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1.  Multicultural voices: Attitudes of older adults in the United States about elder mistreatment 
Ageing and society  2012;34(5):877-903.
Despite international growth in policies to increase the identification and response to elder abuse and neglect, there remain considerable barriers to treating the problem. Some of these barriers may be attributed to how older adults from different racial/ethnic backgrounds define, experience, and seek to remedy elder mistreatment. Using focus group discussions based on case vignettes, this paper examines how older adults from different racial and ethnic backgrounds in the United States perceive elder mistreatment. Five focus groups were conducted with African Americans, English-speaking Latinos, Spanish-speaking Latinos, non-Latino Whites and African American caregivers for older adults. While similar definitions and meanings of elder abuse were expressed across the different racial/ethnic groups, Latino participants introduced additional themes of machismo, respect, love, and early intervention to stop abuse, suggesting that perceptions/beliefs about elder mistreatment are determined by culture and degree of acculturation in addition to race/ethnicity. Most differences in attitudes occurred within groups, demonstrating that perceptions vary by individual as well as by culture. In identifying scenarios that constitute elder mistreatment, some participants felt that certain cases of abuse are actually the persistence of intimate partner violence into old age. Participants also indicated that victims may prefer to tolerate mistreatment in exchange for other perceived benefits (e.g., companionship, security); and out of fear that they could be placed in an institution if mistreatment is reported. Findings suggest the need for person–centred intervention and prevention models that integrate the cultural background, care needs, and individual preferences of older adults.
doi:10.1017/S0144686X12001389
PMCID: PMC4215730  PMID: 25364064
Elder abuse; neglect; ethnicity; culture; acculturation; protective services; Latinos; person-centred intervention
2.  Getting by at home. Community-based long-term care of Latino elders. 
Western Journal of Medicine  1992;157(3):337-344.
Although evidence suggests that the morbidity and mortality of Latino elders (of any Hispanic ancestry) are similar to those of non-Latino whites, Latinos have higher rates of disability. Little is known about influences on the use of in-home health services designed to assist disabled Latino elders. We examine the effects of various cultural and structural factors on the use of visiting nurse, home health aide, and homemaker services. Data are from the Commonwealth Fund Commission's 1988 national survey of 2,299 Latinos aged 65 and older. Mexican-American elders are less likely than the average Latino to use in-home health services despite similar levels of need. Structural factors including insurance status are important reasons, but acculturation is not pertinent. Physicians should not assume that Latino families are taking care of their disabled elders simply because of a cultural preference. They should provide information and advice on the use of in-home health services when an older Latino patient is physically disabled.
PMCID: PMC1011290  PMID: 1413781
3.  Developing Culturally Sensitive Dementia Caregiver Interventions: Are We There Yet? 
Despite evidence of ethnic differences in family caregivers’ experiences, the extent to which caregiver interventions are culturally tailored to address these differences is unknown. A systematic review of literature published from 1980–2009 identified: differences in caregiving experiences of African American, Latino and Chinese American caregivers; psychosocial support interventions in these groups; and cultural tailoring of interventions. Ethnic differences in caregiving occurred at multiple levels (intrapersonal, interpersonal, environmental) and in multiple domains (psychosocial health, life satisfaction, caregiving appraisals, spirituality, coping, self-efficacy, physical functioning, social support, filial responsibility, familism, views toward elders, use of formal services and health care). Only 18 of 47 intervention articles reported outcomes by caregiver ethnicity. Only 11 reported cultural tailoring; 8 were from the REACH initiative. Cultural tailoring addressed: familism, language, literacy, protecting elders, and logistical barriers. Results suggest that more caregiver intervention studies evaluating systematically the benefits of cultural tailoring are needed.
doi:10.1177/1533317510370957
PMCID: PMC3581148  PMID: 20508244
cultural sensitivity; cultural competence; dementia caregivers; Latinos; African Americans; Chinese Americans; support interventions
4.  ANTIDEPRESSANT USE IN A NATIONALLY REPRESENTATIVE SAMPLE OF COMMUNITY-DWELLING US LATINOS WITH AND WITHOUT DEPRESSIVE AND ANXIETY DISORDERS 
Depression and anxiety  2009;26(7):674-681.
Background:
Antidepressant drugs are among the most widely prescribed drugs in the United States; however, little is known about their use among major ethnic minority groups.
Method:
Collaborative Psychiatric Epidemiology Surveys (CPES) data were analyzed to calculate nationally representative estimates of Latino and non-Latino White adults antidepressant use.
Setting:
The 48 coterminous United States was the setting.
Participants:
Household residents aged 18 years and older (N=9,250).
Main outcome:
Past year antidepressant use.
