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1.  Do healthy behaviors decline with greater acculturation?: Implications for the Latino mortality paradox 
Social science & medicine (1982)  2005;61(6):1243-1255.
Relative to non-Latino whites, Latinos in the United States have a lower socioeconomic status (SES) profile, but a lower all-cause mortality rate. Because lower SES is associated with poorer overall health, a great deal of controversy surrounds the Latino mortality paradox. We employed a secondary data analysis of the 1991 National Health Interview Survey to test the health behavior and acculturation hypotheses, which have been proposed to explain this paradox. These hypotheses posit that: (1) Latinos have more favorable health behaviors and risk factor profiles than non-Latino whites, and (2) Health behaviors and risk factors become more unfavorable with greater acculturation. Specific health behaviors and risk factors studied were: smoking, alcohol use, leisure-time exercise activity, and body mass index (BMI). Consistent with the health behaviors hypothesis, Latinos relative to non-Latino whites were less likely to smoke and drink alcohol, controlling for sociodemographic factors. Latinos, however, were less likely to engage in any exercise activity, and were more likely to have a high BMI compared with non-Latino whites, after controlling for age and SES. Results provided partial support for the acculturation hypothesis. After adjusting for age and SES, higher acculturation was associated with three unhealthy behaviors (a greater likelihood of high alcohol intake, current smoking, a high BMI), but improvement in a fourth (greater likelihood of recent exercise). Gender-specific analyses indicated that the observed differences between Latinos and non-Latino whites, as well as the effects of acculturation on health behaviors, varied across men and women. Results suggest that the health behaviors and acculturation hypotheses may help to at least partially explain the Latino mortality paradox. The mechanisms accounting for the relationship between acculturation and risky behaviors have yet to be identified.
doi:10.1016/j.socscimed.2005.01.016
PMCID: PMC3587355  PMID: 15970234
Latino mortality paradox; Smoking; Alcohol use; Exercise; Body mass index; USA
2.  Body Image, Acculturation, and Substance Abuse Among Boys and Girls in the Southwest 
This study explored body image as measured by perceptions of weight and appearance and its impact on adolescent drug use among predominately Mexican American middle school students in the southwest. Outcomes analyzed included lifetime and recent alcohol, cigarette, and marijuana use and antidrug norms. Disliking one’s looks was more of a risk factor for boys, whereas negative weight perceptions were more of a risk factor for girls. Relative to more acculturated (English-dominant) Latinos (N=903), non-Latino Whites (N=121), and other non-Latino youth (N=107), less acculturated (Spanish-dominant) Latino youth (N=212) reported the poorest body image. However, more acculturated Latino youth with poor body image had the greatest risk of substance use. More acculturated Latino boys who disliked their looks reported relatively greater amounts of recent alcohol use, and those who rated their bodies as too thin reported higher lifetime cigarette use, a greater amount and frequency of recent cigarette use, and weaker antidrug norms. More acculturated Latina girls who thought they were too fat reported a greater amount and frequency of recent cigarette use. These findings suggest that low levels of acculturation may protect some Latino youth with poor body image from coping via substance use. In addition, they suggest that poor body image among some Latinos may result less from adoption of American thinness ideals but rather from attitudes and behaviors that devalue the characteristics of Latino appearance.
PMCID: PMC3043457  PMID: 16320438
Body image; acculturation; substance abuse
3.  Neighborhood Effects on Youth Substance Use in a Southwestern City 
This study examines neighborhood influences on alcohol, cigarette and marijuana use among a predominantly Latino middle school sample. Drawing on theories of immigrant adaptation and segmented assimilation, we test whether neighborhood immigrant, ethnic, and socioeconomic composition, violent crime, residential instability, and family structure have differential effects on substance use among youth from different ethnic and acculturation backgrounds. Data are drawn from self-reports from 3,721 7th grade students attending 35 Phoenix, Arizona middle schools. Analysis was restricted to the two largest ethnic groups, Latino students of Mexican heritage and non-Hispanic Whites. After adjusting for individual-level characteristics and school- level random effects, only one neighborhood effect was found for the sample overall, an undesirable impact of neighborhood residential instability on recent cigarette use. Sub-group analyses by individual ethnicity and acculturation showed more patterned neighborhood effects. Living in neighborhoods with high proportions of recent immigrants was protective against alcohol, cigarette, and marijuana use for Latino students at different acculturation levels, while living in predominantly Mexican heritage neighborhoods (mostly non-immigrants) was a risk factor for alcohol and marijuana use for less acculturated Latinos. There were scattered effects of neighborhood poverty and crime, which predicted more cigarette and alcohol use, respectively, but only among more acculturated Latinos. Inconsistent effects confined to bilingual and more acculturated Latinos were found for the neighborhood's proportion of single mother families and its residential instability. No neighborhood effects emerged for non-Hispanic White students. Results suggested that disadvantaged neighborhoods increase substance use among some ethnic minority youth, but immigrant enclaves appear to provide countervailing protections.
doi:10.1525/sop.2007.50.2.273
PMCID: PMC3040571  PMID: 21339890
neighborhood effects; substance use; adolescents; Mexican Americans; acculturation
4.  Prevalence of Psychiatric Illnesses among Ethnic Minority Elderly 
OBJECTIVES
To compare lifetime and 12-month prevalence of DSM-IV psychiatric disorders among a national representative sample of older Latinos, Asians, African-Americans, and Afro-Caribbean to non-Latino Whites.
