Quality Health Services for Hispanics: About Hispanics

HRSA - U.S Department of Health and Human Services, Health Resources and Service Administration

Quality Health Services for Hispanics: The Cultural Competency Component

II. About Hispanics
Understanding the role of Hispanic migration patterns, historical genetic/biological factors, and health status

For Hispanics in the United States, history is a confluence of national and social narratives that have only recently merged into a powerful river of common understanding.

An historical perspective may be an important precursor to understanding the health status of Hispanics. Understanding the migration patterns and other environmental critical events provides perspective to genetic/biological/environmental interaction and helps to clarify potential health behaviors. Current theory states that major demographic events (population migration, bottlenecks, and expansions) leave imprints in the form of altered gene frequencies on the collective human genome.²⁴

An historical perspective may be an important precursor to understanding the health status of Hispanics.

The majority of U.S. Hispanics have a shared pre-colonization American history that reflects a relatively healthy group even though there are high risk factors for some diseases and a low propensity for certain others.²⁵ To some extent, the heterogenous genetic characteristics of Hispanics have been shaped by a number of founder effects, such as migration and invasion by Europeans. Socially and culturally, the majority of Hispanics have a shared historical genetic family located in all of the Americas — North, Central, and South.²⁶

History of migration patterns and critical events may differentiate one group from another in addressing health status, health behaviors, and health beliefs.²⁷

The majority of Hispanics have a shared...historical genetic family located in all of the Americas...

II. About Hispanics Chapter Five: History of Hispanics in the United States

Or why the City by the Bay is not called Saint Francis

Perhaps the health status of Hispanics needs to be further explored from it's own migration patterns, the Americas. As the history of Hispanics is examined in the rest of the chapter, contemplate the critical events before colonization.

In 1453, Constantinople fell to the Ottoman Turks, cutting off Europe's silk and spice trade with India and Asia. Thirty-nine years later an Italian named Christoforo Colombo (Cristobal Colón in Spanish), or Christopher Columbus, sailing west for the Queen of Spain, first reached the New World thinking he had found a new route to the orient.²⁸ His first landfalls included Juana (Cuba) and the island of Hispaniola (the Dominican Republic and Haiti) whose natural wonders so amazed him he declared his eyes, "would never tire of beholding so much beauty, and the songs of the birds large and small."²⁹

Having recorded their first impressions of North America's natural wonders, the early discoverers quickly set about in search of gold and other objects of value. The Conquistadors were committed to expansion of the Spanish empire and recovery of treasure for the crown. Spanish Catholic missions soon followed with the goal of winning new religious converts. Colonial administrators began spreading Spanish culture from Mexico across Central and South America.

Spanish settlement of North America came early and included the first permanent European settlement of the New World at St. Augustine, Florida in 1565. In 1598, Don Juan de Oñate colonized New Mexico.

Yet almost all Hispanic immigration to the United States may be linked not only to the economic opportunities that would attract European and Asian immigrants, but also to U.S. military actions linked to policies of Manifest Destiny (that declared the United States' "God-given right" to all North American territory) and the Monroe Doctrine (which declared United States hegemony over Mexico, Central, and South America and warned European powers not to intervene there). From the Spanish American War that brought Cuba and Puerto Rico under U.S. administration in 1898, to various invasions of the Dominican Republic, Nicaragua, Honduras and other parts of Central America, waves of immigration followed on war, rebellion, and occupation. This process has continued as recently as the 1980s, when large numbers of Guatemalans, Nicaraguans, and Salvadorans fled to the United States to escape civil wars.

Spanish settlement of North America came early... St. Augustine, Florida in 1565. In 1598 Don Juan de Oñate colonized New Mexico.

...Hispanic immigration to the United States may be linked not only to the economic opportunities that would attract European and Asian immigrants, but also to U.S. military actions...

Mexican Americans: "So far from God, so close to the United States," has been a proverb in Mexico for generations, reflecting the often turbulent relationship between the two nations. Continuing through the 1800’s Spain extended its dominance across California and the Southwest. Eventually the goal of the church to convert the indigenous inhabitants would lead to conversions and intermarriage and the survival of large numbers of mestizo, or mixed blood people. Today the California mission system lives on in the names of its early settlements that evolved into towns and cities: San Diego, Los Angeles, Santa Barbara, San Luis Obispo, Monterey, San Jose, and San Francisco.

For Mexicans living in the areas annexed by the Treaty, the border had crossed them adding new language and cultural obstacles that still exist today.

Today, Mexicans and Mexican Americans make up over 57% of the U.S. Hispanic population....

In 1821, Mexico fought to win its independence from Spain. Mexico lost half its northern territory to the United States following the Mexican American war through the Treaty of Guadalupe Hidalgo. For Mexicans living in the areas annexed by the Treaty, the border had crossed them adding new language and cultural obstacles that still exist today.

