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Hispanic adolescents are the fastest growing ethnic-minority age group in America. They are also at high risk for drug, alcohol, and tobacco use. In this paper, the authors discuss the etiology of Hispanic adolescents’ substance abuse, as explained in part by psychological stress. Based on the authors’ research and on other data, a model for preventing substance abuse among Hispanic youths is presented. The model draws from coping, acculturation, social learning, and informal network theories. Concluding with a research agenda, the paper calls for descriptive, correlative, and intervention outcome studies to scientifically understand and prevent substance use among Hispanic adolescents.
Hispanics are America’s fastest growing minority population. By about the year 2000, Hispanic Americans will be our largest ethnic-racial minority group. Comprising Colombian, Cuban, Dominican, Puerto Rican, and Mexican Americans, Hispanics are a young population. Nationally, 20% of all Hispanic Americans are under 15 years of age, compared with 14% of all other Americans. In some areas, New York City, for example, one in every three teenagers is Hispanic.
Recent literature has noted disparate increases among Hispanic adolescents and young adults relative to their Black and nonminority counterparts in deviant behavior. Much of this behavior has been highly correlated with abuse of substances. Among Hispanic youth, for example, alcohol use is associated with school failure (Lundman, 1986; Miller and Ohlin, 1985). In fact, fewer than one-half of all Hispanics complete high school (Malone, 1985). Hispanic homicide, often substance related, has a rate per 100,000 of 88.3 versus 18.5 for non-Hispanics among young males (Loya et al., 1986). Many Hispanic Americans begin drinking regularly before the teen years (Caetano, 1986; Comas-Diaz, 1986; Fernandez-Pol et al., 1986; Gordon, 1981; Leland, 1984; Malone, 1986; Thompson and Wilsnack, 1984). Once developed, substance use patterns are difficult to break. A large literature testifies to the recalcitrance of habitual drinking, as an example. If these problems continue to be neglected, today’s substance use risks among youth may become tomorrow’s alcohol and drug problems among adults.
Therefore, the risks faced by Hispanic adolescents threaten the future of a growing number of Americans. Among the most serious of these risks is substance abuse. Although insight into the etiology of drug use has increased substantially, culturally sensitive research is lacking.
This paper advances scientific knowledge on substance abuse research among Hispanic adolescents. After reviewing data on tobacco, alcohol, and drug use by American Hispanics, the paper relates psychological stress to substance abuse risk. From original research and from data reported by others, we offer a model to understand alcohol and drug abuse risks among Hispanic youth. Our model incorporates coping, acculturation, social learning, and support network theories. With implications for prevention, we suggest how Hispanic adolescents can learn to adaptively deal with stress toward lowering their substance abuse risk. We conclude with an agenda for future research.
Although national statistics are lacking, Hispanic Americans’ substance use can be estimated from correlative and regional data (Blount and Dembo, 1984; Dembo, Blount, Scmeidler, and Burgos, 1986; Tucker, 1985). For instance, Hispanic women present with esophageal cancer 20% more often than non-Hispanic American women–possibly due to heavy smoking and drinking (Bobo, Snow, Gilchrist, and Schinke, in press). Other data “suggest that rates of… cigarette-linked diseases among Latino males may increase within this decade, and continue to increase into the next century” (Marcus and Crane, 1985: 171). Liver cirrhosis, suggestive of alcohol abuse, is more common for Hispanics than for non-Hispanics (Comas-Diaz, 1986; Caetano, 1986; Coombs and Globetti, 1986).
Further, police records show arrest rates for drunkenness of 138 and 38 (per 100,000 population) among Hispanic and non-Hispanic youth, respectively (Maddahian, Newcomb, and Bentler, 1985). Such rates likely affect the greater concern expressed by Hispanic respondents, relative to non-Hispanic respondents, that teenage drinking is a major societal problem (Bruns and Geist, 1984). Multiple substance use is also high among Hispanic adolescents relative to Asian, Black, and nonminority youth (Brunswick and Messeri, 1984). In New York City, American Hispanics disproportionately account for 42% of all drug-related deaths–far in excess of their distribution in the city’s population.