DESIGN
Cross-sectional study conducted in 2001 through 2004.
SETTING
Urban and rural households in the contiguous United States.
PARTICIPANTS
A total of 4,245 community-dwelling residents aged 50 and older living in non-institutional settings. Data are from the NIMH Collaborative Psychiatric Epidemiology Surveys.
METHODS
The World Health Organization Composite International Diagnostic Interview assessed lifetime and 12-month psychiatric disorders. Interviewers matched the cultural background and language preference of participants. Bayesian estimates compared psychiatric disorder prevalence rates among ethnic/racial groups.
RESULTS
After gender adjustments, older non-Latino Whites had higher lifetime rates of any depressive disorder than African-Americans but were no different than older Latinos. Older Asians and Afro-Caribbean had significantly lower lifetime rates of any depressive, anxiety, and substance use disorders than non-Latino Whites. Immigrant Asians had higher lifetime rates of GAD than the U.S.-born Asians and immigrant Latinos had higher lifetime rates of dysthymia and GAD than U. S.-born Latinos. U.S. born Latinos had higher lifetime rates of substance abuse, especially alcohol abuse, than immigrant Latinos. There were no significant differences in the rates of 12-month psychiatric disorders between non-Latino whites and ethnic/racial minorities, except that older African-Americans had higher 12-month rates of any substance use disorder compared to non-Latino Whites.
CONCLUSION
Prevalence rates vary considerably by ethnicity and race as well as by nativity for older minorities, suggesting different patterns of illness and risk.
doi:10.1111/j.1532-5415.2009.02685.x
PMCID: PMC2854540  PMID: 20374401
ethnicity; prevalence; psychiatric illness; older adults
5.  Gender and ethnic disparities contributing to overweight in California adolescents 
Purpose
To explore differences in health behaviors and factors contributing to overweight among 12 to 17 year olds in California.
Methods
Data from the 2005 California Health Interview Survey for 3,315 adolescents self-identified as Latino, Asian, or white were reviewed. Adolescents reported their weight, height, gender, ethnicity, parents’ educational level, household income, physical activity, sedentary activity, breakfast consumption, and family meals.
Results
Overall 34% of boys and 22% of girls in this study were overweight (>85th percentile for age and gender). Approximately 38% of Latinos, 25% of whites, and 16% of Asians were overweight. Latinos were more than twice as likely to be overweight as whites (2.07) and Asians (2.53). Younger adolescents (12–13 years old) and adolescents whose family income is less than 200% of the federal poverty level were more likely to be overweight. Low level of parental education is a risk factor for Latino and Asian girls and white and Latino boys. White girls with a lower socioeconomic status and white boys with more than 2 h daily of television, video, and computer time were more likely to be overweight.
Conclusion
Results suggest gender and ethnic variations in factors that contribute to overweight in California adolescents. To influence the current overweight epidemic, clinicians must develop culturally sensitive and gender-specific interventions that address the unique needs of an ethnically diverse adolescent population.
doi:10.1007/s10389-009-0300-7
PMCID: PMC2967257  PMID: 21088691
Gender; Ethnicity; Adolescent; Overweight; Risk factors
6.  Gender and ethnic disparities contributing to overweight in California adolescents 
Purpose
To explore differences in health behaviors and factors contributing to overweight among 12 to 17 year olds in California.
Methods
Data from the 2005 California Health Interview Survey for 3,315 adolescents self-identified as Latino, Asian, or white were reviewed. Adolescents reported their weight, height, gender, ethnicity, parents’ educational level, household income, physical activity, sedentary activity, breakfast consumption, and family meals.
Results
Overall 34% of boys and 22% of girls in this study were overweight (>85th percentile for age and gender). Approximately 38% of Latinos, 25% of whites, and 16% of Asians were overweight. Latinos were more than twice as likely to be overweight as whites (2.07) and Asians (2.53). Younger adolescents (12–13 years old) and adolescents whose family income is less than 200% of the federal poverty level were more likely to be overweight. Low level of parental education is a risk factor for Latino and Asian girls and white and Latino boys. White girls with a lower socioeconomic status and white boys with more than 2 h daily of television, video, and computer time were more likely to be overweight.
Conclusion
Results suggest gender and ethnic variations in factors that contribute to overweight in California adolescents. To influence the current overweight epidemic, clinicians must develop culturally sensitive and gender-specific interventions that address the unique needs of an ethnically diverse adolescent population.
doi:10.1007/s10389-009-0300-7
PMCID: PMC2967257  PMID: 21088691
Gender; Ethnicity; Adolescent; Overweight; Risk factors
7.  Bullying Victimization as a Mediator of Associations between Cultural/familial Variables, Substance use and Depressive symptoms among Hispanic Youth 
Ethnicity & health  2013;18(4):415-432.
Objectives
This article examines the antecedents and consequences of bullying victimization among a sample of Hispanic high school students. Although cultural and familial variables have been examined as potential risk or protective factors for substance use and depression, previous studies have not examined the role of peer victimization in these processes. We evaluated a conceptual model in which cultural and familial factors influenced the risk of victimization, which in turn influenced the risk of substance use and depression.
Design
Data were collected as part of a longitudinal survey study of 9th and 10th grade Hispanic/Latino students in Southern California (n=1167). The student bodies were at least 70% Hispanic/Latino with a range of socioeconomic characteristics represented. We used linear and logistic regression models to test hypothesized relationships between cultural and familial factors and depression and substance and a meditational model to assess whether bullying victimization mediated these associations.