With close family and community ties remaining on both sides of the frontier, Mexican migration to and from the United States has continued largely uninterrupted since the Treaty of Guadalupe Hidalgo. Today, Mexicans and Mexican Americans make up over 57% of the U.S. Hispanic population and include at least two million seasonal migratory workers who spend part of the year in the United States and part in their native Mexico.³⁰

Puerto Ricans: The second largest Hispanic group (about 20%) in the United States with some 3 million people living on the U.S. mainland and 3.2 million more living on the island.³¹ Borinquen (the indigenous name for Puerto Rico) was discovered by Columbus in 1492 and conquered by Juan Ponce de Leon in 1508. The Taino and Arawak Indians who lived there were quickly killed off through violence, starvation, and forced labor. Yoruba African slaves were then brought to the island to work the sugar cane fields. They eventually won their freedom, intermarried, and incorporated their culture and beliefs into the island life.

In 1815, a second wave of Spanish settlers known as the 'Real Cedula de Gracias' were encouraged to emigrate to Puerto Rico in order to "whiten" its population. Instead, by defining themselves as a new elite, they exacerbated tensions between islanders and their colonial administrators. In 1897 Puerto Rican nationalists declared themselves independent from Spain. A year later, United States forces landed in Puerto Rico, Cuba, and the Philippines during the Spanish-American War. But unlike in Cuba and the Philippines, the United States never gave up its claim on Puerto Rico. In 1917, Puerto Ricans were made United States Citizens under the Jones Act and eligible males were required to enlist in the military. In 1952, Puerto Rico was declared a Commonwealth of the United States, although from within the island there continues to be movements for statehood and independence.

In 1917, Puerto Ricans were made United States Citizens under the Jones Act and eligible males were required to enlist in the military.

Economic underdevelopment on the island, along with the United States' expanding post-war industrial base, and job opportunities led to the migration of close to a million Puerto Ricans to the mainland between 1945 and 1965. Large Puerto Rican communities were established in New York, other parts of the Northeast, and Chicago.

Half a century later people on the mainland continue to maintain close links with their families at home through the Puerto Rican "air bridge," of regular flights between the mainland and Puerto Rico. At the same time the cultural, political, medical, and social needs of Puerto Ricans on the mainland and on the island have tended to diverge over time, although key social agencies like New York's Puerto Rican Family Institute try to bridge that gap by maintaining service centers in both locales.

Cuban Americans comprise about 4% of the Hispanic population in the United States.

Cuban Americans: Cuban Americans comprise about 4% of the Hispanic population in the United States.³² Even though they have the highest level of education and income of any Hispanic group, the median income of Cuban Americans is nevertheless 25% less than that of non-Hispanic whites. Cuba, only 90 miles from Key West, Florida was visited by Columbus in 1492 and colonized by Spain in 1511, during which all the native people were killed.

The largest island in the West Indies, Cuba, and its capitol port Havana, became a major shipping and transportation hub, as well as a key to the trade in rum, sugar, cod, and slaves. It's population was also a mix of European settlers and African slave laborers. Even before the Spanish-American War of 1898, Cubans began emigrating to the U.S..

In 1902, four years after annexing Cuba in the Spanish-American War, the U.S. granted it independence. However, the U.S. maintained a major influence in Cuba over the next fifty years as it became a popular resort destination.

The Cuban Revolution of 1959 that overthrew the regime of Fulgencio Batista and brought Fidel Castro to power drove close to half a million upper and middle-class refugees to south Florida. Later, waves of immigrants from the communist island, such as the "Marielitos" of 1980, included less-skilled people along with some criminals and mentally ill people, released from Castro's jails and asylums.

Central Americans: Since its early settlement, Central America has had a history of turmoil. The economies of Central American countries tend to be unstable because of their dependence on a few agricultural export crops such as coffee, sugar, bananas, and cotton owned by a very small segment of society. Because of the political and economic struggles that the nations of this region have endured, many Central Americans have immigrated to the United States, often in search of refuge from violence and economic instability created by civil wars and other conflicts.

Central Americans have settled in different parts of the country. Salvadorans have settled mainly in Los Angeles and Washington D.C.; Guatemalans in Los Angeles, San Francisco, and Houston; and Nicaraguans in San Francisco and Miami. Many suffer from post traumatic stress problems, relating to their countries' civil wars.

Dominicans: Discovered by Columbus in 1492, the island of Hispaniola later divided following a slave rebellion and the establishment of the independent nation of Haiti. The remaining eastern two-thirds of the island would eventually become the Dominican Republic, a predominantly agricultural Spanish-speaking nation with thick rain forests and spectacular mountain

The Cuban Revolution of 1959 that...brought Fidel Castro to power drove some half million upper and middle-class refugees to south Florida.

