Mal de ojo (evil eye). A spell usually cast on a child when a person with the evil eye admires the child without touching it. Children may be protected by special earrings, necklaces, amulets, or other jewelry, which should not be removed from the child’s person during examinations. The most common treatment is prayer while sweeping the child’s body with a mixture of eggs, lemons, and bay leaves—a treatment called limpia in Mexico and barrida in Puerto Rico. This process is also used to diagnose mal de ojo.

Susto (soul loss). A disease that can attack anyone, regardless of gender, age, racial group, or economic status, believed to result from a series of overwhelming events that causes the soul to become dislodged and escape from the body. It is manifested by a number of clinically diagnosed diseases, including cancer, kidney failure, diabetes, and high blood pressure. The variety of symptoms and pathologies through which susto is manifested absolves patients and relatives of any "guilt" for failing to take timely precautions or seek treatment for the disease. A long time is usually said to elapse between the event or events and the physical manifestations of susto. Many Hispanics of both rural and urban backgrounds accept this theory, regardless of their culture of origin. 

Major Systems of Folk Healing Among Hispanic Populations

Curanderismo. A system of care derived from a mixture of Aztec, Spanish, spiritualistic, homeopathic, and modern medicine, curanderismo is used to treat physical, psychological, and social illnesses. Used throughout Latin America, it is more widely practiced by Mexican immigrants than by Puerto Rican, Cuban, and Caribbean immigrant groups. There is also considerable diversity in curanderismo according to regional culture.

Curanderismo shares many scientific concepts and procedures with modern scientific medicine, and health practitioners should be careful to not dismiss it as "quackery." In fact, because of the major role curanderismo plays in Hispanic health beliefs and practices, hospitals and clinics in metropolitan areas with large Hispanic populations are beginning to cooperate with curanderos—sometimes even placing them on hospital staff.

A practitioner is either a curandero (male) or a curandera (female), and may be a member of the patient’s nuclear or extended family. Sometimes the curandera is a señora or older woman who has developed a reputation for success in treating friends and family. Sometimes the curandero is a sovodor, a male who heals through massage (although this is less frequent in the United States than in Mexico). A partera or midwife is often used in Mexico (and less often by Mexican immigrants in the United States) because a woman is believed to have a better understanding of the female reproductive system than any man, including a "scientific" physician.

Santero or brujería. A structured system of healing magic that originated in what is now Nigeria. When brought to Puerto Rico, Cuba, and Brazil by African slaves, who were later converted to Catholicism, santero became fused with the Catholic system of saints and imagery.

The santero, a religious healer or "spiritualist," performs religious or magical ceremonies, administers potions, and prepares amulets. In Spanish Harlem in New York, parts of Florida, and others areas heavily populated by Puerto Ricans, Cubans, or people from the Caribbean, santeros often practice espiritismo in storefronts, basements, homes, and similar locations. People can also purchase herbs, potions, and charms at a botanica without consulting a healer.

Estimates vary as to the extent to which folk healers and cures are used in the United States, ranging from a low estimate of 4 percent of Hispanics nationwide to a high of 73 percent in a survey of mental health patients at a Los Angeles clinic. As a general rule, providers may assume that Hispanic patients who come to them after having delayed seeking health care for an inordinate length of time may have unsuccessfully tried a folk healing system first. On the other hand, patients who disappear after receiving a negative prognosis or failing to experience an immediate cure may have left the health care system for some form of folk healing. Often, however, they return so late that successful treatment is no longer possible.

Sources for Further Reading

Bullough, B., and V. Bullough. Poverty, Ethnic Identity, and Healthcare. New York: Appleton Century Crofts, 1972.

Caudle, Patricia. "Providing Culturally Sensitive Healthcare to Hispanic Clients." Nurse Practitioner, 18(12), 1993, 40, 43–46, 50–51.

Chisney, A., et al. "Mexican American Folk Medicine: Implications for the Family Physician." Journal of Family Practice, 2(4), 1980, 567–570.

Harwood, Alan. "The Hot-Cold Theory of Disease: Implications for Treatment of Puerto Rican Patients." Journal of the American Medical Association, 216(7), 1971, 1153–1158.

Koss-Chioino, Joan D., and Jose M. Canive. "The Interaction of Popular & Clinical Diagnostic Labeling: The Case of Embrujado." Medical Anthropology, 15, 1993, 171–188.

Logan, Michael H. "New Lines of Inquiry on the Illness of Susto." Medical Anthropology, 15, 1993, 189–200.

Maduro, Renaldo. "Curanderismo and Latino Views of Disease and Curing." Western Journal of Medicine, 139, December 1983, 868–874.

National Coalition of Hispanic Health and Human Service Organizations (COSSMOS). Delivering Preventive Health Care to Hispanics. Washington, D.C., 1990.

Spector, Rachel E. "Health and Illness in the Hispanic-American Community," in Cultural Diversity in Health and Illness. 3rd ed. New Jersey: Appleton & Lange, 1991.

v Health Culture Sketch

Among Hispanics who immigrate to the United States, a large proportion are from Mexico, Puerto Rico, and Cuba. Therefore, a sizeable set of data and research on the health status of these groups is available. However, an increasing number of Hispanic immigrants are emigrating from Central America, including Guatemala and El Salvador, as well as South America. Data still remains relatively scarce on these growing subgroups.

In 1999, Hispanic women of all descents made up 11.2% of the U.S. female population (DHHS, 2000). Latinas, particularly Mexican Latinas, have the highest fertility rates of all ethnic/racial groups in the United States (Giachello, 1994). Fourteen percent of live births to all women in the U.S. in 1990, were to Hispanic women, and of those, 65% were to Mexicans, and 14% were to Central and South Americans (Giachello, 1994).

