Module II

General Health Status of Hispanics

This module presents an overview of the health status of Hispanic subgroups in the United States. The general health status indicators selected for inclusion are: 1) general socioeconomic status measures; 2) access to health care; 3) infant mortality rates; 4) immunization coverage of children; 5) overall mortality, and 6) life expectancy.





Socioeconomic Status

Because health status is closely related to socioeconomic variables, it is important to begin a review of a population's health status with such variables as family income, family size, and living environment. The U.S. Census Bureau has prepared a summary of the characteristics of Hispanic populations in a report titled, "We the Hispanics".

Assignment: Click on "We the Hispanics" to call it up and review its contents. Then answer the following questions:

  1. What types of jobs are Hispanic males most likely to hold? What implications does their type of employment have for their overall income level and health insurance coverage?
  2. What proportion of Hispanic households were classified as living in poverty in 1990? How does this compare with the average for the nation?





Access to Health Care

Access to health care is most commonly measured in terms of insurance coverage and having a regular source of primary care. Treviño et al. (1991) analyzed the health care access data collected as part of the Hispanic Health and Nutrition Examination Survey conducted from 1982-1984 and the more recent 1989 Current Population Survey conducted by the Bureau of the Census.

Assignment: Review the distribution of type of medical coverage by ethnic group in the table tilted "1989 CPS Estimate of Health Insurance Coverage by Race/REthnic Group". This table was taken from the article by Treviño et al.
Answer the following questions:

  1. Which Hispanic subgroup is most likely to have private health insurance coverage?
  2. Which Hispanic subgroup is most likely to have no health insurance coverage of any kind?
  3. Which Hispanic subgroup is the least likely to have no medical insurance of any kind?
1989 CPS Estimate of Health Insurance Coverage by Race/Ethnic Group*
% Coverage
Insurance
Type		 Total
US		 White
Non-
Hispanic		 Black
Non-
Hispanic		 Mexican
American		 Puerto
Rican		 Cuban
American
Private 53.3 68.2 45.4 43.7 43.6 55.6
Medicare 10.8 12.5 7.0 2.9 3.0 10.0
Medicaid 8.3 5.0 23.3 13.7 32.5 11.9
Other
public		 4.2 4.2 4.6 2.9 4.5 2.3
Uninsured 13.4 10.2 19.7 36.9 15.5 20.3
*CPS indicates Current Population Survey

Source: Treviño, FM, Moyer M, Baldez, BV, Stroup- Benham, CA. Health insurance coverage and utilization of health services by Mexican Americans, mainland Puerto Ricans, and Cuban Americans. JAMA. 1991;265:233-237





Assignment: Review Figures 1 and 2 and answer the following questions:

  1. Are Hispanic groups with private health insurance more or less likely to report having a regular source of primary care than groups with public health insurance (Medicare, Medicaid, etc.)?
  2. From the Figure 2, do you conclude that being uninsured is a major determinant or whether or not Hispanic individuals report having a regular source of medical care?
  3. Do individuals with private health insurance see a physician more or less often than those with public health insurance?
  4. Does lack of health insurance appear to limit access to health care in the three Hispanic subgroups studied?


Figure 1: Percentage of Hispanic ethnic groups reporting no physician visit in the past year, by insurance type.






Figure 2: Percentage of Hispanic ethnic groups reporting a regular source of care, by insurance type.






*Analysis of data collected in the National Hispanic Nutrition and Examination Survey, 1983-1984).





INFANT MORTALITY

Infant mortality is one of the most commonly used indicators of a population's health status. Infant mortality refers to deaths occurring in children during the first year of life. The rate is defined as the number of deaths/1,000 live births. It can be broken down further into neonatal mortality (death in the first 27 days after birth) and post-neonatal mortality (death in the interval from 28 to 364 days after birth).

A detailed study of infant mortality risk in the three largest Hispanic subgroups in the U.S. (Mexican-Americans, Puerto Ricans, and Cubans) was carried out by Becerra et al. (1991). These investigators used linked birth and death certificates from the years 1983 and 1984 to determine the distribution of infant birth weights and the risk of neonatal, post-neonatal and infant mortality in three Hispanic subgroups compared to blacks and non- Hispanic whites in the U.S. The study was made possible by the inclusion of a maternal Hispanic identifier on birth and death certificates in 23 states and the District of Columbia. It is estimated that these states contain over 90% of the Hispanic population of the U.S. The authors also use linked birth and death certificates from the Commonwealth of Puerto Rico to provide a comparison between Puerto Ricans in the continental U.S. and in the Commonwealth.