... over half a million Dominicans and their descendants have settled in the United States, with 70% of them located in New York City and adjacent parts of New Jersey.

Although there are various reasons for South American immigration to the United States, two key causes include political instability in certain instances and the search for economic opportunity or prosperity in others.

ranges. Since the U.S. invasion of the Dominican Republic in 1965, during a period of civil unrest, over half a million Dominicans and their descendants have settled in the United States, with 70% of them located in New York City and adjacent parts of New Jersey.

South Americans: Several hundred thousand Colombians have also settled in the U.S., mainly in Florida and New York. Smaller numbers of Hispanics have come to the United States from Venezuela, Ecuador, and other Latin American nations. Although there are various reasons for South American immigration to the United States, two key causes include political instability in certain instances and the search for economic opportunity or prosperity in others.

From a psychosocial perspective the history of Hispanics in the United States clearly indicates that in dealing with Hispanic populations in a medical or social service context, one must recognize the tremendous range of historical experiences that exists among the various sub-groups. Each nationality has its own historical perspective that affect how they view themselves within the context of living in the United States and how the U.S. has treated them. In fact, differences among subgroups may be related to how they entered the U.S., i.e., as legal immigrants, legal refugees, undocumented workers, or as a result of war.

II. About Hispanics Chapter Six: Hispanic Health Status

Understanding the unique and unexpected Health Profile of the Hispanic patient population you serve.

To date, the health profile of Hispanics has not been fully available. The lack of information is primarily due to the historical lack of Hispanic and Hispanic subgroup identifiers in major data sets, including the census, mortality, medical records, the National Health Interview Survey, and many others. Many national data sets added Hispanic identifiers by 1995. By 1996, all States has added Hispanic identifiers to mortality data. Still today, Hispanic identifiers are absent from medical records and many state disease/disorder registries. Without this information, it is difficult to know the complete profile of Hispanic health. Prior to 1995, the historical racial/ethnic classifications often appeared as white and nonwhite which masked relevant information. The transition to the categories of "white", "black", and "others" continued to camouflage pertinent health information about Hispanics. This labeling also contributed to the notion that minority meant black because the populations clustered into "others" were fairly invisible due to the fact that the information was meaningless. Recognition marks a struggle for Hispanics to achieve official Government recognition. This recognition uniquely identifies Hispanic health issues, clearly depicts an Hispanic health profile and mandates a visible presence in minority populations.		To date, the health profile of Hispanics has not been fully available....primarily due to the historical lack of Hispanic and Hispanic subgroup identifiers in major data sets
Another issue which seems to confound the collection of Hispanic information is the misclassification of race/ethnicity. When race/ethnicity is not self-identified, up to one-third of data misclassification has occurred mostly due to the heterogenous phenotypes of the Hispanic population. All Hispanics do not look alike. Some misclassification occurs when those who are asked to self-identify are presented with "white," "African American," and "Hispanic" options. Many Hispanic ethnic groups identify with their heritage or country of origin, such as Mexican, Cuban, Salvadoran, Chilean, etc.		... Another issue which seems to confound the collection of Hispanic information is the misclassifiction of race/ethnicity.

Today in the U.S., Hispanic is considered an ethnicity with any racial background.

Today in the U.S., Hispanic is considered an ethnicity with any racial background. Each racial category can be associated with a specific migration pattern and representative of clusters of the population with a higher prevalence of a particular disease. White is associated with European descent and migration patterns. Black is associated with African descent and migration patterns. Asians have Asian descent and migration patterns – likewise for American Indians, Alaska Natives, Pacific Islanders and Native Hawaiians.

...Hispanic is a U.S. government created term....this labeling has to be both learned and accepted as an identity for those it is attempting to identify.

As noted in Chapter 1, Hispanic is a U.S. government created term; thus, this labeling has to be both learned and accepted as an identity for those who it is attempting to identify. Recognition of the misclassifications has facilitated the Government to partner with Hispanics to reduce mistakes by adding the word "Latino" and asking "Are you Hispanic/Latino?" before asking the race question. However, errors continue because many Hispanics see themselves as a race, not just an ethnicity. In this country, Hispanics are not white nor black in their psychosocial and cultural presentation and treatment.

As science tries to unravel the answer as to whether precursors of disease within kinships are due to some genetic/biological factors or some nonrandom force, the current social labeling of race may confound the answer. As mobilization and diversity of the U.S. population increase, understanding cluster variants and changes in mixed migration patterns will provide insight to engineering and improving the health status of Hispanics and all humans. This understanding will enhance culturally competent services.