Results:
Compared to non-Latino Whites, few Latinos, primarily Mexican Americans, with 12-month depressive and/or anxiety disorders reported past year antidepressant use. Mexican Americans (OR=0.48; 95%CI=0.30–0.77) had significantly lower odds of use compared to non-Latino Whites, which were largely unaffected by factors associated with access to care. Over half of antidepressant use was by respondents not meeting 12-month criteria for depressive or anxiety disorders. Lifetime depressive and anxiety disorders explained another 21% of past year antidepressant use, leaving another 31% of drug use unexplained.
Discussion:
We found a disparity in antidepressant use for Mexican Americans compared to non-Latino Whites that was not accounted for by differences in need and factors associated with access to care. About one third of antidepressant use was by respondents not meeting criteria for depressive or anxiety disorders. Our findings underscore the importance of disaggregating Latino ethnic groups. Additional work is needed to understand the medical and economic value of antidepressant use beyond their primary clinical targets.
doi:10.1002/da.20561
PMCID: PMC2882071  PMID: 19306305
Latinos; Hispanics; Cubans; Mexicans; Puerto Ricans; major depressive disorder; depression; anxiety disorders; antidepressive agents
5.  Utility of the Life Course Perspective in Research With Mexican American Caregivers of Older Adults 
Research on caregiving of elders in Mexican American families is urgently needed. We know little about family caregivers, family transitions in relation to the caregiving role, reciprocal impact of caregivers and care recipients on one another, adaptive strategies, positive benefits of caregiving (caregiver gain), specific caregiving burdens, or supportive interventions for family caregiving. Theory derivation using the concepts and structure of life course perspective provides a way to fill the knowledge gaps concerning Mexican American caregiving families, taking into account their ethnic status as an important Hispanic subgroup and the unique cultural and contextual factors that mark their caregiving experiences.
doi:10.1177/1043659608325847
PMCID: PMC3750709  PMID: 18845694
Mexican American; life course perspective; elder caregiving
6.  How Does the Trajectory of Multimorbidity Vary Across Black, White, and Mexican Americans in Middle and Old Age? 
Objectives.
This research examines intra- and interpersonal differences in multiple chronic conditions reported by Americans aged 51 and older for a period up to 11 years. It focuses on how changes in multimorbidity vary across White, Black, and Mexican Americans.
Methods.
Data came from 17,517 respondents of the Health and Retirement Study (1995–2006) with up to 5 repeated observations. Hierarchical linear models were employed to analyze ethnic variations in temporal changes of reported comorbidities.
Findings.
Middle-aged and older Americans have on average nearly 2 chronic diseases at the baseline, which increased to almost 3 conditions in 11 years. White Americans differ from Black and Mexican Americans in terms of level and rate of change of multimorbidity. Mexican Americans demonstrate lower initial levels and slower accumulation of comorbidities relative to Whites. In contrast, Blacks showed an elevated level of multimorbidity throughout the 11-year period of observation, although their rate of change slowed relative to Whites.
Discussion.
These results suggest that health differences between Black Americans and other ethnic groups including White and Mexican Americans persist in the trajectory of multimorbidity even when population heterogeneity is adjusted. Further research is needed concerning the impact of health disadvantages and differential mortality that may have occurred before middle age as well as exploring the role of nativity, the nature of self-reported diseases, and heterogeneity underlying the average trajectory of multimorbidity for ethnic elders.
doi:10.1093/geronb/gbr106
PMCID: PMC3198247  PMID: 21968384
Chronic disease multimorbidity; Hierarchical linear modeling; Race/ethnic differences
7.  African American, Chinese, and Latino Family Caregivers’ Impressions of the Onset and Diagnosis of Dementia: Cross-Cultural Similarities and Differences 
The Gerontologist  2005;45(6):783-792.
Purpose
We explored cross-cultural similarities and differences in minority family caregivers’ perceptions of the onset and diagnosis of Alzheimer’s disease in their relatives, with specific attention to clinical encounters.
Design and Methods
We performed a meta-synthesis of three qualitative studies conducted in Massachusetts with 22 African American, Latino, and Chinese caregivers.
Results
All participants conveyed striking similarities of thought about normalization of cognitive symptoms until one critical event, usually relocation, precipitated family awareness that an elder’s behavior was not the result of ‘‘normal aging.’’ A lack of knowledge about Alzheimer’s disease, rather than culturally influenced beliefs, was the major deterrent to having an elder’s memory assessed. Community physicians’ failure to recognize Alzheimer’s disease or refer to specialists was more problematic than language or ethnic differences. Physicians’ disrespect for caregivers’ concerns about memory loss was particularly noted by African Americans, stigmatization of persons with Alzheimer’s disease was noted by Chinese, and fears that acculturation would end family home care was noted by Latinos.