Assignment: Review the table titled "Mortality Risks" and answer the following questions:

  1. In which Hispanic subgroup is the neonatal mortality risk the highest? In which one is the post- neonatal mortality risk the highest?
  2. Using the total risk column of the "Mortality Risks" table, calculate the following relative risks of infant mortality (recall from the Measurement of Health Status section of Module I, that the relative risk is a ratio of two risks):

  3. From these patterns of infant mortality risk, what generalizations can you make about infant mortality in Hispanics? Do you believe that socioeconomic factors account for the differences in risk reflected in the "Mortality Risks" Table?

Table 2: Mortality Risks

Race/Ethnicity Birth Weight (grams) Total
<1500 1500-2499 2500-3900 >4000
Neonatal
Non-Hispanics
Whites 353.9 22.8 1.6 1.3 5.2
Blacks 320.5 12.7 2.1 3.9 10.9*
Other# 340.9 19.5 1.8 1.6 6.1*
Hispanics** 333.1 19.6 1.6 1.9 5.6*
Mexicans 337.6 30.7 1.6 1.8 5.2
Puerto Ricans** 338.4 18.4 2.0 4.2 7.9*
Cubans 353.9 13.6 1.5 (1.7) 5.0
Other## 313.2 18.2 1.5 1.6 5.5
Puerto Rico 552.4 44.7 3.6 3.5 11.9*
Total 343.4 20.1 1.8 1.5 6.4
Post-neonatal
Non-Hispanics
Whites 64.5 12.1 2.5 1.6 3.1
Blacks 78.6 13.4 4.4 2.9 6.3*
Other# 72.8 11.0 3.3 2.4 4.0*
Hispanics** 64.1 10.2 2.5 1.4 3.1*
Mexicans 68.3 10.4 2.5 1.4 3.1
Puerto Ricans** 64.3 10.1 2.8 (1.7) 3.7*
Cubans (34.8) (6.9) 1.7 (0.9) 2.0*
Other## 56.0 10.1 2.3 1.5 3.0
Puerto Rico 81.5 8.9 2.2 1.7 3.0*
Total 69.9 12.2 2.8 1.7 3.6
Infant
Non-Hispanics
Whites 935.6 34.6 4.1 2.9 8.3
Blacks 388.9 25.9 6.5 6.7 17.2*
Other# 388.9 30.3 5.0 4.2 10.1*
Hispanics** 375.8 29.6 4.1 3.4 8.7*
Mexicans 382.8 30.8 4.1 3.2 8.3
Puerto Ricans** 380.9 28.4 4.8 5.9 11.6*
Cubans 376.4 20.3 3.2 (2.6) 7.0*
Other## 351.9 28.1 3.8 3.1 8.4
Puerto Rico 588.9 53.2 5.9 5.2 14.9*
Total 389.2 32.1 4.6 3.2 9.8
*Neonatal and infant mortality risks calculated per 1000 live births. Post-neonatal mortality risk calculated per 1000 neonatal survivors.

*Significantly different from risks for non- Hispanic whites (P<.05).

#Includes American Indians, Alaskan natives, Chinese, Japanese, Hawaiian, Filipino, and other races. Infants of unknown race/ethnicity also included.

**Excludes infants born in Puerto Rico (Puerto Rican islanders are reported as "Puerto Rico."

##Includes Central American, South American, and other Spanish ethnic origin.

Source: Becerra JE, Hogue CJR, Atrash H, Pérez N. Infant mortality among Hispanics.JAMA. 1991;265:217-221





IMMUNIZATION COVERAGE

The proportion of children in a population with up-to-date immunizations for childhood infectious diseases can serve as a health status indicator for two reasons: 1) it reflects the risk that children face for preventable, serious childhood infections, such as measles, diphtheria, and polio; 2) it reflects the availability of accessible, affordable health care for children in the population. There is no national monitoring system in the U.S. to track immunization coverage, although the design of such a system is presently being discussed by public health agencies. Thus, information on vaccination coverage must be derived from a variety of special surveys that used different methodologies to study immunization rates.