An examination of the classification/misclassification is based on the hypothesis that each sequence variant that confers disease susceptibility must have arisen in a particular individual at some time in the past and must have been inherited by his or her descendants to create a disease — associated polymorphism prevalent in a population.³³ The cluster could then be examined for the genetic/biological mutations that result from invasion, expansion, and filtration of different migration patterns such as the Spaniards (Europeans) conquering of Mexico's indigenous (Americas).

If this avenue of culturally competent research is pursued, science may be better able to determine whether the pattern and magnitude of phenotypic variation are consistent with random evolutionary forces or whether a more complex explanation is required.

To fully present an Hispanic health profile, specific or targeted research is needed to augment the national depiction. Yet, there is little to no information which details Hispanic health information and treatment outcomes. For example, there is no information on cancer treatment outcomes for Hispanic women with breast cancer; on theoretical models for health behavior changes; on effective community-based alcohol interventions; on pharmacological treatments; etc. The list of inadequate information is exhaustive and can be experienced by each literature search in any area or field.

...there is little to no information which details Hispanic health information and treatment outcomes.

As a result of inadequate national data and specific information, it is difficult to fully determine Hispanic health status and profile. The most recent changes indicate potential shifts in current knowledge. For example, SEER (the National Cancer Institute’s Surveillance Epidemiology and End Results project) expansion in 1995 repositioned Hispanic children with brain cancer from third to first. It is likely that similar shifts will be presented as other data are analyzed and reported.

Due to the lack of information, cultural competence should be practiced by not identifying any one group as having a lesser or greater health status than another.

This incomplete determination of health status makes it difficult to assess the burden of disease and disorders on Hispanics or in comparison to other groups. Due to the lack of information, cultural competence should be practiced by not identifying any one group as having a lesser or greater health status than another. Cultural competence should also be practiced in interpreting data given the fact that Hispanics are often classified as white or black; yet, neither the white or black body of information is fully applicable to Hispanics. There are language, psychosocial, cultural, and biological/genetic differences that confound the application of white and black prevention, intervention, and treatment models and may not have the same internal and external validity. For instance, in genetic research, the Genome project has identified a marker for diabetes in Mexicans. This marker does not appear in non-Mexican whites or Japanese. As more information unravels, Hispanic health status will be clarified.

The Genome project, a major Federal initiative to map genetic components, has declared that genetic factors contribute to virtually every human disease, conferring susceptibility or resistance, or influencing interaction with the environment.³⁴ The Genome project also has determined that racial/ethnic groups are more alike than different.³⁵ However, clusters of the population, often proxied by race/ethnicity, may have a greater prevalence of a particular genetic marker or set of markers (codes for disease).³⁶ Examples include diabetes in Mexicans and Pima Indians, sickle cell anemia in blacks, and Tay Sachs in Jews.

While one cannot be expected to memorize all the data that is provided in this chapter, there are three key points worth remembering in dealing with the issue of Hispanic health status:

Key Facts

Hispanics have lower mortality rates than the overall population but are at greater risk for number of chronic illnesses and diseases. Mortality is not a good measure for this population.

Hispanic populations exhibit a number of positive health indicators in terms of diet; low levels of smoking and illicit drug use; and a strong family structure. However the longer each generation has been in this county these positive indicators tend to deteriorate. Positive aspects of traditional cultures need to be reinforced.

There is similarity, as well as, variability among Hispanic subgroups.

Mortality is not a good measure for the population.

Positive aspects of traditional cultures need to be reinforced.

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 the positive health factors and lead to the adoption of negative ones from U.S. culture (such as smoking, alcohol use, and early sexual activity).

When politicians and policy-makers address topics such as "black and minority health," they're usually referring only to issues and statistics dealing with African-American health profiles and then extrapolating from these, even though Hispanics, with their unique health needs, made up 12% of the population in 1998.³⁷

Unfortunately acculturation among new immigrants and their children seems to weaken the positive health factors and lead to the adoption of negative ones from U.S. culture.

...until 1989, the National Model Death Certificate did not have an Hispanic identifier. As data became more available an Hispanic health profile emerged which ran counter to....the “Minority” health model....

The major reason for this distortion, is that until 1989 the National Model Death Certificate did not have an Hispanic identifier. This prevented the emergence of an authentic Hispanic health profile. As data became more available, an Hispanic health profile emerged which ran counter to the prevailing models of health. The “Minority” health model did not explain the state of Hispanic Health.

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 than white Americans, Hispanics live longer than whites.

Despite having a lower income than white Americans, Hispanics live longer than whites. Hispanics have an average life-expectancy of 75.1 years for men and 82.6 years for women.³⁸ 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. Of course many of these morbidity factors also play a significant role in Hispanic mortality rates.