Implications
Amid ethnocultural differences, there are many similarities in needs that offer providers the possibility to unify quality improvements in Alzheimer’s disease outreach, education, and physicians’ services. Suggestions include providing the public with more confidential access to Alzheimer’s disease information, increasing dementia awareness among community physicians, motivating clinicians to adopt culturally sensitive communication patterns, and providing community education to reduce normalization by families and stigmatization of persons with Alzheimer’s disease.
PMCID: PMC1629080  PMID: 16326660
Alzheimer’s disease; Cultural competence; Race or ethnicity; Meta-synthesis
8.  “The Worst Thing About Hospice Is That They Talk About Death”: Contrasting Hospice Decisions and Experience among Immigrant Central and South American Latinos to US-born White, Non-Latino Cancer Caregivers 
Palliative medicine  2010;24(4):427-434.
Hospice care is promoted as a model for improving end of life care and decreasing burden on caregivers. However, hospice use is low in Latinos and little is known about how Latinos make hospice decisions and experience hospice once enrolled. We used qualitative methods to conduct in-depth interviews and focus groups with 15 Latino bereaved hospice family caregivers and 15 White Non-Latino bereaved hospice family caregivers to describe hospice experiences and evaluate whether cultural factors affected the experience. We identified differences in decision-making and caregiving experience that were influenced by culture. For example, cultural values of denial, secrecy about prognosis and a collective, family-centered system influenced hospice decisions and experience in Latinos but not Non-Latinos. This study identifies a significant dilemma; that is, how to discuss hospice with a patient and family who prefer not to discuss a terminal prognosis. Future research is needed to extend these preliminary results; such results may be useful for designing interventions to improve end of life care and caregiving in Latinos.
doi:10.1177/0269216310366605
PMCID: PMC3570252  PMID: 20507867
Hospice; Latino; End of Life; Cancer; Caregiving; Communication
9.  Cultural Beliefs and Mental Health Treatment Preferences of Ethnically Diverse Older Adult Consumers in Primary Care 
Background
Beliefs concerning the causes of mental illness may help explain why there are significant disparities in the rates of formal mental health service use among racial/ethnic minority elderly as compared with their Caucasian counterparts. This study applies the Cultural Influences on Mental Health framework to identify the relationship between race/ethnicity and differences in: (1) beliefs on the cause of mental illness; (2) preferences for type of treatment; and (3) provider characteristics.
Method
Analyses were conducted using baseline data collected from participants who completed the Cultural Attitudes toward Healthcare and Mental Illness Questionnaire, developed for the PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly) study, a multi-site randomized trial for older adults (65+) with depression, anxiety, or at-risk alcohol consumption. The final sample consisted of 1257 non-Latino Whites, 536 African-Americans, 112 Asian-Americans, and 303 Latinos.
Results
African-Americans, Asian-Americans, and Latinos had differing beliefs regarding the causes of mental illness when compared to Non-Latino Whites. Race/ethnicity was also associated with determining who makes healthcare decisions, treatment preferences, and preferred characteristics of healthcare providers.
Conclusions
This study highlights the association between race/ethnicity and health beliefs, treatment preferences, healthcare decisions, and consumers' preferred characteristics of healthcare providers. Accommodating the values and preferences of individuals can be helpful in engaging racial/ethnic minority patients in mental health services.
doi:10.1097/JGP.0b013e318227f876
PMCID: PMC3258470  PMID: 21992942
race/ethnicity; health beliefs; older adults
10.  Underreporting of Food Intake among Mexican/Mexican-American Women: Rates and Correlates 
Background
Underreporters are those individuals who report a dietary intake level that is not biologically plausible given their physiological status and physical activity level. Underreporting of food intake threatens the validity of dietary assessment; yet, little is known about the prevalence or correlates of underreporting in the Mexican/Mexican-American community.
Objective
To examine underreporting rates and correlates among Mexican/Mexican-American women using dietary data based on repeated 24-hour recalls and the Goldberg equation.
Design
Cross-sectional study of baseline data collected as part of a larger randomized controlled trial through structured interviews and anthropometrics measurements.
Subjects/setting
A random sample of 357 Mexican/Mexican-American women, ranging in age from 21 to 67 years, living in south San Diego near the U.S./Mexico border.
Statistical analyses performed
Age, income level, education level, and weight status, all correlates of underreporting in samples of non-Hispanic white participants, were examined as potential correlates of underreporting among Mexican/Mexican-American women using binary logistic regression. Acculturation was examined to determine if it accounted for additional variance in underreporting. Finally, multivariate analyses using backward stepwise regression were conducted to determine which correlates remained significant in the final model.