The effects of substance abuse do not need recounting. More notable are psychosocial correlates of alcohol and drug abuse. Increasingly implicated in substance abuse risk is psychosocial stress (Labouvie, 1986; Labouvie and McGee, 1986; Newcomb, Maddahian, and Bentler, 1986; Santisteban, 1979; Simcha-Fagan, Gersten, and Langner, 1986; Lazarus and Folkman, 1984; Castro and Miranda, 1985). Recent studies suggest that “the experience of strained social relationships and a heightened sense of powerlessness/helplessness may induce adolescents to rely more heavily on substance use as a means of emotional self-regulation which requires little effort and ability, promises instant effects, and provides a sense of control” (Labouvie, 1986: 333). For example, in a study of 617 fifteen- and eighteen-year-old youths, regarding use of alcohol and marijuana for stress reduction, it was found that environments unable to provide social support mechanisms tended to foster these feelings of powerlessness/helplessness, and that this sense of lack of personal control is “conducive to the development of a relatively strong link between substance use and emotional self-regulation in adolescence” (Labouvie, 1986: 342). Further, those youths most heavily involved in substance use were more likely to utilize these substances as mechanisms for stress reduction (Labouvie, 1986).
While use of substance to mediate stress is not exclusive to Hispanic adolescents, and while precise figures broken down by ethnic group are not available, the collateral evidence cited in this article indicates that this behavior is more prevalent among Hispanic youths. Given their high concentration in impoverished, urban settings characterized by the inability to provide just such social supports as we have discussed, this is not surprising. Not only are Hispanic youth apt to chemically cope with stress, but also they may continue this coping pattern into adulthood. As such, the nature of stress among Hispanic adolescents warrants attention.
“Stress … is a relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources” (Lazarus and Folkman, 1984: 21). Admittedly complex, stress probably influences tobacco, alcohol, and drug use among adolescents and adults. Current research is attempting to isolate more precisely the role of stress in substance abuse, as well as to design and evaluate preventive interventions around stress reduction and increased locus of control in terms of their effect on substance use. But whether stress causes substance misuse is as yet unknown. More certain is that Hispanic youth–particularly those in large cities–experience environmental, social milieu, cognitive, and life event stressors (Castro and Miranda, 1985; Malone, 1986; Vega, Warheit, and Meinhardt, 1985). Environmental stressors for young Hispanics in such cities as New York are noise, substandard and crowded housing, and safety hazards. Each of these stressors is associated with antisocial and emotional problems (Canino, Earley and Rogler, 1980; Cohen, Evans, Stokols, and Krantz, 1986).
Social milieu stressors for urban American Hispanics are poverty, unemployment and underemployment, and racial discrimination (Moritsugo and Sue, 1983; Siddique and D’Arcy, 1984). These stressors correlate with several psychosocial problems (Suedfeld, 1986; Vondra, 1986). Cognitive stressors for Hispanic youth are helplessness perceptions, fatalism, and low self-esteem (Arnkoff, 1986; Wise and Barnes, 1986). In all likelihood, cognitive stressors also contribute to personal and interpersonal problems. Not independent of other stressors, life events of family changes and relocation are frequently disruptive for Hispanic youth (Sterling, Cowen, Weissberg, Lotyczewski, and Boike, 1985; Needle et al., 1986).
Early adolescents, youth aged 9 to 15 years, are most vulnerable to stress-related problems. Early adolescence is a difficult time for all young people (Elias, Gara, and Ubriaco, 1985; Felner, 1984; Segal, 1986). For Hispanic youth, this period may also be accompanied by cultural conflicts and invidious comparisons with advantaged peers. Unsurprisingly, early adolescence is therefore a particularly high-risk period for Hispanic youth. Besides tobacco, alcohol, and drug use, Hispanic early adolescents experience other stress-related problems. Because these problems correlate with substance use, two areas warrant particular mention: school failure and violence.
Less than one-half of all Hispanic youth finish high school, a figure 20% below the completion rate for Blacks, where socioeconomic status is approximately equivalent. (Gutierrez and Montalvo, 1982; Malone, 1985). Often linked with substance use, school failure antecedes lifelong problems (Beauvais and Oetting, 1986; Friedman, Glickman, and Utada, 1985). Leaving school separates young Hispanics from an environmental support system known to boost both earning power and mobility. As a consequence, school failure may reinforce feelings of inferiority and alienation. These feelings in turn may foster substance use (Feldman, Caplinger, and Wodarski, 1983; Murray, 1986). Absent national statistics, rates of Hispanic violence are suggested by regional data. Hispanic homicide rates in New York City are four times the non-Hispanic rates (Loya, Garcia, Sullivan, Vargas, Allen, and Mercy, 1986). Sexual abuse, often violent and substance related, was 60% more frequent among Hispanic families than among nonminority families in one study (Hampton, 1986). Inextricably linked, stress and substance use are likely factors in many Hispanic adolescent suicides (Smith, Mercy, and Rosenberg, 1986; Sumner, 1986).