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

Heart disease
Malignant neoplasms,
Accidents and adverse effects,
Human immunodeficiency virus infection (HIV),
Homicide and legal intervention,
Cerebrovascular diseases,
Diabetes mellitus,
Chronic liver disease and cirrhosis,
Pneumonia and influenza,
Certain conditions originating in the prenatal period.³⁹

Key Concept

Top Ten leading causes of death for Hispanics of all age groups.

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 43% of deaths, whereas they accounted for 59% of all deaths among non-Hispanic whites in 1992.⁴⁰

The top two leading causes of death are the same for the Hispanic and for the non-Hispanic white population: heart disease and cancer.

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 26.3 years, compared to 36.6 years for the non-Hispanic white population.⁴¹ 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 and female child birth.

Within broad age categories the leading causes of mortality are similar. However, some differences still exist.

Homicide and legal intervention consistently ranks higher for Hispanics than for non-Hispanic whites for all age groups between 15–24 years and 45–64 years.
HIV infection for Hispanics aged 1–64 years ranks consistently higher than for non-Hispanic whites.
Diabetes mellitus and chronic liver disease and cirrhosis also rank higher for Hispanic populations aged 45–64 and 65 years and over than for non-Hispanic whites of the same age groups.⁴²

The following sections provide some current known and unknown information about incidence and risk factors for disease. Much more information is needed to fully determine the health status of Hispanics.

Smoking

While Hispanic adults have the lowest rates of smoking, Hispanic eighth graders now have the highest rates of smoking among all their peers

The relationship between smoking and various cancers, heart disease, and respiratory disorders has been well and clearly established. Lung cancer remains the number one cause of death due to carcinomas in both men and women. 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.⁴³

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 51.1% of Hispanic eighth graders had smoked within the previous 30 days compared to 42.1% of non-Hispanic blacks and 49.7% of non-Hispanic whites.⁴⁴

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 good nutrition.⁴⁵

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.

The Hispanic diet is high in fiber, relies on vegetable rather than animal proteins, and includes few dairy products and leafy green vegetables.

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.⁴⁶

Reflecting differences among Hispanic sub-groups, there are findings of both positive and negative nutritional indicators for Hispanic children. While mean iron intakes of Cuban American and Puerto Rican children meet the recommended level for iron, Mexican American infants are below the recommended level. While Hispanics consume less than five fruits and vegetables per day, the intake of chili peppers and tomatoes provide much needed antioxidants. 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.⁴⁷

Although Hispanic women are regarded as coming from a breast-feeding culture, their nursing rates begin to decline as they acculturate to the United States.

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 breast-feeding 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, has also led to a steady decline in breast-feeding in these areas.⁴⁸

... cholesterol levels are lower for Hispanics than those reported for non-Hispanic whites and non-Hispanic blacks.

Cholesterol

Linked to diet and nutrition, cholesterol levels are lower for Hispanics than 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.

Mexican American men are more likely than non-Hispanic white adults to have high serum cholesterol levels. However, Mexican American women are somewhat less likely than non-Hispanic black women and slightly more likely than non-Hispanic white women to have high serum cholesterol levels.⁴⁹

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.

... as Hispanic immigrants and other groups adapt to the dominant culture's diet their serum cholesterol levels begin to rise.

Weight and Exercise

It is estimated that approximately one-third of all adults in the United States are overweight with a greater prevalence among Hispanics. Overweight percentages (based on white standards of body composition) for Mexican American males (39.5%) are higher than for non-Hispanic whites (32.1%) and non-Hispanic blacks (31.5%). A greater percentage of Mexican American females (47.9%) are overweight than non-Hispanic white females (32.4%) but less than non-Hispanic black females (49.5%).⁵⁰

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"). While there is a woeful lack of data on Hispanic populations and exercise, researchers report that men are more likely than women to participate in physical activity and non-Hispanic whites more likely than other ethnic groups. 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.⁵¹

While many Hispanics work in occupations requiring heavy manual labor, many of these activities do not contribute to aerobic fitness

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.

According to SAMHSA's Prevalence of Substance Use Among Racial and Ethnic Subgroups, Hispanics vary markedly in their prevalence of substance abuse, alcohol dependence, and need for illicit drug abuse treatment. Relative to the total population, Mexicans and Puerto Ricans have high prevalence of illicit drug use, heavy alcohol use, alcohol dependence and need for illicit drug abuse treatment. In contrast, Caribbeans, Central Americans, and Cubans have low prevalence and South Americans and other Hispanics have prevalence similar to the total U.S. population.

A 1992 survey found Hispanic males are far more likely to have used alcohol (85.5%) than Hispanic females (67.4%). Hispanic males also report a higher percentage of heavy alcohol use in the past month (5.6%) than non-Hispanic whites (5.1%) or non-Hispanic blacks (4.5%).⁵² This is especially true for Mexican American males.

