Karl Eschbach

Neighborhood context and self-rated health in older Mexican Americans

PURPOSE To determine whether neighborhood characteristics are associated with self-rated health in older Mexican Americans. METHODS Epidemiologic data on 3050 older Mexican Americans residing in the southwestern United States during 1993 and 1994 were merged with 1990 US Census data. All subjects were matched to one of 210 census tracts (neighborhoods). Multilevel ordinal logit models were used to examine relationships between self-rated health and individual- and neighborhood-level variables. RESULTS After adjusting for individual characteristics, older Mexican Americans were more likely to rate their health poorer if they lived in neighborhoods that were economically disadvantaged, less populated by other Hispanics, or located within 50 miles of the US-Mexico border. In addition, residence in a border community moderated the relationship between self-rated health and neighborhood economic disadvantage. The effect of neighborhood economic disadvantage on poorer self-rated health was two to three times stronger for subjects living near the border region than subjects living further away from the border. CONCLUSIONS This study demonstrates the importance of considering several dimensions of neighborhood context, especially for Mexican Americans. Residence in a border community and neighborhood economic disadvantage were important predictors of poorer self-rated health status. In addition, older Mexican Americans experience a health benefit from living in neighborhoods populated with other Hispanics.

Evaluation of Mortality Data for Older Mexican Americans: Implications for the Hispanic Paradox

The authors evaluated underascertainment bias in Hispanic mortality rates from population surveys linked to the US National Death Index (NDI). They compared vital status through 7 years ascertained from an NDI search and from active follow-up for 2,886 Mexican-American subjects, aged >/=65 years at baseline in 1993-1994, from the Hispanic Established Populations for Epidemiologic Studies of the Elderly (EPESE). Estimates of NDI underascertainment were applied to mortality rate ratios for 66,667 older Mexican Americans and non-Hispanic Whites from the 1986-1994 National Health Interview Surveys linked to the NDI. The NDI and active follow-up agreed on vital status for 91.2% of Hispanic EPESE subjects. The NDI did not identify 177 deaths (20.7%) reported by proxies. Underascertainment was greater for women and when stratified by age and nativity. The ratios of proxy-reported to NDI mortality rates were 1.31 (95% confidence interval (CI): 1.06, 1.62) for immigrant men and 1.65 (95% CI: 1.32, 2.08) for immigrant women. Before adjustment, National Health Interview Surveys-NDI age-standardized mortality rate ratios comparing Mexican Americans with non-Hispanic Whites were 0.77 (95% CI: 0.65, 0.92) for men and 0.92 (95% CI: 0.77, 1.09) for women but were 0.84 and 1.18, respectively, with adjustment for underascertainment. Findings suggest that NDI-based Hispanic mortality rates may be understated.

Allostatic Load Among Non-Hispanic Whites, Non-Hispanic Blacks, and People of Mexican Origin: Effects of Ethnicity, Nativity, and Acculturation

OBJECTIVES We investigated ethnic differences in allostatic load in a population-based sample of adults living in Texas City, TX, and assessed the effects of nativity and acculturation status on allostatic load among people of Mexican origin. METHODS We used logistic regression models to examine ethnic variations in allostatic load scores among non-Hispanic Whites, non-Hispanic Blacks, and people of Mexican origin. We also examined associations between measures of acculturation and allostatic load scores among people of Mexican origin only. RESULTS Foreign-born Mexicans were the least likely group to score in the higher allostatic load categories. Among individuals of Mexican origin, US-born Mexican Americans had higher allostatic load scores than foreign-born Mexicans, and acculturation measures did not account for the difference. CONCLUSIONS Our findings expand on recent research from the National Health and Nutrition Examination Survey with respect to ethnicity and allostatic load. Our results are consistent with the healthy immigrant hypothesis (i.e., newer immigrants are healthier) and the acculturation hypothesis, according to which the longer Mexican immigrants reside in the United States, the greater their likelihood of potentially losing culture-related health-protective effects.

Country of birth and language are uniquely associated with intakes of fat, fiber, and fruits and vegetables among Mexican-American women in the United States.

