Medicine:Hispanic paradox

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Short description: Epidemiological finding
Hispanic_America_(orthographic_projection)
Death rates for cancer and heart disease among men aged 45–64, by race and ethnicity: United States, 1999–2017[1]
Death rates for cancer and heart disease among women aged 45–64, by race and ethnicity: United States, 1999–2017[1]

The Hispanic paradox is an epidemiological finding that Hispanic Americans tend to have health outcomes that "paradoxically" are comparable to, or in some cases better than, those of their U.S. non-Hispanic White counterparts, even though Hispanics have lower average income and education, higher rates of disability, as well as a higher incidence of various cardiovascular risk factors and metabolic diseases.

Low socioeconomic status is almost universally associated with worse population health and higher death rates everywhere in the world.[2] The paradox usually refers in particular to low mortality among Hispanics in the United States relative to non-Hispanic Whites.[3][4][5][6][7][8] According to the Center for Disease Control's 2015 Vital Signs report, Hispanics in the United States had a 24% lower risk of mortality, as well as lower risk for nine of the fifteen leading causes of death as compared to Whites.[9]

There are multiple hypotheses which aim to determine the reason for the existence of this paradox. Some attribute the Hispanic paradox to biases created by patterns or selection in migration.[2][6] One such hypothesis is the Salmon Bias, which suggests that Hispanics tend to return home towards the end of their lives, ultimately rendering an individual "statistically immortal" and thus artificially lowering mortality for Hispanics in the United States.[2][6] Another hypothesis in this group is that of the Healthy Migrant, which attributes the better health of Hispanics to the assumption that the healthiest and strongest members of a population are most likely to migrate.[2][6]

Other hypotheses around the Hispanic paradox maintain that the phenomenon is real, and is caused by sociocultural factors which characterize the Hispanic population. Many of these factors can be described under the more broad categories of cultural values, interpersonal context, and community context.[10] Some health researchers attribute the Hispanic paradox to different eating habits, especially the relatively high intake of legumes such as beans and lentils.[11]

Since the 2010s, research has indicated that the Hispanic paradox is disappearing, as Latino mortality increases relative to white Americans, and cardiovascular risk factors are increasing in the Hispanic population.[12][13] In 2023, a study found that the mortality advantage of Hispanics had been largely erased by the COVID-19 pandemic, during which Hispanic death rates disproportionately increased.[14]

History

First coined as the Hispanic Epidemiological Paradox in 1986 by Kyriakos Markides, the phenomenon is also known as the Latino Epidemiological Paradox.[15] According to Markides, a professor of sociomedical sciences at the University of Texas Medical Branch in Galveston, this paradox was ignored by past generations, but is now "the leading theme in the health of the Hispanic population in the United States."[15]

The specific cause of the phenomenon is poorly understood, although the decisive factor appears to be place of birth. It appears that the Hispanic paradox cannot be explained by either the "salmon bias hypothesis" or the "healthy migrant effect",[16] two theories that posit low mortality among immigrants due to, respectively, a possible tendency for sick immigrants to return to their home country before death and a possible tendency for new immigrants to be unusually healthy compared to the rest of their home-country population. Historical differences in smoking habits by ethnicity and place of birth may explain much of the paradox, at least at adult ages.[17] Others have proposed that the lower mortality of Hispanics could reflect a slower biological aging rate of Hispanics.[18] However, some believe that there is no Hispanic paradox, and that inaccurate counting of Hispanic deaths in the United States leads to an underestimate of Hispanic mortality.[19]

Statistical findings

Mortality

Despite having lower socioeconomic status, higher rates of disability,[20] obesity,[21] cardiovascular disease[22] and type 2 diabetes,[23] most Hispanic groups, excepting Puerto Ricans, demonstrate lower or equal levels of mortality to their non-Hispanic White counterparts.[24] The Center for Disease Control reported in 2003 that Hispanic's mortality rate was 25 percent lower than non-Hispanic whites and 43 percent lower than African Americans.[15] This mortality advantage most commonly found among middle-aged and elderly Hispanics. The death rates of Hispanics to non-Hispanic whites was found to exceed 1.00 in the twenties, decreases by age 45, then is severely reduced to 0.75–.90 by at age 65, persisting until death. When controlling for socioeconomic factors, the health advantage gap for Mexican Americans, the largest Hispanic population in the US, increases noticeably.[24]