Alcohol appears to be the major drug of abuse among Hispanics.

Alcohol appears to be the major drug of abuse among Hispanics. Among high-school students, 55% of Hispanic males report current alcohol use compared to 51.1% of non-Hispanic whites and 48.2% of non-Hispanic black males. Additionally, 39.4% of Hispanic high-school males report episodic heavy drinking, the highest rate among any group. Hispanic females in high school are less likely than non-Hispanic whites but more likely than non-Hispanic blacks to report any alcohol use.⁵³

Most recent research, has demonstrated that drinking patterns and rates of alcohol-related problems often differ among Hispanic subgroups. According to the Hispanic Health and Nutrition Examination Survey, Mexican-Americans and Puerto Rican men have higher rates of heavy drinking than do Cuban-American men.⁵⁴ In the same survey, Mexican American women have higher rates of both abstinence and frequent heavy drinking than do Cuban-American and Puerto Rican women.

It has also been demonstrated in several studies that a higher level of acculturation is related to greater alcohol consumption, especially in relatively young Hispanic women.⁵⁵ The prevalence of alcohol dependence is higher among U.S. born Mexican-American women than among Puerto Rican and immigrant women.⁵⁶ Recent Cuban immigrants appear to have patterns of alcohol consumption and alcohol problems that resemble those of Mexican Americans and Puerto Ricans.⁵⁷ Acculturation also was positively associated with the total number of drinks that Cuban-American and Mexican-American women consumed and with the volume of alcohol that Mexican-American women consume per occasion.⁵⁸

...a higher level of acculturation is related to greater alcohol consumption, especially in relatively young Hispanic women.

Overall, only 29.2% of Hispanics report ever having used an illicit drug including marijuana in their lifetime, compared to 33.6% of non-Hispanic blacks and 37.7% of non-Hispanic whites. Hispanics are also less likely to report using illicit drugs during the past year (10.8%), compared to 11.3% of non-Hispanic whites and 11.5% of non-Hispanic blacks. However, the percentage of Hispanics reporting cocaine use within the past month (1.2%) is higher than that of non-Hispanic blacks (1%) and over twice as high as that of non-Hispanic whites (0.5%). Hispanics are less likely to have used crack cocaine in the past year (0.5%), than blacks (1.1%) but more likely than whites (0.3%). Inhalants represent a particular threat for Hispanic adolescents: 6.5% of Hispanics age 12–17 report they've used inhalants, compared to 6.2% of white youth and 3.1% of black youth.⁵⁹

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.

...Hispanic high-school students are more likely to have made at least one suicide attempt (13.4%), compared to their non-Hispanic black (8.9%) and non-Hispanic white (7.8%) peers.

Studies find that Hispanic high-school students are more likely to have made at least one suicide attempt (13.4%), compared to their non-Hispanic black (8.9%) and non-Hispanic white (7.8%) 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 (21%), than their non-Hispanic black (10.8%) or non-Hispanic white (10.4%) peers. Rates for female students are higher than for male students across all racial and ethnic categories.⁶⁰

Violence is another increasing challenge to the health and wellbeing of Hispanic youth. The percentage of deaths from homicide and legal intervention is almost five times greater for Hispanic adolescents and young adults (36.8%) than that of their non-Hispanic white peers (7.4%). Twenty-two percent of Hispanic high-school students now report they fear physical and violent attacks when going to and from school.⁶¹

Accidents are the third leading cause of death among Hispanics, accounting for 9% of all Hispanic deaths, but only the fifth leading cause among non-Hispanic whites at 4%. For children, accidents and adverse effects are the leading cause of death for all groups. For Hispanic children, the rate of accidental deaths (15.4 per 100,000 persons under the age of 14) is similar to that for non-Hispanic white children (15.1) and lower than that for non-Hispanic black children (23.6). When examining accidental death rates due to motor vehicle accidents, the death rate for Mexican American children (9.4) is higher than that for either white or black children.⁶² 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 greatly over-represented in the number of arrests for drunk driving.

Environment

In addition to lifestyle and behaviors, health status is signifi cantly 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 accord ing 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). Additionally, 18.5% of Hispanics are exposed to the nation's worst air pollution (as opposed to 9.2% of blacks and 6% of whites).⁶³ Studies indicate that Puerto Rican children are also more than three times as likely as non- Hispanic white children to suffer from active asthma.⁶⁴

When examining accidental death rates due to motor vehicle accidents, the death rate for Mexican American children (9.4) is higher than that for either white or black children.

...Hispanics in the United States, face the highest rates of exposure to pollution and toxic substances.