Toward preventing substance abuse and other stress-related problems among Hispanic youth, we offer a model derived from our data and from kindred findings. The model incorporates coping, acculturation, social learning, and support network theories.
“Coping with stress…” Tache and Selye (1986) wrote, “can be accomplished… (1) by removing stressors from our lives, (2) by not allowing certain neutral events to become stressors, (3) by developing a proficiency in dealing with conditions we do not want to avoid, and (4) by seeking relaxation or diversion from demand” (p. 20). Lazarus and Folkman (1984) defined coping as “Constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands” (p. 41). Hispanic youth, by these definitions, may lack the resources to cope with substance abuse and related stress. Such resources include more than mere knowledge about the health and social risks involved. Techniques that have been empirically shown to enhance coping skills increase youths’ abilities to withstand direct and indirect interpersonal, intrapersonal and environmental pressures through cognitive-behavioral interventions designed to encourage specific skills and ways of thinking. Increased self-esteem, sense of personal control, heightened self-confidence, values clarification, assertiveness skills, and stress-management techniques are examples of approaches that have been effective in intervention trials (Blount and Dembo, 1984; Botvin, 1983; Demob, Blount, Schmeidler, and Burgos, 1986; Dupont and Jason, 1984; Schinke, 1981; Schinke and Gilchrist, 1984; Schinke, Gilchrist, Snow, and Schilling, 1985a; Schinke, Schilling et al., 1985b; Zoller and Maymon, 1986).
Further, Hispanic youth may not possess an inherent awareness of stressors in their lives, let alone the ability to remove or deal with them (Snyder, Dishion, and Patterson, 1986; Stiffman, Jung, and Feldman, 1986). Less than ideal living conditions, language barriers, and early socialization processes may leave Hispanic adolescents ill-prepared to cope with external and internal demands.
At present, there is insufficient literature documenting the effectiveness of prevention intervention tailored specifically to the cultural and environmental needs of Hispanic youth. A good deal more research is needed to augment existing findings and, indeed, new studies are currently underway (Palleja, 1986; Zayas and Bryant, 1984; Botvin, 1986; Botvin et al., 1984; Orlandi, 1985; Orlandi, 1986; Schinke, Schilling, and Gilchrist, 1986; Schinke, Zayas, Schilling, and Palleja, in press; Bobo, Cvetkovich, Trimble, Gilchrist, and Schinke, in press).
Early results are encouraging. An ongoing tobacco use preventive study, for example, employs intervention protocols designed to help youths defined as high risk manage stress relative to peer, family, and school pressures around tobacco use onset and maintenance (Moncher and Schinke, unpublished manuscript). Measures from this research on derived outcome variables of knowledge, stress-management skills, and assertiveness at pretest, posttest, and follow-up periods indicate that Hispanic and non-Hispanic adolescents randomly assigned to intervention conditions continue to improve, with no mean differences in improvement between the two ethnic groups.
Substance abuse prevention could equip Hispanic adolescents with coping skills to counter everyday stressors. By the foregoing definitions, preventive intervention could help Hispanic youth cope by lowering stress through activities and friendships that reduce their exposure to alcohol and drugs. When youths cannot avoid risky situations, they could anticipate and offset negative stressors. Toward this end, youths could apply self-instructional coping skills. Through self-instruction, adolescents could recognize situational, interpersonal, and emotional stressors. Recognized, these stressors might be more easily offset through practice and implementation of self-instructional coping statements.
Emphasizing personal praise and self-affirmation for stress reduction and for substance abuse avoidance, these statements could be acquired in group or individual counseling sessions. For instance, adolescents in small groups could imagine themselves under pressure to use alcohol or drugs. Progressively, youths could then say aloud, whisper, and silently think self-instructional coping statements. From counselors and peers, adolescents could receive feedback on their coping abilities. Youths could thus master coping strategies in protected milieu before applying the skills when confronted with substance use pressures.