Hispanics do not have a mortality advantage over non-Hispanic Whites in all mortality rates; they have higher rates for mortality from liver disease, cervical cancer, AIDS, homicide (males), and diabetes.[3]

Infant mortality

Another important indicator of health is the infant mortality rate, which is also either equal to or lower than that of non-Hispanic Americans. A study by Hummer, et al. found that infants born to Mexican immigrant women in the United States have about a 10 percent lower mortality in the first hour, first day, and first week than that of infants born to non-Hispanic white, U.S.-born women.[25] In 2003, the national Hispanic infant mortality rate was found to be 5.7, nearly equal to that of non-Hispanic white Americans and 58 percent lower than that of African Americans.[15]

The children of Mexican immigrant women also have a lower infant mortality rate than that of U.S.-born Mexican-American women, even though the latter population usually has a higher income and education, and are much more likely to have health insurance.[26]

Reasons for the paradox

Socio-economic factors

According to Alder and Estrove (2006), the more socioeconomically advantaged individuals are, the better their health.[27] Access to health insurance and preventative medical services are one of the main reasons for socioeconomic health disparities. Economic hardship within the household can cause distress and affect parenting, causing health problems among children leading to depression, substance abuse, and behavior problems. Low socioeconomic status is correlated with increased rates of morbidity and mortality. Mental health disorders are an important health problem for those of low socioeconomic status; they are two to five times more likely to develop a diagnosable disorder than those of high socioeconomic status, and are more likely to face barriers to getting treatment. Furthermore, this lack of treatment for mental disorders can affect educational and employment opportunities and achievement.[28]

Residential segregation

Important to the understanding of migrant community health is the increasingly stratified American society, manifested in residential segregation. Beginning in the 1970s, the low to moderate levels of income segregation in the United States began to degrade.[29] As the rich became richer, so did their neighborhoods. This trend was inversely reflected in the poor, as their neighborhoods became poorer. As sociologist Douglas Massey explains, "As a result, poverty and affluence both became more concentrated geographically."[29] Professor of public administration and economics John Yinger writes that "one way for poor people to win the spatial competition for housing is to rent small or low-quality housing." However, he continues, low-quality housing often features serious health risks such as lead paint and animal pests. Though lead-based paint was deemed illegal in 1978, it remains on the walls of older apartments and houses, posing a serious neurological risk to children. Asthma, a possible serious health risk, also has a clear link to poverty. Moreover, asthma attacks have been associated with certain aspects of poor housing quality such as the presence of cockroaches, mice, dust, dust mites, mold, and mildew. The 1997 American Housing Survey found that signs of rats or mice are almost twice as likely to be detected in poor households as in non-poor households.[30]

Cultural values

Speculation of a sociocultural advantage stems from the idea that many traditional Hispanic cultural values are protective in health.[8] One such value is that of simpatia, a drive toward social harmony, which may serve to ameliorate social conflict and the negative stress-related health implications that come with it.[4] Familismo (family-centeredness) and allocentrismo (valuing the group) are both values which emphasize the needs of the group in accordance to those of the individual.[4] Respeto is another familial value in which family members are largely invested in care of their elders.[8] Emphasis on family attachment in the Latino culture is believed to foster social cohesion and a sturdy social support network, which is protective of health during adverse circumstances.[4][8] Furthermore, familial support has been associated with higher likelihood of taking preventative health measures and of seeking medical attention when ill.[4] Overall psychological and physical well-being has been found to be better in individuals who come from a supportive family than those who experience family conflict, which is why the family-centered culture of Hispanics may be advantageous in health.[4]