Hispanic children in Los Angeles have the highest rates of brain cancer and rising rates of leukemia. 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...is highly toxic to humans. Unfortunately it is sometimes used by Hispanics as a folk medicine or spiritual agent.		Mercury, commonly known as "quicksilver" or Azogue (in Spanish) is highly toxic to humans. Unfortunately it is sometimes used by Hispanics as a folk medicine or spiritual agent. Azogue is frequently sold in botanicas — small stores that carry religious and cultural products. Azogue is sold in 3–5 ounce capsules. 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.		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 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."

Farmworkers

Of the billion pounds of pesticides used annually in the United States 80% is used in agriculture. Hispanics comprise 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.

In urban areas, low- income Hispanics are more likely to rent older homes and apartments which may contain antiquated lead plumbing (and wall paint).

Hispanics comprise 71% of all seasonal agricultural workers and 95% of all migrant farmworkers.

..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.

Hispanics...are over represented in the electronics sector as laborers and assemblers, and in the oil and petrochemical industry.

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.⁶⁵ 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.

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; stress and mental health; and, tuberculosis. These are areas that could be of particular interest if you are a health care provider working with Hispanic patients.

AIDS and HIV

The Centers for Disease Control and Prevention (CDC) reported a cumulative total of 711,344 cases of AIDS in the United States by June 1999. Hispanics accounted for 18% (129,555) of the cumulative AIDS cases. In 1982, Hispanics represented 7% of the U.S. population; yet, accounted for 13% of all AIDS cases in that year. By December 1997, Latinos represented 12% of the total U.S. population; yet, accounted for 21% of the new AIDS cases.⁶⁶ HIV diagnoses increased 10% among Hispanics as observed in the most recent data available. At the same time, it decreased slightly among African Americans and among Whites.

The annual incidence rate of AIDS for Hispanic adults is 4 times that of non Hispanic white adults.

As of June 1999, there have been 22,936 AIDS cases among Latinas. Of that number, 41% of those cases are directly related to injecting drugs (9,399). Heterosexual contacts account for 47% of the cases (10,753). Within this heterosexual category, 5,031 Latinas became infected due to sexual contact with an injecting drug user. Disparities in health outcomes by race/ethnicity and gender show that AIDS incidence and deaths declined most dramatically for whites and least among women and people of color.

AIDS strikes Puerto Ricans the hardest, followed by Cubans, probably in part because Puerto Ricans and Cubans are concentrated in East Coast cities where AIDS has taken a high toll. Mexican Americans seem less affected by the epidemic. Overall, Hispanic men are nearly twice as likely as white non-Hispanic men to die from AIDS, and Hispanic women are nearly five times as likely to die from the disease as white non-Hispanic women. Factors that contribute to disparities in AIDS incidence and mortality among Hispanics, when compared to whites, include late identification of HIV infection, less access to experienced HIV/AIDS physicians, less access to HIV therapy that meets federal guidelines and lack of health care insurance to pay for drug therapies.

Cancer

Malignant neoplasms are the second leading cause of death in the United States among both Hispanics and non-Hispanic whites, although Hispanics have a slightly lower rate.

Malignant neoplasms are the second leading cause of death in the United States among both Hispanics and non-Hispanic whites, although Hispanics have a slightly lower rate. In terms of total numbers, of 520,578 deaths classified as due to malignant neoplasms: non-Hispanic whites accounted for 81.8%, non-Hispanic blacks for 11.2%, and Hispanics 2%.⁶⁷

Hispanics have a higher incidence of colorectal cancer, as well as cancer of the pancreas, cervix, prostate, and stomach, with twice the rate of cervical and stomach cancers than that found among non-Hispanic whites. Among Hispanic women rates of cervical cancer for Mexican American women and Puerto Rican women are more than twice as high as the incidence rates for non-Hispanic white women. However, the incidence rate for breast cancer among Mexican American women and Puerto Rican women is lower than that for white non-Hispanic women or non-Hispanic black women.⁶⁸

Prostate cancer in Hispanic males is the only group increasing in incidence.⁶⁹ Brain cancer of Hispanic children in Los Angeles moved from third to first in incidence.⁷⁰ Lung cancer is the leading cause of death of all cancers for both men and women. Despite lower incidence of breast cancer, Hispanic women have high mortality rates.