Results
Acculturative stress and family cohesion were significantly associated with bullying victimization. Family cohesion was associated with depression and substance use. Social support was associated with alcohol use. Acculturative stress was associated with higher depression. The associations between acculturative stress and depression, family cohesion and depression, and family cohesion and cigarette use were mediated by bullying victimization.
Conclusion
These findings provide valuable information to the growing, but still limited, literature about the cultural barriers and strengths that are intrinsic to the transition from adolescence to emerging adulthood among Hispanic youth. Our findings are consistent with a mediational model in which cultural/familial factors influence the risk of peer victimization, which in turn influences depressive symptoms and smoking, suggesting the potential positive benefits of school based programs that facilitate the development of coping skills for students experiencing cultural and familial stressors.
doi:10.1080/13557858.2012.754407
PMCID: PMC3723765  PMID: 23297708
Hispanic; acculturation; family cohesion; bullying victimization; depression; substance use
8.  Acculturation and Cardiovascular Behaviors Among Latinos in California by Country/Region of Origin 
Despite generally lower socioeconomic status and worse access to healthcare, Latinos have better overall health outcomes and longer life expectancy than non-Latino Whites. This “Latino Health Paradox” has been partially attributed to healthier cardiovascular (CV) behaviors among Latinos. However, as Latinos become more acculturated, differences in some CV behaviors disappear. This study aimed to explore how associations between acculturation and CV behaviors among Latinos vary by country of origin. Combined weighted data from the 2005 and 2007 California Health Interview Survey (CHIS) were used to investigate associations between acculturation level and CV behaviors among Latinos by country of origin. Among all Latinos, increased acculturation was associated with more smoking, increased leisure-time physical activity, and greater consumption of fast foods, but no change in fruit/vegetable and less soda intake. These trends varied, however, by Latino sub-groups from different countries of origin. Country of origin appears to impact associations between acculturation and CV behaviors among Latinos in complex ways.
doi:10.1007/s10903-011-9483-4
PMCID: PMC3564577  PMID: 21626297
Acculturation Cardiovascular behaviors Latinos Country of origin
9.  Immigration Generation Status and its Association with Suicide Attempts, Substance Use, and Depressive Symptoms among Latino Adolescents in the USA 
This study investigated the relation between suicide attempts and immigrant generation status using the Latino subset of the National Longitudinal Study of Adolescent Health, a school-based, nationally representative sample. This study also examined whether generation status predicted risk factors associated with elevated suicide behaviors, namely illicit substance use, problematic alcohol use, and depressive symptoms. Finally, hypothesizing that elevated depressive symptoms and substance use mediate the relation between immigrant generation status and suicide attempts among Latino adolescents, a path model was tested. Our findings revealed immigrant generation status was a determinant for suicide attempts, problematic alcohol use, repeated marijuana use, and repeated other drug use for Latino adolescents. US-born Latinos with immigrant parents (i.e., second-generation youth) were 2.87 (95% CI, 1.34, 6.14) times more likely to attempt suicide, 2.27 (95% CI, 1.53, 3.35) times more likely to engage in problematic alcohol use, 2.56 (95% CI, 1.62, 4.05) times more likely to engage in repeated marijuana use, and 2.28 (95% CI, 1.25, 4.17) times more likely to engage in repeated other drug use than were foreign-born youth (i.e., first-generation youth). Later-generations of US-born Latino youth with US-born parents were 3.57 (95% CI, 1.53–8.34) times more likely to attempt suicide, 3.34 (95% CI, 2.18–5.11) times more likely to engage in problematic alcohol use, 3.90 (95% CI, 2.46, 6.20) times more likely to engage in repeated marijuana use, and 2.80 (95% CI, 1.46, 5.34) times more likely to engage in repeated other drug use than were first-generation youth. Results from the path analysis indicated that repeated other drug use may mediate the effect of generation status on suicide attempts.
doi:10.1007/s11121-008-0105-x
PMCID: PMC2662363  PMID: 18855139
Suicide; Hispanic Americans; Immigration; Adolescence; Substance use; Depression
10.  Health-related characteristics and preferred methods of receiving health education according to dominant language among Latinos Aged 25 to 64 in a large Northern California health plan 
BMC Public Health  2008;8:305.
Background
Latinos are a fast growing segment of the U.S. health care population. Acculturation factors, including English fluency, result in an ethnic group heterogeneous with regard to SES, health practices, and health education needs. This study examined how demographic and health-related characteristics of Spanish-dominant (SD), Bilingual (BIL), and English-dominant (ED) Latino men and women aged 25–64 differed among members of a large Northern California health plan.
Methods
This observational study was based on data from cohorts of 171 SD (requiring an interpreter), 181 BIL, and 734 ED Latinos aged 25–64 who responded to random sample health plan member surveys conducted 2005–2006. Language groups were compared separately by gender on education, income, behavioral health risks (smoking, obesity, exercise frequency, dietary practices, health beliefs), health status (overall health and emotional health, diabetes, hypertension, high cholesterol, heartburn/acid reflux, back pain, depression), computer and Internet access, and health education modality preferences.