Interpersonal context

Social comparison theory

Social comparison theory proposes that individuals make comparisons with others, most often those of a similar group, in order to evaluate their own well-being and worth.[31] The psychological implications that these comparisons present depend on the nature of the comparisons. Upward comparisons often result in negative psychological effects due to feelings of disadvantage when being compared to those higher in the hierarchy. Conversely, lateral and downward comparisons often result in satisfaction when one sees himself as better off than those lower in the hierarchy.[31] Latino Americans and noncitizen Latinos are expected to make lateral or downward comparisons, either to other low-economic status Latinos and/or to relatives and friends in their home country. Such downward comparisons would result in boosted self-esteem and less psychological stress, resulting in better health.[31]

Social networks and support

Social capital is thought to be a significant moderator in the advantageous health outcomes of Latinos.[4][8] It has been found that the magnitude of the effect of social integration on mortality is greater than smoking fifteen cigarettes a day.[8] Characteristic values of Latino culture such as familismo and allocentrismo contribute to greater social cohesion and social support networks.[4] This tight social fabric is a mechanism which fosters resilience through social support.[8] Resilience is the ability to adapt to a disadvantageous experience and high resilience is protective in health.[32]

Hypotheses

Barrio advantage

One hypothesis for the Hispanic paradox proposes that living in the same neighborhood as people with similar ethnic backgrounds confers significant advantages to one's health. In a study of elderly Mexican-Americans, those living in areas with a higher percentage of Mexican-Americans had lower seven-year mortality as well as a decreased prevalence of medical conditions, including stroke, cancer, and hip fracture.[33] Despite these neighborhoods' relatively high rates of poverty due to lack of formal education and a preponderance of low paying service sector jobs, residents do not have the same mortality and morbidity levels seen in similarly disadvantaged socioeconomic neighborhoods. These neighborhoods do have intact family structures, community institutions, and kinship structures that span households, all of which are thought to provide significant benefits to an individual's health.[33] These social network support structures are especially important to the health of the elderly population as they deal with declining physical function. Another reason for this phenomenon could be that those Hispanic-Americans that live among those of similar cultural and social backgrounds are shielded from some of the negative effects of assimilation to American culture.[33]

Characteristics of the community in which one lives can also affect health.[7][10] Latino immigrants living in communities with a large proportion of Latinos experience better health than immigrants who live in communities with a smaller proportion of Latinos.[7][10] This is thought to be at least in part due to greater levels of social ties within majority-Latino communities which have been associated with greater social integration and social support.[10] While strong family ties definitively promote psychological and physical well-being, weaker ties such as those formed with other members of the community are thought to have similar health-promoting effects.[10] High collective efficacy, trust within the community which engenders mutually beneficial action, within Latino communities has also been shown to be protective of health, particularly in ameliorating asthma and breathing problems.[7] Better health outcomes for those living in communities with a high proportion of Latinos have been hypothesized to result from increased information exchange facilitated through a common language and ethnicity, as well as from benefits conferred through greater social support within the community.[7]

Acculturation

Acculturation, a phenomenon whereby individuals internalize habits and beliefs of a new culture upon being immersed in its social institutions, is also believed to influence the health of Latinos in the United States.[2][10][5][4] In this case, acculturation of Latino immigrants would mean the relinquishment of the characteristic sociocultural aspects of Latino culture listed above in favor of characteristics which are more representative of the American lifestyle. Research has given mixed results regarding the idea that the health of Latino immigrants worsen as length of stay in the United States increases.[2] As Latinos adopt American tendencies, for example, it is thought that the strong social support networks of tight-knit Latino communities are eroded, and the resulting stress begets worse health outcomes.[4] On the other hand, greater acculturation to the United States has been associated with worsening in some health behaviors, including higher rates of smoking and alcohol use, but improvement in others, such as physical activity.[5] It is important to note, however, that measurements of acculturation such as length of time in the United States, proportion of Latino friends, and language use are proxy measures and as such are not completely precise.[5][2] Furthermore, it is possible that confounding factors such as socioeconomic status influence the mixed effects of acculturation seen in health outcomes and behaviors.[2]