Coronary Heart Disease, Stroke, and Hypertension

Diseases of the heart were the leading cause of death among Hispanics in 1998.		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 (83.3 deaths per 100,000), than for whites (297.6) or blacks (237.3). 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.⁷¹
...Hispanics have a higher prevalence of conditions that increase their risk for coronary heart disease, including obesity and diabetes.		Cerebrovascular disease (stroke) is the sixth leading cause of death among Hispanics, accounting for 5% of all Hispanic deaths. It is the third leading cause of death among non-Hispanic whites, accounting for 6.7% of all deaths.⁷² Since hypertension, diabetes, and obesity are all 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 effect" prevalent in Hispanics, future research may be able to isolate and identify this mechanism, and use it to lower rates of cerebrovascular disease.
Hispanic men are more likely to have undiagnosed, untreated, or uncontrolled hypertension than the national average.		Hypertension affects 24.4% of Mexican American males and 22.9% of Mexican American females.⁷³ 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 suggested that race is a significant factor in hypertension: 9% of non-Black Hispanics were found to be hypertensive, compared to 12% of Black Hispanics.⁷⁴

Diabetes

Non-insulin dependent 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 shows that 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 45–74.⁷⁵

...Puerto Ricans and Mexican Americans, who are about twice as likely to be afflicted by it [diabetes] as non-Hispanic whites.

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 Pima Indian heritage.

Environmental Health

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.

The environmental health status of Hispanic communities is poor, and is a major source of health problems. Among their high risk exposures: ambient air pollution; worker exposure to chemicals in industry; pollution indoors; 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

Although rates of mental illness may be similar to whites, the prevalence of particular mental health problems, the manifestation of symptoms, and help-seeking behaviors within Hispanic subgroups need attention and further research. The prevalence of depressive symptomatology is higher in Hispanic women (46%) than men (19.6%); yet, the known risk factors do not totally explain the gender difference.⁷⁶ Acculturation appears to be a factor in depression as well. Duran found differences in depression in Hispanic women dependent on acculturation.⁷⁷

A recent report from the National Alliance for Hispanic Health focuses our concern on "The State of Hispanic Girls." The statistics are unsettling. One in three Hispanic girls has seriously considered suicide, the highest rate of any racial or ethnic group. The Commonwealth Fund survey shows a strong connection between depression among girls and participation in risky behaviors. Girls subject to depression or lacking in self confidence are twice as likely to report use of cigarettes, alcohol, and illicit drugs than their non-depressed peers. In addition, Cubans are less likely to die from treatable illnesses than other Hispanics, but they have the highest suicide rates, surpassing those of white non-Hispanics. The trauma of exile and family separation may explain the differences.

One in three Hispanic girls has seriously considered suicide, the highest rate of any racial or ethnic group.

There are several stressors related to social adjustment to the dominant culture which affect several generations of Hispanics. Al-Issa has defined three:

Acculturative Stress, which is most typically felt by immigrants who are faced with the turmoil of leaving their homeland and adapting to a new society.
Socioeconomic stress, which is often experienced by ethnic minorities who feel disempowered because of inadequate financial resources and limited social class standing.
Minority stress, which refers to the tensions that
minorities encounter resulting from racism.⁷⁸

Although some overlap exists among these stressors, they are conceptually distinct forces and often require specific coping strategies. Each stressor influences the quality of life and mental health of non-whites regardless of immigration status.

The concept of social adjustment stressors has historical roots in two theories: Durkheim's (1933) theory of anomie and Leighton's (1968) theory of mental illness and social disintegration.

...rapid cultural change causes a condition called anomie — the absence within a society of common social norms and controls...people lack clear behavioral guidelines, possibly resulting in destructive tendencies.

According to Durkheim's theory, rapid cultural change causes a condition called anomie — the absence within a society of common social norms and controls. Under those conditions, people lack clear behavioral guidelines, possibly resulting in destructive tendencies (e.g. depression and alcohol abuse). Leighton proposed that social disintegration and lack of social cohesion precipitate psychological distress and mental illness. He argued that rapid social change and disruptions (e.g. low and unstable income, conflict cultural values, and fragmented communication networks) cause high stress levels that can result in deviant behaviors and psychological disorders. Although most Hispanics in this country are born in the U.S., even prior to the border moving, the current minority status supports the existence of these social adjustment stressors.

Hispanics are identified as a high-risk group for mental health problems, particularly for depression, 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; 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 General Psychiatry published an article, which provided compelling data that Mexican born United States residents had less mental illness than Mexican Americans.⁷⁹ This was contrary to the years of myth that Hispanic immigrants would suffer more mental illness than Hispanics born in the United States 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.		...Mexican born U.S. residents had less mental illness than Mexican Americans.
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 antisocial 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.⁸⁰		...immigrant children who hold fast to their parents' ethnic communities may do better than those who assimilate rapidly...
John Hopkins 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.⁸¹		...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, ...

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

Among Hispanics TB is most prevalent in young adults, ages 25–44.

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. During this period, the number of cases of TB increased 26.8% among non-Hispanic blacks, 46.2% among Asian/Pacific Islanders, and 74.5% among Hispanics. The risk of contracting TB among Hispanics is more than four 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.⁸²

Conclusion:

It is crucial to assess 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 provided, as well as, to assure proper compliance with protocols by patients.