Results
Compared with ED Latinos, higher percentages of the SD and BIL groups had very low educational attainment and low income. While groups were similar in prevalence of diabetes, hypertension, and high cholesterol, SD were less likely than ED Latinos to rate overall health and emotional well-being as good, very good, or excellent and more likely to report heartburn and back pain (women only). The groups were similar with regard to smoking and obesity, but among women, SD were more likely to be physically inactive than ED, and BIL were less likely than SD and ED groups to eat <3 servings of fruit/vegetables per day. SD and BIL of both genders were significantly less likely than ED Latinos to believe that health practices had a large impact on health. Compared to ED men and women, SD and BIL Latinos had significantly lower Internet and computer access. As a result, SD Latinos had a greater preference for lower technology health education modalities such as videos and taped phone messages.
Conclusion
There are important differences among Latinos of different English language proficiency with regard to education, income, health status, health behaviors, IT access, and health education modality preferences that ought to be considered when planning and implementing health programs for this growing segment of the U.S. population.
doi:10.1186/1471-2458-8-305
PMCID: PMC2556675  PMID: 18782454
11.  "A Latino Advantage in Oral Health-Related Quality of Life is Modified by Nativity Status" 
Social science & medicine (1982)  2010;71(1):205-211.
Explanations for the social gradient in health status are informed by the rare exceptions. This cross-sectional observational study examined one such exception, the “Latino paradox” by investigating the presence of a Latino advantage in oral health-related quality of life and the effect of nativity status on this relationship. A nationally representative sample of adults (n = 4208) completed the National Health and Nutrition Examination Survey (NHANES) 2003–2004. The impact of oral disorders on oral health-related quality of life was evaluated using the NHANES Oral Health Impact Profile. Exposures of interest were race, ethnicity and nativity status. Covariates included sociodemographic characteristics, smoking status, self-rated health, access to dental care and number of teeth. Unconditional logistic regression models estimated odds of impaired oral health-related quality of life for racial/ethnic and nativity groups compared to the Non-Latino white population. Overall prevalence of impaired oral health-related quality of life was 15.1%. A protective effect of Latino ethnicity was modified by nativity status, such that Latino immigrants experienced substantially better outcomes than non-Latino whites. However the effect was limited to first-generation Latinos. U.S. born Latinos did not share the oral health-related quality of life advantage of their foreign-born counterparts. This advantage was not attributable to the healthy migrant phenomenon since immigrants of non-Latino origin did not differ from Non-Latino whites. The excess risk among Non-Hispanic Blacks was rendered non-significant after adjustment for socioeconomic position. A protective effect conferred by Latino nativity is unexpected given relatively disadvantaged socioeconomic position of this group, their language barrier and restrictions to needed dental care. As the Latino advantage in oral health-related quality of life is not explained by healthy immigrant selection, cultural explanations seem more likely than explanations based on characteristics of individuals.
doi:10.1016/j.socscimed.2010.03.031
PMCID: PMC2885514  PMID: 20434250
USA; Acculturation; Hispanic; Disparities; Epidemiology; Social Class; Oral Health; nativity; Latino paradox; ethnicity
12.  Fitting in: The Roles of Social Acceptance and Discrimination in Shaping the Daily Psychological Well-Being of Latino Youth 
Social science quarterly  2012;93(1):173-190.
Objectives
We examine how acculturation experiences such as discrimination and social acceptance influence the daily psychological well-being of Latino youth living in newly emerging and historical receiving immigrant communities.
Methods
We use data on 557 Latino youth enrolled in high school in Los Angeles or in rural or urban North Carolina.
Results
Compared to Latino youth in Los Angeles, Latino youth in urban and rural North Carolina experienced higher levels of daily happiness, but also experienced higher levels of daily depressive and anxiety symptoms. Differences in nativity status partially explained location differences in youths’ daily psychological well-being. Discrimination and daily negative ethnic treatment worsened; whereas social acceptance combined with daily positive ethnic treatment and ethnic and family identification improved daily psychological well-being.
Conclusions
Our analysis contributes to understanding the acculturation experiences of immigrant youth and the roles of social context in shaping adolescent mental health.
doi:10.1111/j.1540-6237.2011.00830.x
PMCID: PMC3289137  PMID: 22389534
Latino; Hispanic; Mental Health; Assimilation
13.  THE LATINO ADOLESCENT MALE MORTALITY PEAK REVISITED: ATTRIBUTION OF HOMICIDE AND MOTOR VEHICLE CRASH FATALITY 
OBJECTIVE
The Latino Epidemiologic Paradox describes favorable health profiles for Latinos compared to non-Latino Whites despite poverty, low education, and low access to health care. Our study objective was to determine if the anomaly to the Latino Epidemiological Paradox and the Latino Adolescent Male Mortality Peak in California mortality data persists.
METHODS
Cases were California residents (1999–2006) of any race and ethnicity that died (N = 1,866,743) in California from any cause of death. Mortality rates and rate ratios were calculated according to causes of death for 5 year age groups.
RESULTS
For males and females combined, age-adjusted mortality rates were 509 for Latinos and 681 for non-Latino Whites per 100,000/yr. Latino male mortality rate ratios exceeded 1.0 compared to non-Latino White males only for 15–19 yrs (1.41 95%CI 1.35–1.49) and 20–24 yrs (1.24 95%CI 1.19–1.29). Latinas had lower mortality rates than non-Latino White females for all ages over 15 years. Male homicide rates for Latinos increased over the study period, but did not reach the rates reported for the years 1989–1997. Both male homicide and motor vehicle crash mortality rates were higher for Latinos than non-Latino Whites and peaked at 20–24 yrs. Latino crash mortality rate exceeded the rate for non-Latino Whites overall and for each year 2003–2006. Crash mortality for males 15–24 yrs increased from 2000–2006.