From our data and from other research, acculturation theory sheds further light on substance abuse risk among Hispanic adolescents. Briefly, acculturation theory refers to the three phases of contact, conflict, and adaptation through which both migrant and host cultures and individuals move, before functional assimilation may be achieved. It is maintained that there is a relationship between (1) the level of successful acculturation along a continuum and (2) the degree of stress to which individuals within the migrant culture–and the culture itself–will be subjected (Palleja, 1986, unpublished manuscript; Szapocznik, Scopetta, and King, 1978; Szapozcnik, Scopetta, Kurtinas, and Arnalde, 1987; Szapozcnik, Scopetta, and Tillman, 1978; Berry and Annis, 1974; Canino, Earley, and Rogler, 1980; Carballo, 1970; Herskovits, 1983; Prieto, 1978; Zayas, 1986; Zayas and Bryant, 1984).
Among second-generation Puerto Rican youth in New York City, Palleja correlated acculturation mode, or orientation, with stress-related problem-behavior risk (Palleja, 1986). Monoculturally oriented youth–adolescents aligned with Hispanic culture or with the host American culture–had greater stress-related problem risk than biculturally oriented youth–adolescents aligned equally with Hispanic and non-Hispanic cultures. Data from Cuban Americans report similarly lower incidence of aggression, conduct disorders, and psychiatric disturbances among bicultural youth than among youth exclusively bound to Hispanic or non-Hispanic values (Szapocznik, Scopetta, and King, 1978).
Coincident with these data is the notion of bicultural competence that allows youth to “blend the adaptive values and roles of both the culture in which they were raised and the culture by which they are surrounded” (LaFromboise, 1982: 12). Elaborating on bicultural competence, LaFromboise and Rowe (1983) observed:
A socially competent, bicultural assertive lifestyle involves being benevolently interested in the needs of the group, socially responsible to perpetuate a belief system that highly values personal rights and the rights of others. … Subgoals include the knowledge and practice of … communication skills to enhance self-determination; coping skills to resist the pressure to acculturate … and discrimination skills to determine the appropriateness of assertive behavior, (p. 592)
A related theory is the humanistic interaction model of acculturation. Designed to “have maximal utility and flexibility for future research endeavors involving Hispanics” (Garza and Gallegos, 1985: 374), this model designates five components of acculturation influences:
“Socio-ecological influences” incorporate socioeconomic and other non-cultural environmental factors which directly affect “family influences” (e.g., socialization practices and parental attitudes). The “individual” component includes personality in addition to other affective and cognitive components, while “social behavior” refers simply to overt behavioral expressions of individuals. Finally, the socio-ecological component also interacts with the “multicultural influences” which encompass language and societal sanctions, (p. 374)
Together, these theories can direct preventive interventions with Hispanic adolescents at risk for alcohol and drug abuse. To date, while several studies employing these methodologies are in early phases, sufficient data do not yet exist to yield conclusive results.
Harmonious with acculturation theories, intervention must be tailored to help Hispanics prevent substance abuse (Sullivan and Guglielmo, 1986). For instance, through ethnic pride content, preventive intervention can show adolescents how to apply such cultural values as dignidad, respeto, and caridad to lower their risk for alcohol and drug abuse (Gil, 1984; Zayas, 1986; Zayas and Bryant, 1984). Among Hispanic people, dignidad emphasizes individual self-worth. Related to this emphasis is respeto, a value of rituals and ceremonies to guide interpersonal interactions. Caridad is a priority for assisting, supporting, and tangibly aiding other Hispanic people in need.
Additionally, such alternative belief systems as espiritismo and santeria could provide avenues for Hispanic adolescents to counter urges and pressures toward substance misuse. In some Hispanic cultures, espiritismo and santeria point to explanations for psychosocial problems and can lead to adaptive coping efforts. Ethnic pride content can thereby infuse cultural elements into substance abuse preventive interventions. As a result, intervention can encourage youths to apply their cultural heritage and skills to prevent substance abuse.
Bicultural values content can further allow youths to define their Hispanic orientation along a continuum. At one end of the continuum is a monocultural Hispanic mode; at the other end is a monocultural host society mode. A bicultural orientation is a joint orientation encompassing a balanced range of values, attitudes, and behaviors. Figure 1 depicts this theory graphically. By learning how acculturation affects everyday decisions and actions, Hispanic youth can make better choices about alcohol and drug use.