Results
Rates of underreporting varied across the five detection methods employed, from 11.9% (n=42) to 81.3% (n=286). Obese weight status was the only significant correlate across all five underreporting detection methods and remained significant in the final model. Using backward stepwise regression, the final model showed weight status to be a significant correlate of underreporting both at the overweight (p<0.05) and obese levels (p<0.01). In addition, Anglo orientation score (p<0.05) remained significant in the final model, as well as the age group of 51 years or older (p<0.05).
Conclusions
Consistent with previous studies, underreporters in this Mexican/Mexican-American sample were more likely to be overweight or obese, and were older. They also were more likely to identify with the dominant Anglo culture. Additional studies are needed to further examine underreporting error in dietary assessment among Latinos, and to determine whether the effects of acculturation on underreporting are found in other Latino subgroups.
doi:10.1016/j.jada.2008.12.013
PMCID: PMC2702205  PMID: 19328257
underreporting; Mexican/Mexican-American; acculturation; Goldberg equation; 24-hour dietary recall
11.  Mexican American Elders’ Use of Home Care Services 
Applied nursing research : ANR  2009;22(1):26-34.
Mexican American (MA) elders are more functionally impaired at younger ages than other elders yet use home care services (HCS) less. To determine possible reasons, nine questionnaires were completed in Spanish or English by MA elders and caregivers living in southern Arizona (n=280). Contextual, personal, and attitudinal factors were significantly associated with use of HCS; and cultural/ethnic factors were significantly associated with confidence in HCS. Interventions should be designed and tested to increase use of HCS by Mexican American elders, by increasing service awareness and confidence in HCS, while preserving expectations of familism and reducing caregiving burden.
doi:10.1016/j.apnr.2007.03.002
PMCID: PMC4029060  PMID: 19171292
utilization; home care services; Mexican American elders; family caregiving
12.  Psychological Distress Among Latino Family Caregivers of Adults With Schizophrenia: The Roles of Burden and Stigma 
Objective
Little research has focused on the mental health of Latino caregivers with a relative with schizophrenia, despite data showing that up to three-quarters of Latino persons with schizophrenia live with their families. This study examined the relation between caregivers’ mental health and perceived burden and stigma and characteristics of the patient and caregiver.
Methods
Interviews were conducted in the language of preference (Spanish or English) in Wisconsin, California, and Texas with 85 Latinos caring for an adult with schizophrenia. Measures included the Center for Epidemiologic Studies–Depression Scale, the Zarit Burden Scale, and the Greenley Stigma Scale.
Results
General population studies of Mexican Americans have found that between 12% and 18% meet the cutoff for being at risk of depression; however, 40% of the sample met this criterion. Younger caregiver age, lower levels of caregivers’ education, and higher levels of the patients’ mental illness symptoms were predictive of higher levels of caregivers’ depressive symptoms. Caregivers’ perceived burden mediated the relation between patients’ psychiatric symptoms and caregivers’ depression. Caregivers’ perceived stigma was significantly related to caregivers’ depressive symptoms, even when the analyses statistically adjusted for psychiatric symptoms and demographic variables.
Conclusions
The high rates of depressive symptoms among Latino families caring for a relative with schizophrenia suggest that interventions should include attention to the mental health and recovery of family caregivers in addition to the patient’s recovery. Younger Latino caregivers and those with lower levels of education are particularly at risk of depression.
doi:10.1176/appi.ps.58.3.378
PMCID: PMC2396526  PMID: 17325112
13.  Differences in Environmental Control and Asthma Outcomes Among Urban Latino, African American, and Non–Latino White Families 
Latino and African American children with asthma are at increased risk for asthma morbidity compared with non–Latino White children. Environmental control (ie, environmental exposures and family strategies to control them) may contribute to greater asthma morbidity for ethnic minority children living in urban environments. This study examined ethnic differences in a semi-structured assessment of environmental control, associations between environmental control and asthma outcomes (asthma control, functional limitation, and emergency department [ED] use), and ethnic differences in environmental triggers in a sample of urban Latino, African American, and non–Latino White families. One hundred thirty-three children (6–13 years of age) and their caregivers completed demographic questionnaires, measures of asthma control and morbidity, and a semi-structured interview assessing environmental control. Reported environmental control differed significantly by ethnicity (P<0.05), with Latino families reporting higher levels of environmental control. Reported environmental control was significantly associated with asthma control (P<0.017) and functional limitation (P<0.017). Reported environmental control and ED use were significantly associated in Latino families (P<0.05). Non–Latino White and African American families reported more secondhand smoke exposure than Latino families (P<0.001). Latino families reported more optimal home environmental control than other ethnic groups. Substantial ethnic differences in asthma triggers suggest that observed ethnic disparities in asthma may be due, at least in part, to differences in the home environment.
doi:10.1089/ped.2011.0081
PMCID: PMC3255502  PMID: 22276226
14.  Using colorectal trends in the U.S. to identify unmet primary care needs of vulnerable populations 
Preventive medicine  2012;55(2):131-136.