The extent of a Hispanic American's acculturation in the United States, or their assimilation to mainstream American culture, is relative to his or her health.[3] One of the main negative effects of acculturation on health has been on substance abuse. More assimilated Latinos have higher rates of illicit drug use, alcohol consumption, and smoking, especially among women.[34] Another negative effect of acculturation is changes in diet and nutrition. More acculturated Latinos eat fewer/less fruits, vegetables, vitamins, fiber and protein and consume more fat than their less acculturated counterparts.[34] One of the most significant impacts of acculturation on Latino health is birth outcomes. Studies have found that more acculturated Latinas have higher rates of low birthweight, premature births, teenage pregnancy and undesirable prenatal and postnatal behaviors such as smoking or drinking during pregnancy, and lower rates of breastfeeding.[34] Acculturation and greater time in the United States has also been associated with negative mental health impacts. US-born Latinos or long-term residents of the United States had higher rates of mental illness than recent Latino immigrants.[35] In addition, foreign-born Mexican Americans are at significantly lower risk of suicide and depression than those born in the United States.[35] The increased rates of mental illness is thought to be due to increased distress associated with alienation, discrimination and Mexican Americans attempting to advance themselves economically and socially stripping themselves of traditional resources and ethnically based social support.[36]

Healthy migrant effect

The "healthy migrant effect" hypothesizes that the selection of healthy Hispanic immigrants into the United States is reason for the paradox.[3] International immigration statistics demonstrate that the mortality rate of immigrants is lower than in their country of origin. In the United States, foreign-born individuals have better self-reported health than American-born respondents. Furthermore, Hispanic immigrants have better health than those living in the US for a long amount of time.

Salmon Bias

A second popular hypothesis, called the "Salmon Bias", attempts to factor in the occurrence of returning home.[3] This hypothesis purports that many Hispanic people return home after temporary employment, retirement, or severe illness, meaning that their deaths occur in their native land and are not taken into account by mortality reports in the United States. This hypothesis considers those people as "statistically immortal" because they artificially lower the Hispanic mortality rate.[3] Certain studies hint that it could be reasonable. These studies report that though return migration, both temporary and permanent, depend upon specific economic and social situations in communities, up to 75 percent of households in immigrant neighborhoods do some kind of return migration from the U.S. However, Abraido-Lanza, et al. found in 1999 that the "Salmon Hypothesis" cannot account for the lower mortality of Hispanics in the US because, according to their findings, the Hispanic paradox is still present when non-returning migrants are observed (e.g. Cubans).[3]

Slow biological aging

Horvath et al. (2013) have proposed that the lower mortality of Hispanics could reflect a slower biological aging rate of Hispanics.[18] This hypothesis is based on the finding that blood and saliva from Hispanics ages more slowly than that of non-Hispanic whites, African Americans, and other populations according to a biomarker of tissue age known as epigenetic clock.[18]

Comparison with other ethnicities

One of the most important aspects of this phenomenon is the comparison of Hispanics' health to non-Hispanic African Americans' health. Both the current and historical poverty rates for Hispanic and non-Hispanic African American populations in the United States are consistently starkly higher than that of non-Hispanic white and non-Hispanic Asian Americans.[30] Dr. Hector Flores explains that "You can predict in the African–American population, for example, a high infant-mortality rate, so we would think a [similar] poor minority would have the same health outcomes." However, he said, the health poor outcomes are not present in the Hispanic population.[15] For example, the age-adjusted mortality rate for Hispanics living in Los Angeles County was 52 percent less than the blacks living in the same county.[15]

Comparison to non-Hispanic white Americans

Although Hispanic Americans are twice more likely to be living under the poverty line and three times more likely to not have health insurance than non-Hispanic white Americans, they have a longer life span than them by 3 years. More Hispanics, than any other racial group, are uninsured and are in general less likely to use medical care. The median life span of Hispanic Americans is an average of 81.8 years and non-Hispanic white Americans have an average of 78.8 years.[37] This could be explained from scientist taking DNA samples from multiple ethnic groups, the blood from Latino aged more slowly than any other group.[37] It is also found that Hispanics, when first migrating to the US, have lower smoking rates, better diet and general health. Hispanic infant mortality is also less than NHWs with an average of 5.8 per 1000 births and 9.1 per 1000 births for non-Hispanic whites. In 2012, new cancer cases of all sites among Hispanic men and Non-Hispanic men had a ratio of 0.7, Hispanic men having 362.2 and Non-Hispanic men having 489.9.[38] In comparison to non-Hispanic Whites, Hispanic men are 10 percent less likely to be diagnosed with prostate cancer. Hispanic women, compared to NHW, were found to be 30 percent less likely to be diagnosed with breast cancer.