The Centers for Disease Control and Prevention (CDCP) conducted a survey of immunization records of children entering kindergarten in 1991-92 in 18 of the largest urban areas in the U.S. and three counties. The immunization records were classified as being "up-to-date" if the child had received the recommended doses of vaccines by 24 months of age (4 diphtheria/tetanus/ pertussis (DPT) doses, 3 oral polio (OPV), and 1 measles/mumps/rubella (MMR)). The records were classified as "age appropriate" if the doses had been administered within 30 days of the recommended age of delivery for each dose. The results of survey are shown in Figure 3.

Assignment: Review Figure 3 and answer the following questions.

  1. What are the lowest proportions of immunization coverage found in the survey? In what community were the lowest levels found?
  2. How many of the communities surveyed have large Hispanic populations?
The relationship between ethnic group identification and delayed receipt of the MMR vaccine at 15 months of age was evaluated in a study of immunization coverage among members of the Kaiser-Permanente Medical Care Program, a large California health maintenance organization (Lieu et al, 1994). Since the subjects in this study had access to low-cost health care, predictors of delayed immunization that were independent of financial considerations could be studied. Overall, the 15-month MMR vaccine was delayed more than 30 days in 29% of children. In a multivariate analysis that controlled for several predictors (Table 3) neither Hispanic or Black ethnicity was independently related to delayed immunizations. However, the number of children in the family, the parent not knowing when the next shot was due, and the parent reporting not having a regular doctor, all increased the likelihood of delayed immunization.

Figure 3: Proportion of children age-appropriately immunized (red bars) and up-to-date (blue-bars) at 24 mounths of age with any dose of the 4:3:1 vaccination series, selected sites, United States, 1991-1992.

source: Zell ER, Dietz V, Stevenson J, Cochi S, Bruce R. Low vaccination levels on US preschool and school-age childern.
JAMA. 1994;271:833-839.






Table 3. Logistic Regression Analysis of Predictors of a Delay of 90 Days or More in Measles-Mumps-Rubella Immunization: Northern California Kaiswer Permanente Medical Care Program, 1992

Adjusted
Odds Ratio		 95%
Confidence Interval		 p
Black race 2.0 0.9, 4.3 NS
Asian race 1.6 0.8, 3.3 NS
Latino race/ethnicity 1.1 0.5, 3.4 NS
Number of children in family 1.4 1.1, 1.8 .007
How far in advance previous appointment was made* 0.7 0.5, 1.0 NS
No regular doctor by parent's report 2.9 1.0, 8.6 0.5
Didn't know when next shot was due 2.0 1.2, 3.5 .01
Amount parent worries about risks of shots** 0.7 0.6, 0.8 .03
*Ordinal variable. 1=less than 1 month, 2=1 to 2 months, 3=more than 2 months. Thus, having made the last appointment farther in advance was associated with a lower risk of delayed immunization.
**Ordinal variable. 1=not at all, 2=a little, 3=a moderate amount, 4=a great deal. Thus, worrying more about the risks of vaccines was associated with lower rates of delayed immunization.

Source: Lieu TA, Black SB, Ray P, Chellino M, Shinefield HR, Adler NE. Risk factors for delayed immunization among children in an HMO. Am J Public Health 1994;84:1624- 1625





In a population-based survey of immunization coverage in Houston children conducted by Baylor faculty and local public health organizations (Hanson et al., 1995), the coverage was found to be low (17% age appropriate coverage, and 36% up-to-date coverage), although not as low as reported by Zell et al. Hispanic ethnicity, and other maternal characteristics, such as education and income, were not independently associated with immunization rates. Fifty-four percent of parents who reported their children as being fully immunized were incorrect. Barriers to immunization identified by parents included cost, transportation, and the health care provider not delivering a scheduled immunization because of the child was ill.

Assignment: Based on your review of the data presented here, give your assessment of the extent to which Hispanic children from birth to age 5 are likely to be appropriately immunized, and discuss what measures might be most effective in increasing immunization coverage.





OVERALL MORTALITY

The major causes of death in 1992 (the most recent year for which statistics are available) for Hispanics, non- Hispanic Whites and Blacks are shown in Table 4.