Background
Colorectal cancer screening (CRC) disparities have worsened in recent years.
Objective
To examine progress toward Healthy People 2010 goals for CRC screening among ethnic/racial groups, including disaggregated Latino groups.
Methods
Multivariate logistic regressions examined associations between ethnicity/race and primary outcomes of self-reported guideline-concordant CRC screenings considering time trends for 65,947 respondents of the Medical Expenditure Panel Survey from 2000–2007 age 50-years and older from six groups (non-Latino White, non-Latino Black, Puerto Rican, Cuban, Mexican, and Other Latino). We also tested for modification effects by education, income, and health insurance.
Results
Most groups approached Healthy People 2010 CRC screening rate goals, including non-Latino Whites (47%), non-Latino Blacks (42%) and Puerto Ricans (40%), while Mexicans remained disparately lower (28%). Higher education, income and insurance coverage, partially attenuated this lower likelihood, but Mexican rates remained significantly lower than non-Latino Whites for receiving endoscopy in the past 5 years {OR(95% CI) =0.68(0.59–0.77)} and having received any CRC screening {0.70(0.62–0.79)}.
Conclusions
Among ethnic/racial groups examined, only Mexicans met healthcare disparity criteria in CRC screening. Findings suggest that healthcare equity goals can be attained if resources affecting continuity of care or ability to pay for preventive services are available, and targeted populations are adequately identified.
doi:10.1016/j.ypmed.2012.05.016
PMCID: PMC3786063  PMID: 22659226
15.  Ethnic Variation in Timing of Hospice Referral: Does Having No Informal Caregiver Matter? 
Journal of palliative medicine  2008;11(3):484-491.
Background
The length of hospice stay, as an indicator of timing of hospice referral, is an important outcome to examine in end-of-life care because it is relevant to the quality and cost efficiency of end-of-life care that patients receive. Although the majority receives nonmedical care from informal caregivers, many elderly hospice users rely on paid caregivers or staff of residential facilities.
Objective
This study examined whether availability of informal primary caregiver interact with ethnicity to affect length of hospice stay.
Design
A retrospective cross-sectional study.
Setting/subjects
Data on 3024 hospice patients aged 65 and older discharged between 1997 and 2000 was extracted from the National Center for Health Statistics' National Home and Hospice Care Survey (NHHCS).
Measurements
Length of hospice stay prior to death or discharge.
Results
Survival analysis revealed that among patients with formal caregivers, minority patients were likely to have significantly shorter hospice stays than non-Hispanic whites. There were no significant ethnic differences in length of stay among patients with informal caregivers.
Conclusions
Our findings suggest that ethnic differences in length of stay should be discussed in terms of type of caregiver, not just type of setting, since patients in residential facilities can have informal primary caregivers who are vigilant advocates for their dying relatives. We discuss possible reasons for the influence of having formal caregivers on length of stay of minority elders.
doi:10.1089/jpm.2007.0149
PMCID: PMC2719542  PMID: 18363492
16.  Colorectal Cancer Test Use among Californians of Mexican Origin: Influence of Language Barriers 
Ethnicity & disease  2009;19(3):315-322.
Objectives
Striking decreases in colorectal cancer (CRC) incidence have been seen recently in non-Latino Whites but not in Latinos. The purpose of our study was to examine the influence of limited English proficiency (LEP) on differences in CRC test use rates between Mexican American and non-Latino White adults in California and reported reasons for not getting a CRC exam.
Design
Cross-sectional analysis of the 2005 California Health Interview Survey (CHIS).
Setting
Representative sample of non-institutionalized adults living in California.
Participants
Mexican American (n=1,529) and non-Latino White men and women aged 50 and older (n=16,775) who had not been diagnosed with CRC.
Analysis
Logistic regression analyzed the effect of ethnicity and limited English proficiency (LEP) on CRC test use after adjusting for sociodemographics, healthcare access, health status, and other health behaviors.
Main Outcome Measures
Respondents' likelihood of not receiving the CRC exam was examined as a function of ethnicity and LEP status; differences in reasons for not receiving CRC testing between ethnic groups were also examined.