Finally, substance abuse prevention with Hispanic adolescents must occur through personalismo and confianza. Personalismo, a warm face-to-face interpersonal style, enhances intervention effectiveness with Hispanic youth (Hardy-Fanta, 1986). Confianza, designating a close, trusting relationship, can be achieved as counselors earn Hispanic adolescents’ respect by exhibiting rapport and caring.
Cognitive and behavioral social-learning theory is evident in the foregoing definitions of coping. Also salient for preventing alcohol and drug abuse are cognitive problem-solving skills. These skills could allow Hispanic youths to systematically define, generate solutions for, and resolve alcohol and drug use problems (Perry and Jessor, 1986; Schinke and Gilchrist, 1984; Schinke, Gilchrist, Schilling et al., 1985a; Schinke, Schilling et al., 1985b). Social-learning behavioral skills are necessary for Hispanic youths to negate interpersonal stressors, role modeling, and pressures toward substance use (Dupont and Jason, 1984; Schinke, 1981). Learning theory can also inform intervention delivery. For instance, youths should receive intervention on a schedule to maximize their acquisition, recall, and application of prevention content (Nader et al., 1986).
Preventive intervention can integrate social-learning content and procedures in several ways. Illustrative are cognitive problem-solving elements that can help youth stop and think, identify options, choose their best options, act consonant with these options, and praise themselves for appropriate action, when faced with substance abuse opportunities. Youths can learn behavioral skills by observation and practice of such elements as gestures, eye contact, voice intonation, affect, and word choice. Here, Spanish- and English-language systems deserve careful attention in substance abuse prevention efforts with Hispanic American youth.
Intervention delivery procedures derived from social-learning theory should give youths an initially concentrated curriculum of instruction and practice. After this concentrated introduction, intervention can continue through booster sessions. For instance, adolescents could receive one or more boosters every 6 months after initial intervention. Booster sessions could update and strengthen youths’ learning as they face new and changing pressures. These sessions may also generate opportunities to build and maintain natural and preventive supports among Hispanic youths and their peers and families. Booster sessions have proved effective in enhancing prevention intervention around substance use/abuse in a number of studies (Botvin, Renick, and Baker, 1983; Schinke, Gilchrist, Schilling, and Senechal, 1986; Schinke, Gilchrist, Schilling, Snow, et al., 1986; Schinke, Gilchrist, and Snow, 1985; Schinke, Gilchrist, Snow, and Schilling, 1985; Schinke, Schilling, Gilchrist, Barth, et al, 1985b).
“Hispanic Americans have a very strong family and community orientation.… Hispanics view the community as an extension of the family and feel that it has a protective and healing force that may be used to reinforce an individual’s own coping skills” (Malone, 1985: 55). Despite these conclusions, Hispanic families are underresearched entities with regard to nurturing and sustaining adolescents substance abuse prevention efforts (Fischer, Sollie, and Morrow, 1986). In part, these influences are characterized by la unidad de familia, the enduring alliance that distinguishes many Hispanic families (Browner, 1986). Parent-child conflicts and sibling quarrels aside, Hispanic family members are apt to maintain close contact.
Drug and alcohol abuse prevention with Hispanic youth can benefit from support networks. Prevention efforts can recognize la unidad de familia, or familism, values and preferences by involving Hispanic nuclear family members in the intervention process. Too, interventions could engage extended kinship network members–relatives, neighbors, community leaders–through compadrazgo (Prieto-Bayard and Baker, 1986). Compadrazgo describes traditional relationships between godparents, padrinos, or coparents, compadres, and godchildren, or ahijados. Prevention efforts could facilitate compadrazgo by engaging extended kinship network members in intervention.
Through family and extended kinship network member involvement, substance abuse prevention programs could accomplish two objectives. First, family and extended kinship network members could learn how they can reinforce youths’ alcohol- and drug-avoidance efforts. Second, family and kinship members could develop social and environmental supports to help youths prevent alcohol and drug abuse. Social supports would include informal, neighborhood, and family systems to assist youths in avoiding substance misuse. Environmental supports could include changes at school and in the community to prevent substance abuse.