CONCLUSION
The anomaly and the mortality peak persist with notable attribution to homicide and crashes. Without homicide, the mortality peak would not exist. Mortality disparities for Latino adolescent males from these two causes of death in California appear to be growing.
doi:10.1136/ip.2010.028886
PMCID: PMC3065499  PMID: 21134905
Anomaly; Disparity; Injury; Latino; Paradox
14.  Pediatrician Identification of Latino Children at Risk for Autism Spectrum Disorder 
Pediatrics  2013;132(3):445-453.
BACKGROUND AND OBJECTIVES:
Latino–white disparities in age at autism spectrum disorder (ASD) diagnosis may be modified by primary care pediatrician (PCP) practices and beliefs. The objectives of this study were to assess ASD and developmental screening practices, attitudes toward ASD identification in Latino children, and barriers to ASD identification for Latino children, in a sample of 267 California PCPs.
METHODS:
In mail-based PCP survey, we assessed rates of bilingual general developmental and ASD screening, perceptions of parent ASD knowledge in Latino and white families, reports of difficulty assessing for ASDs in Latino and white children, and perceptions of barriers to early ASD identification for Latinos.
RESULTS:
Although 81% of PCPs offered some form of developmental screening, 29% of PCPs offered Spanish ASD screening per American Academy of Pediatrics guidelines, and only 10% offered both Spanish general developmental and Spanish ASD screening per American Academy of Pediatrics guidelines. Most PCPs thought that Latino (English and Spanish primary family language) parents were less knowledgeable about ASDs than white parents. PCPs had more difficulty assessing ASD risk for Latino children with Spanish primary family language than for white children, even when the PCP conducted recommended ASD screening or had >25% Latino patients. The most frequent barrier to ASD identification in Latinos was access to developmental specialists.
CONCLUSIONS:
Multiple factors in the primary care setting may contribute to delayed ASD identification for Latinos. Promoting language-appropriate screening, disseminating culturally appropriate ASD materials to Latino families, improving the specialist workforce, and providing PCP support in screening and referral of Latino children may be important ways to reduce racial and ethnic differences in care.
doi:10.1542/peds.2013-0383
PMCID: PMC3876760  PMID: 23958770
autism spectrum disorder; Hispanic Americans; pediatrics; health care disparities; child development; developmental disabilities; developmental screening
15.  Prevalence, Risk, and Correlates of Posttraumatic Stress Disorder across Ethnic and Racial Minority Groups in the U.S 
Medical care  2013;51(12):1114-1123.
Objectives
We assess whether posttraumatic stress disorder (PTSD) varies in prevalence, diagnostic criteria endorsement, and type and frequency of traumatic events (PTEs) among a nationally representative U.S. sample of 5071 non-Latino whites, 3264 Latinos, 2178 Asians, 4249 African Americans, and 1476 Afro-Caribbeans.
Methods
PTSD and other psychiatric disorders were evaluated using the World Mental Health-Composite International Diagnostic Interview (WMH-CIDI) in a national household sample that oversampled ethnic/racial minorities (n=16,238) but was weighted to produce results representative of the general population.
Results
Asians have lower prevalence rates of probable lifetime PTSD while African Americans have higher rates as compared to non-Latino whites, even after adjusting for type and number of exposures to traumatic events, and for sociodemographic, clinical and social support factors. Afro-Caribbeans and Latinos seem to demonstrate similar risk to non-Latino whites, adjusting for these same covariates. Higher rates of probable PTSD exhibited by African Americans and lower rates for Asians, as compared to non-Latino whites, do not appear related to differential symptom endorsement, differences in risk or protective factors or differences in types and frequencies of PTEs across groups.
Conclusions
There appears to be marked differences in conditional risk of probable PTSD across ethnic/racial groups. Questions remain about what explains risk of probable PTSD. Several factors that might account for these differences are discussed as well as the clinical implications of our findings. Uncertainty of the PTSD diagnostic assessment for Latinos and Asians requires further evaluation.
doi:10.1097/MLR.0000000000000007
PMCID: PMC3922129  PMID: 24226308
Posttraumatic Stress Disorders across racial and ethnic minority groups; diagnosis
16.  When Life is a Drag: Depressive Symptoms Associated with Early Adolescent Smoking 
Adolescent nicotine use continues to be a significant public health problem. We examined the relationship between the age of youth reporting current smoking and concurrent risk and protective factors in a large state-wide sample. We analyzed current smoking, depressive symptoms, and socio-demographic factors among 4,027 adolescents, ages 12–17 years using multivariate logistic regression (see 2005 California Health Interview Survey (CHIS) Public Use File). Consistent with previous work, Latinos, girls, those whose family incomes were below the poverty level, and those with fair-poor health were more likely to display depressive symptoms. Males, whites, older teens and those in fair-poor health were more likely to be current smokers. In a multivariate analysis predicting depressive symptoms, the interaction between age and current smoking was highly significant (Wald Χ2=15.8, p<.01). At ages 12–14 years, the probability of depressive symptoms was estimated to be four times greater among adolescents who currently smoked, compared to those who were not current smokers. The likelihood of depressive symptoms associated with current smoking decreases with age and becomes non-significant by 17 years. Interventions to reduce smoking may be most useful among youth prior to age 12 years and must be targeted at multiple risks (e.g. smoking and depression).
doi:10.1080/17450128.2013.797129
PMCID: PMC3928103  PMID: 24563657
17.  Role of Referrals in Mental Health Service Disparities for Racial and Ethnic Minority Youth 
Objective
To investigate racial/ethnic differences in teachers’ and other adults’ identification and/or encouragement of parents to seek treatment for psychiatric problems in their children and to evaluate if and whether identification/encouragement is associated with service use.