21st century waning of the paradox

Since the 21st century, a number of studies have published results which contradict the Hispanic paradox, suggesting that the health status of Hispanic Americans is declining. These findings include a higher incidence of cardiovascular disease risk factors among Hispanics,[12] higher rates or obesity,[12] increasing deaths from stroke even as white deaths remain stable,[12] and a larger increase in deaths from heart failure.[12] Other researchers have predicted that the paradox will disappear as obesity rates rise rapidly among Hispanic males, in particular.[13] A 2023 study published found that the Hispanic mortality advantage had been erased by the COVID-19 pandemic. Hispanic death rates increased at a much higher rate than White Americans death rates, during this period.[14]

Criticism

Some public health researchers have argued that the Hispanic paradox is not actually a national phenomenon in the United States. In 2006, Smith and Bradshaw argued that no Hispanic paradox exists. They maintain that life expectancies were nearly equal for non-Hispanic White and Hispanic females, but less close for non-Hispanic White and Hispanic males.[19] Turra and Goldman argue that the paradox is concentrated among the foreign born from specific national origins, and is only present in those of middle to older ages. At younger ages, they explain, deaths are highly related to environmental factors such as homicides and accidents. Deaths at older ages, they maintain, are more related to detrimental health-related behaviors and health status at younger ages. Therefore, immigration-related processes only offer survival protection to those at middle and older ages; the negative impact of assimilation into poor neighborhoods is higher on the mortality of immigrants at a younger age.[24] In contrast, Palloni and Arias hypothesize that this phenomenon is most likely caused by across-the-board bias in underestimating mortality rates, caused by ethnic misidentification or an overstatement of ages.[39] These errors could also be related to mistakes in matching death records to the National Health Interview Survey, missing security numbers, or complex surnames.[24]

Although it may not mean progress for all Hispanics, NPR.org claims some Hispanic migrants' lifestyles have been drastically improving within the United States due to Latino unemployment being at an all-time low of 4.2 percent.[40] The low unemployment rates have enabled families like the one talked about in the NPR.org article to have multiple streams of income by individuals working more than one job.