Results
More than 40% of Californian Mexican American adults aged 50 and older have never had either fecal occult blood test or lower endoscopy CRC tests. Mexican Americans were more likely to have difficulty understanding their doctor due to language barriers (P<.01). Mexican Americans more often reported provider barriers in getting an endoscopy (ie, test was not recommended by their medical provider) than non-Latino Whites (P=.01). After adjustment for covariates, Mexican Americans were 1.32 times and those with LEP were 1.68 times more likely to have never had either CRC test.
Conclusions
Limited English proficiency significantly decreased the likelihood of getting tested for CRC (P<.01). Eliminating language barriers should result in improvements in CRC test use among limited English proficiency Mexican Americans.
PMCID: PMC2757758  PMID: 19769015
Mexican Americans; Colonoscopy; Colorectal Cancer; Screening
17.  Enhancing the Quality of Life of Dementia Caregivers from Different Ethnic or Racial Groups 
Annals of internal medicine  2006;145(10):727-738.
Background
Caring for a family member with dementia is extremely stressful, contributes to psychiatric and physical illness among caregivers, and increases the risk for caregiver death. Finding better ways to support family caregivers is a major public health challenge.
Objective
To test the effects of a structured multicomponent intervention on quality of life and clinical depression in caregivers and on rates of institutional placement of care recipients in 3 diverse racial or ethnic groups.
Design
Randomized, controlled trial.
Setting
In-home caregivers in 5 U.S. cities.
Participants
212 Hispanic or Latino, 219 white or Caucasian, and 211 black or African-American caregivers and their care recipients with Alzheimer disease or related disorders.
Intervention
Caregivers within each racial or ethnic group were randomly assigned to an intervention or to a control group. The intervention addressed caregiver depression, burden, self-care, and social support and care recipient problem behaviors through 12 in-home and telephone sessions over 6 months. Caregivers in the control group received 2 brief “check-in” telephone calls during the 6-month intervention.
Measurements
The primary outcome was a quality-of-life indicator comprising measures of 6-month caregiver depression, burden, self-care, and social support and care recipient problem behaviors. Secondary outcomes were caregiver clinical depression and institutional placement of the care recipient at 6 months.
Results
Hispanic or Latino and white or Caucasian caregivers in the intervention group experienced significantly greater improvement in quality of life than those in the control group (P < 0.001 and P = 0.037, respectively). Black or African-American spouse caregivers also improved significantly more (P = 0.003). Prevalence of clinical depression was lower among caregivers in the intervention group (12.6% vs. 22.7%; P = 0.001). There were no statistically significant differences in institutionalization at 6 months.
Limitations
The study used only a single 6-month follow-up assessment, combined heterogeneous cultures and ethnicities into a single group, and excluded some ethnic groups.
Conclusions
A structured multicomponent intervention adapted to individual risk profiles can increase the quality of life of ethnically diverse dementia caregivers.
PMCID: PMC2585490  PMID: 17116917
18.  Racial/Ethnic- and Education-Related Disparities in the Control of Risk Factors for Cardiovascular Disease Among Individuals With Diabetes 
Diabetes Care  2012;35(2):305-312.
OBJECTIVE
There is limited information on whether recent improvements in the control of cardiovascular disease (CVD) risk factors among individuals with diabetes have been concentrated in particular sociodemographic groups. This article estimates racial/ethnic- and education-related disparities and examines trends in uncontrolled CVD risk factors among adults with diabetes. The main racial/ethnic comparisons made are with African Americans versus non-Latino whites and Mexican Americans versus non-Latino whites.
RESEARCH DESIGN AND METHODS
The analysis samples include adults aged ≥20 years from the National Health and Nutrition Examination Survey (NHANES) 1988–1994 and the NHANES 1999–2008 who self-reported having diabetes (n = 1,065, NHANES 1988–1994; n = 1,872, NHANES 1999–2008). By use of logistic regression models, we examined the correlates of binary indicators measuring 1) high blood glucose, 2) high blood pressure, 3) high cholesterol, and 4) smoking.
RESULTS
Control of blood glucose, blood pressure, and cholesterol improved among individuals with diabetes between the NHANES 1988–1994 and the NHANES 1999–2008, but there was no change in smoking prevalence. In the NHANES 1999–2008, racial/ethnic minorities and individuals without some college education were more likely to have poorly controlled blood glucose compared with non-Latino whites and those with some college education. In addition, individuals with diabetes who had at least some college education were less likely to smoke and had better blood pressure control compared with individuals with diabetes without at least some college education.
CONCLUSIONS
Trends in CVD risk factors among individuals with diabetes improved over the past 2 decades, but racial/ethnic- and education-related disparities have emerged in some areas.
doi:10.2337/dc11-1405
PMCID: PMC3263918  PMID: 22190677
19.  Oral health status and the epidemiologic paradox within latino immigrant groups 
BMC Oral Health  2012;12:39.