Method
Data on identification/encouragement to seek treatment for externalizing disorders (i.e., attention-deficit/hyperactivity disorder, oppositional-defiant disorder, and/or conduct disorder) and internalizing disorders (i.e., major depressive episode/dysthymia and/or separation anxiety disorder) and services used were obtained for 6,112 adolescents (13–17 years of age) in the National Comorbidity Survey Adolescent Supplement. Racial/ethnic differences were examined for Latinos, non-Latino blacks, and non-Latino whites.
Results
There were few racial/ethnic differences in rates of youth identification/encouragement and how identification/encouragement related to service use. Only non-Latino black youth with low severity internalizing disorders were less likely to be identified/encouraged to seek services compared with non-Latino white youth with the same characteristics (odds ratio [OR] = 0.4, 95% confidence interval [CI] = [0.2–0.7]). Identification/encouragement increased the likelihood of seeking services for externalizing and internalizing disorders for all youth. However, compared with their non-Latino white counterparts, non-Latino black youth who met criteria for internalizing disorders appeared less likely to have used any services (OR = 0.4, 95%, CI = 0.2–;0.7), after adjusting for identification/encouragement, clinical, and sociodemographic characteristics. Non-Latino black youth with internalizing disorders and without identification/encouragement were less likely to use the specialty care sector than their non-Latino white counterparts.
Conclusions
In this study of a nationally representative sample of adolescents, almost no ethnic/racial differences in identification/encouragement were found. However, identification/encouragement may increase service use for all youth.
doi:10.1016/j.jaac.2012.05.005
PMCID: PMC3652396  PMID: 22721593
referral; disparities; ethnic; minority; services
18.  Prevalence of physical symptoms and their association with race/ethnicity and acculturation in the United States 
General Hospital Psychiatry  2012;34(4):323-331.
Objective
Physical symptoms are common and a leading reason for primary care visits, however data are lacking on their prevalence among racial/ethnic minorities in the United States. This study aimed to compare the prevalence of physical symptoms among White, Latino, and Asian Americans, and examine the association of symptoms and acculturation.
Methods
We analyzed data from the National Latino and Asian American Study, a nationally-representative survey of 4864 White, Latino, and Asian Americans adults. We compared the age- and gender-adjusted prevalence of fourteen physical symptoms among the racial/ethnic groups and estimated the association between indicators of acculturation (English proficiency, nativity, generational status, and proportion of lifetime in the United States) and symptoms among Latino and Asian Americans.
Results
After adjusting for age and gender, the mean number of symptoms was similar for Whites (1.00) and Latinos (0.95) but significantly lower among Asian-Americans (0.60, p < 0.01 versus Whites). Similar percentages of Whites (15.4%) and Latinos (13.0%) reported 3 or more symptoms, whereas significantly fewer Asian-Americans (7.7%, p<0.05 versus Whites) did. In models adjusted for sociodemographic variables and clinical status (psychological distress, medical conditions, and disability), acculturation was significantly associated with physical symptoms among both Latino and Asian Americans, such that the most acculturated individuals had the most physical symptoms.
Conclusions
The prevalence of physical symptoms differs across racial/ethnic groups, with Asian Americans reporting fewer symptoms than Whites. Consistent with a ‘healthy immigrant’ effect, increased acculturation was strongly associated with greater symptom burden among both Latino and Asian Americans.
doi:10.1016/j.genhosppsych.2012.02.007
PMCID: PMC3383871  PMID: 22460006
Acculturation; Asian Americans; Epidemiology; Hispanic Americans; Signs and Symptoms
19.  Ethnic Minority Children’s Active Commuting to School and Association with Physical Activity and Pedestrian Safety Behaviors* 
Background
Children’s active commuting to school, i.e. walking or cycling to school, was associated with greater moderate-to-vigorous physical activity, although studies among ethnic minorities are sparse.
Objectives
Among a low-income, ethnic minority sample of fourth grade students from eight public schools, we examined (1) correlates of active commuting to school and (2) the relationship between active commuting to school and moderate-to-vigorous physical activity.
Methods
We conducted a cross-sectional analysis of baseline measurements from a sample of participants (n=149) aged 9–12 years from a walk to school intervention study in Houston, Texas. The primary outcome was the weekly rate of active commuting to school. Daily moderate-to-vigorous physical activity, measured by accelerometers, was a secondary outcome. Child self-efficacy (alpha=0.75), parent self-efficacy (alpha=0.88), and parent outcome expectations (alpha=0.78) were independent variables. Participant characteristics (age, gender, race/ethnicity, distance from home to school, acculturation, and BMI percentile) were independent sociodemographic variables. We used mixed-model regression analyses to account for clustering by school and a stepwise procedure with backward elimination of non-significant interactions and covariates to identify significant moderators and predictors. School-level observations of student pedestrians were assessed and compared using chi-square tests of independence.