See also


References

  1. ↑ 1.0 1.1 Anderson, Robert N. (2005), "National Vital Statistics Reports", SAGE Publications, Inc., doi:10.4135/9781412952484.n432, ISBN 9781412904759 
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 "Understanding the Hispanic paradox". Ethn Dis 11 (3): 496–518. 2001. PMID 11572416. 
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Abraído-Lanza, Ana F; Dohrenwend, Bruce P; Ng-Mak, Daisy S; Turner, J Blake (1999). "The Latino mortality paradox: A test of the "salmon bias" and healthy migrant hypotheses". American Journal of Public Health 89 (10): 1543–8. doi:10.2105/AJPH.89.10.1543. PMID 10511837. 
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 Gallo, Linda C.; Penedo, Frank J.; Espinosa de los Monteros, Karla; Arguelles, William (December 2009). "Resiliency in the Face of Disadvantage: Do Hispanic Cultural Characteristics Protect Health Outcomes?". Journal of Personality 77 (6): 1707–1746. doi:10.1111/j.1467-6494.2009.00598.x. ISSN 0022-3506. PMID 19796063. 
  5. ↑ 5.0 5.1 5.2 5.3 Abraído-Lanza, Ana F.; Chao, Maria T.; Flórez, Karen R. (September 2005). "Do healthy behaviors decline with greater acculturation?: Implications for the Latino mortality paradox". Social Science & Medicine 61 (6): 1243–1255. doi:10.1016/j.socscimed.2005.01.016. ISSN 0277-9536. PMID 15970234. 
  6. ↑ 6.0 6.1 6.2 6.3 Abraído-Lanza, A F; Dohrenwend, B P; Ng-Mak, D S; Turner, J B (October 1999). "The Latino mortality paradox: a test of the "salmon bias" and healthy migrant hypotheses.". American Journal of Public Health 89 (10): 1543–1548. doi:10.2105/ajph.89.10.1543. ISSN 0090-0036. PMID 10511837. 
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Cagney, Kathleen A.; Browning, Christopher R.; Wallace, Danielle M. (May 2007). "The Latino Paradox in Neighborhood Context: The Case of Asthma and Other Respiratory Conditions". American Journal of Public Health 97 (5): 919–925. doi:10.2105/ajph.2005.071472. ISSN 0090-0036. PMID 17395846. 
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 Ruiz, John M.; Campos, Belinda; Garcia, James J. (May 2016). "Special issue on Latino physical health: Disparities, paradoxes, and future directions.". Journal of Latina/o Psychology 4 (2): 61–66. doi:10.1037/lat0000065. ISSN 2163-0070. 
  9. ↑ The Lancet (May 2015). "The Hispanic paradox". The Lancet 385 (9981): 1918. doi:10.1016/s0140-6736(15)60945-x. ISSN 0140-6736. PMID 26090624. 
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 Abraído-Lanza, Ana F.; Echeverría, Sandra E.; Flórez, Karen R. (2016-03-18). "Latino Immigrants, Acculturation, and Health: Promising New Directions in Research". Annual Review of Public Health 37 (1): 219–236. doi:10.1146/annurev-publhealth-032315-021545. ISSN 0163-7525. PMID 26735431. 
  11. ↑ Young, R. P.; Hopkins, R. J. (2014). "A review of the Hispanic paradox: Time to spill the beans?". European Respiratory Review 23 (134): 439–449. doi:10.1183/09059180.00000814. PMID 25445942. 
  12. ↑ 12.0 12.1 12.2 12.3 12.4 "The 'Hispanic paradox': Does a decades-old finding still hold up?". 2023-05-10. https://www.heart.org/en/news/2023/05/10/the-hispanic-paradox-does-a-decades-old-finding-still-hold-up. 
  13. ↑ 13.0 13.1 Nicole, Wendee (2023). "Paradox Lost? The Waning Health Advantage among the U.S. Hispanic Population". Environmental Health Perspectives 131 (1): 12001. doi:10.1289/ehp11618. ISSN 0091-6765. PMID 36607287. 
  14. ↑ 14.0 14.1 "Error: no |title= specified when using {{Cite web}}". https://academic.oup.com/pnasnexus/article/2/6/pgad173/7185600. ""The increase in Hispanic Americans' death rates during the pandemic largely erased their previous survival advantage relative to non-Hispanic White Americans and pushed their mortality rates above the average of other wealthy countries at all but the oldest ages."" 