Background
According to the United States census, there are 28 categories that define “Hispanic/Latinos.” This paper compares differences in oral health status between Mexican immigrants and other Latino immigrant groups.
Methods
Derived from a community-based sample (N = 240) in Los Angeles, this cross-sectional study uses an interview covering demographic and behavioral measures, and an intraoral examination using NIDCR epidemiologic criteria. Descriptive, bivariate analysis, and multiple regression analysis were conducted to examine the determinants that are associated with the Oral Health Status Index (OHSI).
Results
Mexican immigrants had a significantly higher OHSI (p < .05) compared to other Latinos. The multilinear regression showed that both age and gender (p < .05), percentage of untreated decayed teeth (p < .001), number of replaced missing teeth (p < .001), and attachment loss (p < .001) were significant.
Conclusions
Compared with the other Latino immigrants in our sample, Mexican immigrants have significantly better oral health status. This confirms the epidemiologic paradox previously found in comparisons of Mexicans with whites and African Americans. In this case of oral health status the paradox also occurs between Mexicans and other Latinos. Therefore, when conducting oral health studies of Latinos, more consideration needs to be given to differences within Latino subgroups, such as their country of origin and their unique ethnic and cultural characteristics.
doi:10.1186/1472-6831-12-39
PMCID: PMC3528412  PMID: 22958726
Oral health status index; Immigrant; Latinos; Epidemiologic paradox
20.  HIV Risks and Seroprevalence Among Mexican American Injection Drug Users in California 
AIDS and Behavior  2009;15(1):95-102.
Latinos in the United States are an ethnically diverse group disproportionately affected by HIV/AIDS. We describe HIV seroprevalence, HIV risk behaviors and utilization of health services among Mexican American injection drug users (IDUs) in California (n = 286) and compare them to White (n = 830) and African American (n = 314) IDUs. Study participants were recruited from syringe exchange programs (n = 24) in California. HIV seroprevalence among Mexican Americans (0.5%) was dramatically lower than Whites (5%) and African Americans (8%). Mexican Americans reported fewer sex-related risks than Whites and African Americans though injection-related risks remained high. Compared to Whites, Mexican Americans were more likely to participate in drug treatment during a 6 month period (AOR 1.5, 95% CI 1.1, 2.0) but less likely to receive any health care (AOR 0.6, 95% CI 0.5, 0.8). Exploring cultural and structural factors among Mexican American IDUs may offer new insights into how to maintain low rates of HIV seroprevalence and reduce barriers to health care utilization.
doi:10.1007/s10461-009-9614-2
PMCID: PMC3023026  PMID: 20020194
Injection drug use; HIV/AIDS; Mexican American; Syringe coverage; Drug treatment; Health care utilization
21.  Economic Need among Older Latinos: Applying The Elder Economic Security Standard™ Index 
The first official U.S. federal poverty line was developed in the 1960s; since the mid-1990s the scientific consensus has been that it has become outdated and inaccurate. This article explains the key elements of the current federal measure that are inaccurate for older adults in general and older Latinos specifically. An alternative is described that addresses the key failings of the current measure. The alternative, the Elder Economic Security Standard™ Index (Elder Index), adapts a national methodology to the basic costs of living in California for 2007 using data from the American Community Survey, and other public data sources. The results show that the amount needed for basic economic security in California is higher than the federal poverty level in all counties, and averages about twice the federal level. Housing costs are the largest component of costs in most counties, although health care is the largest component for couples in lower housing cost counties. Among singles and couples age 65 and over in California, almost 60% of Latinos have incomes below the Elder Index compared to one-quarter of non-Latino whites. The rates are higher among renters, and older Latinos are more likely than non-Latino whites to rent. Applying the Elder Index in California documents the disproportionate rates of economic insecurity among older Latinos. The findings indicate that changes to public programs such as Social Security and Medicare that decrease benefits or increase costs will have disproportionately negative impact on the ability of most older Latinos to pay for basic needs.
doi:10.1007/s10823-013-9201-x
PMCID: PMC3770826  PMID: 23857068
poverty; older adults; California; health care costs; housing; Latinos
22.  Ethnic Differences in Caregiver Quality of Life in Pediatric Asthma 
Objective
The aim of this study was to determine ethnic and site differences in quality of life (QOL) in a sample of Latino (Puerto Rican and Dominican) and non-Latino White (NLW) caregivers of children with asthma in mainland US and Island PR. We also investigated ethnic and site differences in associations between caregiver QOL and indicators of asthma morbidity.
Method
Seven-hundred and eighty-seven children with asthma (7–16 years of age) and their primary caregivers participated. Primary caregivers completed a measure of QOL, child asthma control, and emergency department utilization, among other measures.