Assignment:

  1. Identify the causes of death that are among the top ten in one ethnic group, but not in one or both of the others.
  2. In general, do the top 10 leading causes of death seem similar among the three ethnic groups, or are the differences more striking than the similarities?



Table 4. Rank of Cause of Death, by Ethnic Group

Hispanics White non-Hispanics Blacks
1 Diseases of heart Diseases of heart Diseases of heart
2 Malignant neoplasms, including neoplasms of lymphatic and hematopoietic tissues Malignant neoplasms, including neoplasms of lymphatic and hematopoietic tissues Malignant neoplasms, including neoplasms of lymphatic and hematopoietic tissues
3 Accidents and adverse effects Cerebrovascular disease Cerebrovascular diseases
4 Human immunodeficiency virus infection Chronic obstructive pulmonary diseases and allied conditions Homicide and legal intervention
5 Homicide and legal intervention Accidents and adverse effects Accidents and adverse effects
6 Cerebrovascular disease Pneumonia and influenza Human immunodeficiency virus infection
7 Diabetes mellitus Diabetes mellitus Diabetes mellitus
8 Chronic liver disease and cirrhosis Suicide Pneumonia and influenza
9 Pneumonia and influenza Chronic liver disease and cirrhosis Certain conditions originating in the perinatal period
10 Certain conditions originating in the perinatal period Human immunodeficiency virus infection Chronic obstructive pulmonary diseases and allied conditions
Source: US Dept of Health and Human Services Public Health Service Monthly Vital Statistics Report. Vol 43, No. 6(S)




The relative mortality of Hispanics compared to non- Hispanics has been studied by Sorlie et al. These investigators matched samples of the U.S. population surveyed from 1973 to 1985 by the Census Bureau as part of the Current Population Survey program to the National Death Index. The Current Population Survey is conducted periodically to monitor economic trends and includes questions about employment, income and ethnic identification. The National Death Index is maintained by the National Center for Health Statistics and is a repository for death certificate information, including date and cause of death, for the entire country. The authors analyzed the age-specific death rates and causes of death for Mexicans, Cubans, Puerto Ricans, and other Hispanics, and compared them to death rates for all non- Hispanics.

Assignment: Review Table 5 and answer the following questions.

  1. Is there any Hispanic subgroup that has a higher mortality rate relative to non-Hispanics?
  2. Is the relative mortality pattern of Hispanics compared to non-Hispanics the same in men and women?



Table 5. Age-Adjusted Ratio of Mortality Rates in Persons of Hispanic Origin to Mortality Rates in Non-Hispanics*

Men
45-64 years of age		 Women
45-64 years of age
Mexican 0.77** 0.92
Puerto Rican 0.93 0.82
Cuban 0.71 0.47**
Other Hispanic 0.69** 0.67**
All Hispanic 0.76** 0.79**
Non-Hispanic 1.00 1.00
*National Longitudinal Mortality Study, 1979 to 1987 follow-up, 12 survey cohorts combined.
**95% confidence interval does not include 1.00.

Adapted from: Sorlie PD, Backlund E, Johnson NJ, Rogot E. Mortality by Hispanic status in the United States. JAMA 1993;270:2464-2468





Assignment: Table 6 contains cause-specific mortality rate ratios for Hispanics compared to non-Hispanics. Review Table 6 and answer the following questions. Keep in mind that if the 95% confidence interval shown in parentheses next to the rate ratio includes 1.0, the difference in mortality rates cannot be considered statistically significant.

  1. From what causes are Hispanic males more likely to die than non-Hispanic males?
  2. From what causes are Hispanic females more likely to die than non-Hispanic females?
  3. How would you summarize the data on relative mortality in Hispanics and non-Hispanics presented in the Sorlie analysis?

Table 6. Cause-Specific Mortality Rate Ratios for Hispanics Compared to Non-Hispanics.