  15. ↑ 15.0 15.1 15.2 15.3 15.4 15.5 Chung, Juliet (29 Aug 2006). "Hispanic Paradox: Income may be lower but health better than most". The Seattle Times. http://seattletimes.com/html/nationworld/2003233307_hispanichealth29.html. 
  16. ↑ "The Impact of Salmon Bias on the Hispanic Mortality Advantage: New Evidence from Social Security Data". Popul Res Policy Rev 27 (5): 515–530. 2008. doi:10.1007/s11113-008-9087-4. PMID 19122882. 
  17. ↑ "Explaining low mortality among US immigrants relative to native-born Americans: the role of smoking". Int J Epidemiol 40 (3): 786–93. June 2011. doi:10.1093/ije/dyr011. PMID 21324939. 
  18. ↑ 18.0 18.1 18.2 "An epigenetic clock analysis of race/ethnicity, sex, and coronary heart disease.". Genome Biol 17 (1): 171. 2016. doi:10.1186/s13059-016-1030-0. PMID 27511193. 
  19. ↑ 19.0 19.1 "Rethinking the Hispanic paradox: death rates and life expectancy for US non-Hispanic White and Hispanic populations". Am J Public Health 96 (9): 1686–92. September 2006. doi:10.2105/AJPH.2003.035378. PMID 16380579. 
  20. ↑ Hayward, Mark D. (20 November 2013). "Does the Hispanic Paradox in U.S. Adult Mortality Extend to Disability?". Population Research and Policy Review (Springer Science and Business Media LLC) 33 (1): 81–96. doi:10.1007/s11113-013-9312-7. ISSN 0167-5923. PMID 25821283. 
  21. ↑ "Q&A: Does the 'Hispanic Paradox' still exist?". 24 May 2016. https://www.princeton.edu/news/2016/05/24/qa-does-hispanic-paradox-still-exist. 
  22. ↑ Cortes-Bergoderi, Mery; Goel, Kashish; Murad, Mohammad Hassan; Allison, Thomas; Somers, Virend K; Erwin, Patricia J.; Sochor, Ondrej; Lopez-Jimenez, Francisco (2013). "Cardiovascular mortality in Hispanics compared to non-Hispanic whites: A systematic review and meta-analysis of the Hispanic paradox". European Journal of Internal Medicine (Elsevier BV) 24 (8): 791–799. doi:10.1016/j.ejim.2013.09.003. ISSN 0953-6205. PMID 24095273. ""Compared to non-Hispanic whites (NHW), Hispanics are reported to have greater prevalence of several cardiovascular (CV) risk factors such as obesity, type 2 diabetes mellitus (DM), dyslipidemia with high triglycerides and lower levels of high-density lipoprotein (HDL) cholesterol and physical inactivity [4]. Hispanics also have lower socioeconomic status, less access to health care, and achieve lower levels of education, all factors associated with higher rates of cardiovascular disease (CVD) [5]. Despite the increased prevalence of CV risk factors, several studies have shown a paradoxically lower rate of CVD among Hispanics as compared to NHW, including lower CV mortality. This observation has been referred to as the Hispanic paradox [6]. However, some studies have shown the opposite, raising the question of whether the Hispanic paradox was the result of methodological problems not accounted for in the original studies [7]."". 
  23. ↑ Lerman-Garber, Israel (2004). ""Diabetes and cardiovascular disease. Is there a true Hispanic paradox?"". Revista de Investigacion Clinica 56 (3): 282–296. ISSN 0034-8376. PMID 15612509. https://pubmed.ncbi.nlm.nih.gov/15612509/. Retrieved 28 May 2023. 
  24. ↑ 24.0 24.1 24.2 24.3 Turra, Cassio M.; Goldman, Noreen (2007). "Socioeconomic Differences in Mortality Among U.S. Adults: Insights Into the Hispanic Paradox". The Journals of Gerontology: Series B 62 (3): S184–92. doi:10.1093/geronb/62.3.S184. PMID 17507594. 
  25. ↑ Hummer, Robert A.; Powers, Daniel A.; Pullum, Starling G.; Gossman, Ginger L.; Frisbie, W. Parker (2007). "Paradox Found (Again): Infant Mortality Among the Mexican-Origin Population in the United States". Demography 44 (3): 441–57. doi:10.1353/dem.2007.0028. PMID 17913005. 