Results
Ethnic and site differences were found on total QOL scores (ΔF(1, 783) = 29.46, p < .001). Island PR caregivers reported worse QOL scores than RI Latino and NLW caregivers; RI Latino caregivers reported significantly worse QOL scores than NLW caregivers. In RI Latino and Island PR children, worse caregiver QOL was associated with asthma that was not in control and with 1 or more ED visits.
Conclusion
Latino caregivers may be experiencing a greater level of burden related to their child’s asthma than NLW caregivers. Caregiver QOL in pediatric asthma may be a reflection of broader, contextual stress that some Latino caregivers experience on a daily basis (e.g., cultural beliefs, acculturation). Future research should continue to investigate mechanisms that explain the burden associated with pediatric asthma in Latino families, as well as whether QOL assessments should consider the impact of everyday stressors on caregiver QOL in pediatric asthma.
doi:10.1097/DBP.0b013e318264c2b7
PMCID: PMC3463809  PMID: 23027132
pediatric asthma; quality of life; caregivers; disparities; ethnicity
23.  Predictors of Intensive End-of-Life and Hospice Care in Latino and White Advanced Cancer Patients 
Journal of Palliative Medicine  2013;16(10):1249-1254.
Abstract
Background
The role of end-of-life (EOL) care preferences and conversations in receipt of care near death for Latinos is unclear.
Objective
This study examines rates and predictors of intensive EOL and hospice care among Latino and white advanced cancer patients.
Design
Two-hundred-and-ninety-two self-reported Latino (n=58) and white (n=234) Stage IV cancer patients participated in a U.S. multisite, prospective, cohort study from September 2002 to August 2008. The Latino and white, non-Hispanic participants were interviewed and followed until death, a median of 118.5 days from baseline.
Measurements
Patient-reported, baseline predictors of EOL care included EOL care preference; terminal illness acknowledgement; EOL discussion; completion of a DNR order; and religious coping. Caregiver postmortem interviews provided information regarding EOL care received. Intensive EOL care was defined as resuscitation and/or ventilation followed by death in an intensive care unit. Hospice was either in- or outpatient.
Results
Latino and white patients received intensive EOL and hospice care at similar rates (5.2% and 3.4% for intensive care, p=0.88; 70.7% versus 73.4% for hospice, p=0.33). No white or Latino patient who reported a DNR order or EOL discussion at baseline received intensive EOL care. Religious coping and a preference for life-extending care predicted intensive EOL care for white patients (adjusted odds ratio [aOR] 6.69 [p=0.02] and aOR 6.63 [p=0.01], respectively), but not for Latinos. No predictors were associated with Latino hospice care.
Conclusions
EOL discussions and DNR orders may prevent intensive EOL care among Latino cancer patients. Efforts should continue to engage Latino patients and caregivers in these activities.
doi:10.1089/jpm.2013.0164
PMCID: PMC3791053  PMID: 24053593
24.  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
25.  Latino Access to the Patient-Centered Medical Home 
Journal of General Internal Medicine  2009;24(Suppl 3):514-520.
Background
Disparities can be caused by minorities receiving care in low-quality settings. The patient-centered medical home (PCMH) has been identified as a model of high-quality primary care that can eliminate disparities. However, Latinos are less likely to have PCMHs.
Objective
To identify Latino subgroup variations in having a PCMH, its impact on disparities, and to identify factors associated with Latinos having a PCMH.
Design
Analysis of the 2005 MEPS Household Component, a nationally representative survey with an oversample of Latino adults. The total sample was 24,000 adults, including 6,200 Latinos.
Measurements
The PCMH was defined as having a regular provider, who provides total care, fosters patient engagement in care, and offers easy access to care. Self reports of preventive care (cholesterol screening, blood pressure check, mammography, and prostate-specific antigen screening) and patient experiences were examined.
Results
White (57.1%) and Puerto Rican (59.3%) adults were most likely to have a PCMH, while Mexican/Mexican Americans (35.4%) and Central and South Americans (34.2%) were least likely. Much of the disparity was caused by lack of access to a regular provider. Respondents with a PCMH had higher rates of preventive care and positive patient experiences. Disparities in care were eliminated or reduced for Latinos with PCMHs. The regression models showed private insurance, which is less common among all Latinos, was an important predictor of having a PCMH.
Conclusions
Eliminating health-care disparities will require assuring access to the PCMH. Addressing differences in health-care coverage that contribute to lower rates of Latino access to the PCMH will also reduce disparities.
doi:10.1007/s11606-009-1119-1
PMCID: PMC2764044  PMID: 19842000
Latino subgroup; primary care; medical home; quality; patient experience; patient-centered medical home

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