Men Women
Cause of Death No. of
Deaths		 Standardized Rate Ratio
(95% Confidence Interval) 		No. of
Deaths		 Standardized Rate Ratio
(95% Confidence Interval)
Cancer (All) 190 0.69 (0.60-0..72) 149 0.61 (0.52-0.72)
Colon 13 0.47 (0.27-0.82) 10 0.40 (0.21-0.75)
Pancreatic 12 0.72 (0.39-1.34) 9 0.75 (0.39-1.46)
Lung 49 0.52 (0.39-0.70) 20 0.45 (0.29-0.71)
Prostatic 23 0.97 (0.64-1.48) ... NA**
Breast ... NA 31 0.53 (0.37-0.78)
Ovarian ... NA 14 0.80 (0.46-1.39)
Diabetes 32 1.86 (1.28-2.70) 35 2.38 (1.68-3.36)
Cardiovascular disease 368 0.65 (0.58-0.72) 277 0.80 (0.71-0.91)
Heart disease 306 0.65 (0.58-0.73) 210 0.81 (0.70-0.93)
Ischemic heart disease 212 0.60 (0.44-0.83) 132 0.75 (0.63-0.89)
Cerebrovascular disease 41 0.60 (0.44-0.83) 49 0.76 (0.57-1.01)
Respiratory disease 71 0.78 (0.61-.099) 54 1.09 (0.82-1.45)
Chronic obstructive pulmonary disease 23 0.46 (0.30-0.70) 16 0.65 (0.39-1.09)
Pneumonia/influe nza 35 1.21 (0.85-1.72) 31 1.67 (1.15-2.42)
Liver disease/cirrhosis 46 1.96 (1.41-2.71) 19 1.67 (1.02-2.74)
Accident
Motor vehicle 27 0.95 (0.62-1.46) 12 0.88 (0.48-1.61)
Other 33 0.82 (0.56-1.22) 7 0.43 (0.19- 0.99)
Suicide 20 0.62 (9.38-0.99) 5 0.67 (0.25-1.75)
Homicide 26 3.60 (2.29-5.66) 7 2.00 (0.93-4.38)
All Causes*** 914 0.74 (0.69-0.79) 648 0.82 (0.76-0.89)
... indicate fewer than five deaths.
*National Longitudinal Mortality Study, 1979 to 1987 follow-up, 12 survey cohorts combined, participants aged 25 years or older.
**NA indicates not applicable.
***Includes categories not listed above because of the small number of deaths from other causes.

Source: Sorlie PD, Backlund MS, Johnson NJ, Rogot E. Mortality by Hispanic status in the United States. JAMA. 1993;270:2464-2468.





LIFE EXPECTANCY

Assignment: From the information presented in this module write a brief summary of your conclusions regarding the health status of Hispanic subgroups in the U.S.

Life expectancy, ( see section in module I on life expectancy) the average number of years a person is expected to live after a certain attained age, provides an indication of the overall health of a population--to the extent that health can be defined in terms of survival probabilities. Table 6 reflects the life expectancy at birth for Hispanics, Blacks and non-Hispanic whites, by gender, in Texas from 1970 to 1993.

Assignment: Review Table 7 and answer the following questions:

  1. Which group has, on average, the highest life expectancy at birth?
  2. Which group has, on average, the lowest life expectancy at birth?
  3. Has any group changed its position relative to another group over the 23 years reflected in the figure?
  4. Do the trends in Table 7 suggest that socioeconomic status is a major determinant of ethnic group differences in life expectancy in the U.S. in the late 20th century?

Table 7. Life Expectance at Birth for Selected Years.

White Black Hispanic
Year Total Male Female Total Male Female Total Male Female
1970 73.3 69.4 77.3 65.3 61.5 69.1 71.1 68.3 74.0
1975 74.8 71.3 78.4 68.1 64.3 71.9 73.8 70.7 77.0
1980 75.5 72.3 78.8 69.2 65.1 73.2 74.5 70.9 78.2
1985 76.2 73.1 79.3 70.6 66.8 74.3 76.9 73.9 80.0
1988 77.0 74.2 79.9 70.4 66.3 74.3 76.8 73.9 79.7
1990 75.7 72.2 79.1 69.4 64.9 73.9 76.6 73.2 80.0
1991 76.9 74.1 79.7 70.4 66.4 74.4 77.5 74.7 80.2
1992 76.2 74.5 79.4 70.0 65.9 74.0 76.6 74.0 79.2
1993 76.2 73.7 78.8 70.0 66.0 73.9 76.7 74.0 79.6
Source: Texas Dept of Health, Texas Vital Statistics 1993 Annual Report.




Assignment: From the information presented in this module write a brief summary of your conclusions regarding the current health status of Hispanic subgroups in the U.S.





REFERENCES