  26. ↑ DeCamp, Lisa Ross; Choi, Hwajung; Fuentes-Afflick, Elena; Sastry, Narayan (28 November 2014). "Immigrant Latino Neighborhoods and Mortality Among Infants Born to Mexican-Origin Latina Women". Maternal and Child Health Journal (Springer Science and Business Media LLC) 19 (6): 1354–1363. doi:10.1007/s10995-014-1640-7. ISSN 1092-7875. PMID 25430802. 
  27. ↑ Adler, Nancy E.; Ostrove, Joan M. (1999). "Socioeconomic Status and Health: What We Know and What We Don't". Annals of the New York Academy of Sciences 896 (1): 3–15. doi:10.1111/j.1749-6632.1999.tb08101.x. PMID 10681884. Bibcode: 1999NYASA.896....3A. 
  28. ↑ "Socioeconomic Status and Health". APA Public Interest Government Relations Office. http://www.apa.org/about/gr/issues/socioeconomic/ses-health.pdf. 
  29. ↑ 29.0 29.1 Massey, Douglas S. (2004). "The New Geography of Inequality in Urban America". in Henry, C. Michael. Race, Poverty, and Domestic Policy. New Haven: Yale University Press. pp. 173–87. ISBN 978-0-300-12984-7. https://books.google.com/books?id=_DmN-Zq-WPIC&pg=PA173. 
  30. ↑ 30.0 30.1 Yinger, John (2009). "Housing Discrimination and Residential Segregation as Causes of Poverty". in Danziger, Sheldon H.; Haveman, Robert H.. Understanding Poverty. Harvard University Press. pp. 359–91. ISBN 978-0-674-03017-6. https://books.google.com/books?id=vuy6JGuLdi0C&pg=PA359. 
  31. ↑ 31.0 31.1 31.2 Campbell, Kelly; Garcia, Donna M.; Granillo, Christina V.; Chavez, David V. (2012-04-30). "Exploring the Latino Paradox". Hispanic Journal of Behavioral Sciences 34 (2): 187–207. doi:10.1177/0739986312437552. ISSN 0739-9863. 
  32. ↑ Smith, Matthew Lee; Bergeron, Caroline D.; McCord, Carly E.; Hochhalter, Angela K.; Ory, Marcia G. (2018), "Successful Aging and Resilience: Applications for Public Health, Health Care, and Policy", Resilience in Aging (Springer International Publishing): pp. 17–33, doi:10.1007/978-3-030-04555-5_2, ISBN 9783030045548 
  33. ↑ 33.0 33.1 33.2 Eschbach, Karl; Ostir, Glenn V.; Patel, Kushang V.; Markides, Kyriakos S.; Goodwin, James S. (2004). "Neighborhood Context and Mortality Among Older Mexican Americans: Is There a Barrio Advantage?". American Journal of Public Health 94 (10): 1807–12. doi:10.2105/AJPH.94.10.1807. PMID 15451754. 
  34. ↑ 34.0 34.1 34.2 Lara, Marielena; Gamboa, Cristina; Kahramanian, M. Iya; Morales, Leo S.; Hayes Bautista, David E. (2005). "Acculturation and Latino Health in the United States : A Review of the Literature and its Sociopolitical Context". Annual Review of Public Health 26: 367–97. doi:10.1146/annurev.publhealth.26.021304.144615. PMID 15760294. 
  35. ↑ 35.0 35.1 "Latino Community Mental Health Fact Sheet". Nami Multicultural Action Center. http://www.nami.org/Content/NavigationMenu/Find_Support/Multicultural_Support/Annual_Minority_Mental_Healthcare_Symposia/Latino_MH06.pdf. 
  36. ↑ Kaplan, Mark S.; Marks, Gary (1990). "Adverse effects of acculturation: Psychological distress among Mexican American young adults". Social Science & Medicine 31 (12): 1313–19. doi:10.1016/0277-9536(90)90070-9. PMID 2287960. 
  37. ↑ 37.0 37.1 "The Hispanic paradox: scientists finally find out why Latinos age more slowly". 24 November 2016. https://www.weforum.org/agenda/2016/11/the-hispanic-paradox-scientists-finally-find-out-why-latinos-age-more-slowly/. 
  38. ↑ "Cancer – The Office of Minority Health". https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=61. 
  39. ↑ Palloni, Alberto; Arias, Elizabeth (2004). "Paradox Lost: Explaining the Hispanic Adult Mortality Advantage". Demography 41 (3): 385–415. doi:10.1353/dem.2004.0024. PMID 15461007. 
  40. ↑ "Hispanic Unemployment Has Hit Record Lows. But Does That Mean Progress?" (in en). https://www.npr.org/2019/05/25/725354469/hispanic-unemployment-has-hit-record-lows-but-does-that-mean-progress. 



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