Results
Among our sample, which was 61.7% Latino, the overall rate of active commuting to school was 43%. In the mixed model for active commuting to school, parent self-efficacy (std. beta = 0.18, p=0.018) and age (std. beta = 0.18, p=0.018) were positively related. Latino students had lower rates of active commuting to school than non-Latinos ( 16.5%, p=0.040). Distance from home to school was inversely related to active commuting to school (std. beta = 0.29, p<0.001). In the mixed model for moderate-to-vigorous physical activity, active commuting to school was positively associated (std. beta = 0.31, p <0.001). Among the Latino subsample, child acculturation was negatively associated with active commuting to school (std. beta = −0.23, p=0.01). With regard to school-level pedestrian safety observations, 37% of students stopped at the curb and 2.6% looked left-right-left before crossing the street.
Conclusion
Although still below national goals, the rate of active commuting was relatively high, while the rate of some pedestrian safety behaviors was low among this low-income, ethnic minority population. Programs and policies to encourage safe active commuting to school are warranted and should consider the influence of parents, acculturation, and ethnicity.
PMCID: PMC3160673  PMID: 21874160
Latino; ethnicity; active commuting to school; physical activity; pedestrian safety; safe routes to school
20.  Depression and Anxiety among First-Generation Immigrant Latino Youth: Key Correlates and Implications for Future Research 
We examined how the migration and acculturation experiences of first-generation Latino youth contributed to their psychological well-being. Data came from the Latino Adolescent Migration, Health, and Adaptation (LAMHA) study, which surveyed 281 first-generation Latino immigrant youth, ages 12–19. Using logistic regression, we evaluated how migration stressors (i.e. traumatic events, choice of migration, discrimination, and documentation status) and migration supports (i.e. family and teacher support, acculturation, and personal-motivation) were associated with depressive symptoms and anxiety. We found that migration stressors increased the risk of both depressive symptoms and anxiety. Time in the US and support from family and teachers reduced the risk of depressive symptoms and anxiety. Compared to documented adolescents, undocumented adolescents were at greater risk of anxiety, and children in mixed-status families were at greater risk of anxiety and marginally greater risk of depressive symptoms.
doi:10.1097/NMD.0b013e3181e4ce24
PMCID: PMC3139460  PMID: 20611049
Adolescent; Latino; Hispanic; Immigrant; First Generation; Mental Health
21.  A Cross-National Study of Preadolescent Substance Use: Exploring Differences Between Youth in Spain and Arizona 
Substance use & misuse  2008;43(11):1571-1593.
This study aims to comparatively examine drug use in Arizona and Spain, in order to know if similarities and differences in drug use patterns justify the administration in Spain of U.S. prevention intervention programs. Data were obtained from independent samples of seventh-grade students recruited from urban public schools and surveyed in 1998: 4,035 ethnically diverse Arizona students (Latinos and non-Hispanic Whites), and 2,243 Spanish-White students. Comparisons using Odds ratios and Chi-square tests allowed assessment of differences in drug use rates between preadolescents in Arizona and Spain taking into account gender. Furthermore, ethnicity differences in preadolescent drug use and in psychosocial risk factors were explored using multivariate analysis (ANOVA and logistic regression). Our results showed similar trends in drug use between Arizona and Spain students, with gateway drugs already in use by early adolescents, and with higher rates of drug use among males than among females. However, cross-national differences in marijuana/cannabis use were noteworthy: Arizona preadolescents were over 25 times more likely to report marijuana/cannabis use than preadolescents from Spain. Moreover, when ethnic differences were considered, Latinos in Arizona reported higher marijuana/cannabis use compared with non-Latino students. Drug use patterns among Latino preadolescents, as well as the relevance of some risk factors among the diverse groups, were strongly influenced by their level of acculturation. Study limitations and the implications of our findings for early drug use prevention and future research are discussed.
doi:10.1080/10826080802241078
PMCID: PMC2730163  PMID: 18752161
Preadolescents; substance use; cross-national; Spain; Arizona; gender; ethnicity
22.  Recruiting Ethnically Diverse General Internal Medicine Patients for a Telephone Survey on Physician-Patient Communication 
BACKGROUND
Limited evidence exists on the effectiveness of recruitment methods among diverse populations.
OBKECTIVE
Describe response rates by recruitment stage, ethnic-language group, and type of initial contact letter (for African-American and Latino patients).
DESIGN
Tracking of response status by recruitment stage and ethnic-language group and a randomized trial of ethnically tailored initial letters nested within a cross-sectional telephone survey on physician-patient communication.
PARTICIPANTS
Adult general medicine patients with ≥1 visit during the preceding year, stratified by 4 categories: African-American (N= 1,400), English-speaking Latino (N= 894), Spanish-speaking Latino (N= 965), and non-Latino white (N= 1,400).
MEASUREMENTS AND RESULTS
Ethnically tailored initial letters referred to shortages of African-American (or Latino) physicians and the need to learn about the experiences of African-American (or Latino) patients communicating with physicians. Of 2,482 patients contacted, eligible, and able to participate (identified eligibles), 69.9% completed the survey. Thirty-nine percent of the sampling frame was unable to be contacted, with losses higher among non-Latino whites (46.5%) and African Americans (44.2%) than among English-speaking (32.3%) and Spanish-speaking Latinos (25.1%). For identified eligibles, response rates were highest among Spanish-speaking Latinos (75.2%), lowest for non-Latino whites (66.4%), and intermediate for African Americans (69.7%) and English-speaking Latinos (68.1%). There were no differences in overall response rates between patients receiving ethnically tailored letters (72.2%) and those receiving general letters (70.0%).