By engaging parents, siblings, and kinship networks, intervention would tap potent influences on youths’ substance use risk. Expectedly, interventions that join support networks with youth-directed procedures may synergistically build adolescents’ prevention skills (Jason, Durlak, and Holton-Walker, 1984). Illustrative would be intervention that provided Hispanic youths with coping, bicultural, and social-learning-based skills, while engaging their immediate and extended family and kinship network members in work toward substance abuse prevention objectives. Again, it is too soon for studies employing such research designs as described here to provide data.
This relationship between psychological stress and substance abuse among Hispanic youth warrants further research. Specifically, this research could follow three nonexclusive tacks. A first tack is to document substance use rates and patterns among Hispanic youth. Work in this area faces challenges (Newcomb and Bentler, 1986). Because they are an ethnic-minority group rather than a racial-minority group, Hispanic Americans elude research identification efforts. For instance, vital and health statistics either identify Hispanic people as White or categorize them by surname, language, and country of origin (Aday, Chiu, and Anderson, 1980; Deyo, 1980; Hayes-Bautista, 1980). Some states keep no records by ethnicity. Further, a significant number of Hispanic Americans are undocumented aliens, about whom little is known (Davis, Haub, and Willette, 1983). Other Hispanic adults and youths may fail to identify themselves as Hispanic, choosing instead another ethnic affiliation. Consequently, no reliable national data exist on substance use by Hispanic adolescents. These data are needed.
A second research tack is to disaggregate psychosocial influences on Hispanic adolescents’ tobacco, alcohol, and drug use. In line with our earlier model, research on stress, coping, and substance abuse can start with extant theory and data. Theoretically, stress is “a relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources,” whereas coping includes “cognitive and behavioral efforts to manage specific external and/or internal demands” (Lazarus and Folkman, 1984: 21,141). Likewise, past findings recommend “measures that consider stress as a transaction between the person and the environment or between stressor and appraisal” (Fleming, Baum, and Singer, 1984: 946). Future studies, therefore, could employ cognitive, behavioral, and environmental measures of stress and coping. The results of these studies will have heuristic and programmatic payoffs for prevention research with Hispanic adolescents at risk for substance abuse (Eiseman, Wingard, and Huba, 1984).
A third tack for substance abuse research is to develop and test culturally sensitive intervention models. Noted before, these models must account for coping, acculturation, social-learning, and support-network variables. Whatever the theoretical orientation, preventive intervention efforts cannot neglect the influences of Hispanic adolescent peer groups, families, and kinship network members. Culturally sensitive intervention is key to the acceptance of substance abuse prevention efforts by Hispanic youth, families, and communities.
American Hispanic young people, as a result of the recent evidence of their disproportionately high risk status, are only now beginning to receive attention among researchers in the field of substance abuse prevention. Minority researchers must be identified and trained to help guide appropriately sensitive intervention development among Hispanic and other minority groups. The National Cancer Institute, through its Minority Investigator Supplement program, has recognized the wisdom of such an approach. More must be done. Government at all levels, universities, and other institutions where such research is conducted need to reevaluate priorities and make resources available both for extensive minority prevention research and for the development of programs to facilitate the mainstreaming of capably trained, sensitive, and motivated minority researchers.
Admittedly, the substance abuse problems confronting Hispanic Americans do not lend themselves to easy research–let alone to facile solutions. We need only examine the general state of such research to realize the great difficulties in technology transfer given the diversities inherent in American culture. Vast differences exist among American Hispanic groups. Dissimilarities in substance use problems within these groups are undeniable. Research needs within like cultural groups also vary by geographic location, socioeconomic status, family composition, and other interpersonal and environmental factors. Further, applied research with any ethnic-racial minority group, particularly cross-cultural research, faces risks (Cvetkovich, Earle, Schinke, Gilchrist, and Trimble, in press; Schinke, Gilchrist, Schilling, Walker et al., in press).
Without question, the benefits of new research–whether it is descriptive, correlative, or intervention outcome in design–are worth the risks. Perhaps the analysis and model we offer in this paper will move our Hispanic and majority-culture colleagues to accept those risks. It may be said that preventive research in general has far to go before effective interventions will be empirically proven successful and dissemination can take place. Much of the study data reported here indicates that we are moving forward in small steps. This is the nature of the research process. We must continue our collective scientific efforts if enhancements are to occur and better solutions are to be developed.