Geographic Distribution in U.S.

Latin Americans consist of people from the Caribbean, Central America, and North and South America. According to the U.S. Bureau of the Census, in 1997, Latin Americans made up 50.7% of the total foreign-born population of the United States (U.S. Bureau of the Census, 1999). In 1999, of all Latin Americans in the U.S., 35.5% were foreign-born (U.S. Bureau of the Census, 2000). The South had the highest percent distribution of foreign-born Latin Americans; 61.4% of the total foreign-born population in the South were Latin American. In that region of the U.S., the two states of common Latino settlement were Florida (72.5% of the total foreign-born residing in Florida were Latino), and Texas (75.9% of the total foreign-born residing in Texas were Latino).

The West had the second highest percent distribution of Latin Americans; 53.3% of the total foreign-born population in the West were Hispanic (U.S. Bureau of the Census, 1999). In that region, California had a significant percentage of Latin Americans among its foreign-born (54.0%) (U.S. Bureau of the Census, 1999).

Mexico is the country in Latin America that contributed the single greatest number of immigrants. In 1997, over half of all Latin American immigrants were from Mexico (7 out of 13 million) (U.S. Bureau of the Census, 1999).

New Latino immigrants commonly settle in certain areas of the United States, depending on their specific country of origin (Kramer, Tracy, & Ivey, 1999). For example:

• Colombia: NY, FL, NJ

• Cuba: FL

• Dominican Republic: NY

• El Salvador: CA

• Guatemala: CA

• Mexico: CA, TX, IL 

General Characteristics

Latinas, particularly Mexican Latinas, have the highest fertility rates of all ethnic/racial groups in the United States. Fourteen percent of live births to all women in the U.S. in 1990 were to Hispanic women. Of those, 65% were to Mexicans and 14% were to Central and South Americans (Giachello, 1994). On average, Latinas are younger than non-Hispanic women at the age of first pregnancy and have more children (Juarbe, 1995; Taylor, Ko, & Pan, 1999). This can be attributed to cultural norms of early marriage and childbirth. In fact, motherhood is so central to being a woman in Latin American culture that few women even question whether or not they are going to have children. Knowledge of this cultural norm can be particularly helpful for health care providers when approaching family planning issues.

Hispanics are highly traditional in their health practices. They are commonly distrustful of physicians and of modern medical practices and technology. For example, thirty-three percent of Latinos (versus 24% of the total U.S. population) believe home remedies are more effective at treating illness than prescribed medications (Molina, Zambrana, & Aguirre-Molina, 1994). This can stem from their traditional health beliefs, but may also be amplified by dissatisfaction with the services and approach of various American health care providers. Educational levels have also been shown to have an effect on health status, utilization of health services, use of traditional medicine, and the belief in the effectiveness of folk remedies. In 1990, Latina mothers were less likely to have completed 12 or more years of education (46%) than white (85%) and African-American mothers (70%) (Giachello, 1994). Among Latinos, the less educated and foreign-born are more likely to consult folk medicine practitioners, although this may be the case across many cultures and ethnicities (Molina, Zambrana, & Aguirre-Molina, 1994). However, Hispanics often use home remedies and folk health practices in conjunction with modern medicine. Therefore, HCPs should recognize that these patients do in fact understand the need for modern medicine. As long as these folk health practices are not contradictory to other treatment, there is no need to discourage Latino patients from using them. In fact, by integrating these home remedies into biomedical treatment, the HCP can build the confidence of the patient, which in turn can increase patient compliance with a treatment plan.

Latino immigrants are commonly unfamiliar with the system of referrals to specialists that is widespread in the United States. They are accustomed to going directly to the kind of doctor that deals with their particular ailment rather than first to a "primary care physician." Most Latin American countries also do not require prescriptions for most medications, including contraception and antibiotics. Thus, these concepts inherent in the American health care system are often foreign to the new Latino immigrant and may therefore impact how they utilize health care services in the U.S. For example, if a Hispanic immigrant has limited financial resources, she may not have the money to go to the doctor just to get a prescription for oral contraceptives. If she was using this method of birth control in her home country, where she could easily obtain it over-the-counter, she may be reluctant to change methods and, as a result, may discontinue birth control altogether. 

Health Care Decision-Making

Hispanic culture is based on strong familial ties and interdependency among members of a family. It is not uncommon for a home to include extended family members. These individuals are seen as an integral part of the close family experience. Decision-making regarding health care is often done as a family. It is therefore important for health care providers to consult and encourage opinions made by family members during the consultation and throughout the patient’s care. However, although there is a strong family focus regarding health care decisions, there is still a traditional gender influence. For example, compliance with the health care provider’s recommendations is strengthened if the man of the house feels that he is playing a primary role in "restoring or maintaining the health of his offspring or wife" (Molina, Zambrana, & Aguirre-Molina, 1994).

Decisions about contraception and abortion are felt to belong primarily to the woman in Hispanic culture (Amaro, 1988; Taylor, Ko, & Pan, 1999). However, as in all cultures, the men have their own opinions about the couple’s use of contraception and can have a strong influence on actual contraceptive practices. In Latino culture, which is often male-dominated, some men may avoid use of contraception since bearing several children is often seen as a sign of a man’s virility and machismo (Ortiz & Casas, 1990; Unger & Molina, 2000; Wiest, 1993). This may make it difficult for a Latina to negotiate contraceptive use with her partner.