CONCLUSIONS
Household contact and individual response rates differed by ethnic-language group, highlighting the importance of tracking losses by stage and subpopulation. Careful attention to recruitment yielded acceptable response rates among all groups.
doi:10.1111/j.1525-1497.2005.0078.x
PMCID: PMC1490122  PMID: 15963168
recruitment; telephone survey; African Americans; Latinos; physician-patient communication
23.  Missed sleep and asthma morbidity in urban children 
Background
Children living in urban environments have many risk factors for disrupted sleep, including environmental disturbances, stressors related to ethnic minority status, and higher rates of stress and anxiety. Asthma can further disrupt sleep in children, but little research has examined the effects of missed sleep on asthma morbidity.
Objective
To examine the associations among missed sleep, asthma-related quality of life (QoL), and indicators of asthma morbidity in urban children with asthma from Latino, African American, and non-Latino white backgrounds. Given the importance of anxiety as a trigger for asthma symptoms and the link between anxiety and disrupted sleep, the associations among anxiety, asthma morbidity indicators, and missed sleep were also tested.
Methods
Parents of 147 children ages 6 to 13 years completed measures of asthma morbidity and missed sleep, parental QoL, and child behavior.
Results
Higher reports of missed sleep were related to more frequent school absences, more activity limitations, and lower QoL across the sample. The associations between missed sleep and asthma morbidity were stronger for Latino children compared with non-Latino white and African American children. For children with higher anxiety, the associations between missed sleep and asthma morbidity were stronger than for children with lower anxiety.
Conclusion
Results offer preliminary support for missed sleep as a contributor to daily functioning of children with asthma in urban neighborhoods. Missed sleep may be more relevant to Latino families. Furthermore, anxiety may serve as a link between sleep and asthma morbidity because higher anxiety may exacerbate the effects of disrupted sleep on asthma.
doi:10.1016/j.anai.2012.05.015
PMCID: PMC3426919  PMID: 22727156
24.  Co-occurrence of mental and physical illness in U.S. Latinos 
Background
This study describes the prevalence of comorbid physical and mental health problems in a national sample of U.S. Latinos. We examined the co-occurrence of anxiety and depression with prevalent physical chronic illnesses in a representative sample of Latinos with national origins from Mexico, Cuba, Puerto Rico, and other Latin American countries.
Method
We used data on 2,554 Latinos (75.5% response rate) ages 18 years and older from the National Latino and Asian American Study (NLAAS). The NLAAS was based on a stratified area probability sample design, and the sample came from the 50 states and Washington, DC. Survey questionnaires were delivered both in person and over the telephone in multiple languages, including Spanish and English. Psychiatric disorders were assessed using the World Mental Health Survey Initiative version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI). Physical chronic illness was assessed by self-reported history.
Results
Puerto Ricans had the highest prevalence of meeting criteria for any comorbid psychiatric disorder (more than one disorder). Puerto Ricans had the highest prevalence (22%) of subject-reported asthma history, while Cubans had the highest prevalence (33%) of cardiovascular disease. After accounting for age, sex, household income, number of years in the U.S., immigrant status, and comorbid anxiety and depression, anxiety was associated with diabetes and cardiovascular disease, in the entire sample. Depression and comorbid anxiety and depression were associated with asthma but not with other physical diseases, in the entire sample. The relationship between chronic physical and mental illness was not confounded by immigration status or number of years in the U.S.
Discussion
Despite previous findings that link acculturation with both chronic physical and mental illness, this study does not find that number of years in the US nor nativity explain the prevalence of psychiatric-medical comorbidities. This study demonstrates the importance of considering psychiatric and medical comorbidity among specific ethnic groups, as different patterns emerge than when using aggregate ethnic measures. Research is needed on both the pathways and the mechanisms of comorbidity for the specific Latino groups.
doi:10.1007/s00127-006-0121-8
PMCID: PMC2791952  PMID: 17013767
25.  Distinct Beliefs, Attitudes, and Experiences of Latino Smokers: Relevance for Cessation Interventions 
Purpose
Determine the extent to which Latino smokers are using effective interventions for smoking cessation, with particular focus on nicotine replacement therapy (NRT). Related aims were to explore cultural, attitudinal, knowledge, and socioeconomic variables associated with treatment use.
Design
Cross-sectional telephone survey of two groups of Colorado adult smokers: Latinos (n = 1010) and non-Latino whites (n = 519).
Setting
Colorado.
Methods
Computer-assisted telephone survey in either Spanish or English. Survey addressed sociodemographic variables; smoking and cessation history; knowledge, attitudes, and beliefs about smoking and quitting; and experiences in and attitudes toward the health care setting.
Participants
Latino and non-Latino white adult Colorado residents who reported being regular smokers.
Results
Colorado Latinos report using NRT substantially less often than do non-Latino whites residing in the state. This and other differences in the study were more pronounced in Latinos characterized as low acculturation on the basis of a language preference variable. Latinos smoke somewhat less than non-Latino whites and report lower levels of dependence. They appear to be motivated to quit but endorse attitudes and beliefs antithetical to NRT use. Health care access was lower among Latinos, and this was related to lower reports of lifetime NRT use. Receipt of recommended practitioner intervention (the “five As”) did not differ by ethnicity.
Conclusions
Results suggested that use of effective cessation interventions among Latinos may be enhanced by education about nicotine addiction and NRT. Policy change to increase health care access also showed promise.
doi:10.4278/ajhp.100616-QUAN-200
PMCID: PMC3166215  PMID: 21510796
Cigarette Smoking; Hispanic Americans; Culture; Acculturation; Smoking Cessation; Prevention Research

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