OBJECTIVE Previous research on the relationship between diet and acculturation among Hispanics has produced inconsistent results. This study examined the association between diet, country of birth, and a language acculturation scale among Mexican-American women. DESIGN The study used a cross-sectional design with data from the 2000 National Health Interview Survey and its Cancer Control Module. The module was administered to one adult per household and included 17 dietary intake questions. SUBJECTS/SETTING Subjects were 1,245 nonpregnant women of Mexican descent between 25 and 64 years of age residing in the United States who were interviewed in their homes. STATISTICAL ANALYSIS PERFORMED Least-squares regression with sampling weights and adjustment of standard errors for survey design effects was used to estimate the associations between country of birth, language acculturation, and percent energy from fat, intake of fiber, and intake of fruits and vegetables, with statistical control for age, education, and marital status. RESULTS In multivariate models, US-born women consumed fewer grams of fiber per day (beta=-2.44; P<0.01) and a larger percentage of energy from fat (beta=2.06; P<0.01) than Mexican-born women. Greater English language use was associated with decreased consumption of fiber (P<0.01), and a decline in fruit and vegetable intake with a greater decline for US-born (P<0.10). CONCLUSIONS Acculturation is associated with several unfavorable dietary changes. Women who were born in the United States are at greater risk of declining dietary quality compared to Mexican-born women, and US-born English-speaking women have more unfavorable dietary profiles. Research and public health education concerning dietary intake should consider both country of birth and language.

Neighborhood composition and incidence of cancer among Hispanics in the United States

Hispanics in the United States have a 33% lower age‐adjusted incidence of cancer and a 38% lower cancer mortality rate compared with non‐Hispanic whites. This may be secondary to health behaviors that vary with residential and economic assimilation. The authors investigated whether cancer incidence among Hispanics increased with residential and economic assimilation into mainstream culture.

The Hispanic Mortality Advantage and Ethnic Misclassification on US Death Certificates

OBJECTIVES We tested the data artifact hypothesis regarding the Hispanic mortality advantage by investigating whether and to what degree this advantage is explained by Hispanic origin misclassification on US death certificates. METHODS We used the National Longitudinal Mortality Study, which links Current Population Survey records to death certificates for 1979 through 1998, to estimate the sensitivity, specificity, and net ascertainment of Hispanic ethnicity on death certificates compared with survey classifications. Using national vital statistics mortality data, we estimated Hispanic age-specific and age-adjusted death rates, which were uncorrected and corrected for death certificate misclassification, and produced death rate ratios comparing the Hispanic with the non-Hispanic White population. RESULTS Hispanic origin reporting on death certificates in the United States is reasonably good. The net ascertainment of Hispanic origin is just 5% higher on survey records than on death certificates. Corrected age-adjusted death rates for Hispanics are lower than those for the non-Hispanic White population by close to 20%. CONCLUSIONS The Hispanic mortality paradox is not explained by an incongruence between ethnic classification in vital registration and population data systems.

Hispanic Paradox in Adult Mortality in the United States

This chapter provides an update to our earlier review on the Hispanic paradox in adult mortality (Markides and Eschbach 2005). We focus primarily on manuscripts published beginning in 2005. As in our earlier review, we concentrate on mortality at adult and older ages. When relevant, however, we will draw on recent literature examining other outcomes, such as disability, health behaviors, medical conditions, and mental health.

Census Disability Rates Among Older People by Race/Ethnicity and Type of Hispanic Origin

Over the last 20 years or so there has been mounting evidence that Hispanics as a group as well as Hispanic populations from individual countries are characterized by relatively favorable mortality profiles despite generally disadvantaged socioeconomic profiles (Markides and Coreil, 1986; Markides, Rudkin, Angel, and Espino, 1977; Markides and Eschbach, 2005; Franzini, Ribble, and Keddie, 2001; Palloni and Morenoff, 2001; Sorlie, Rogot, and Johnson, 1993). The advantage shown in vital statistics is greatest, though such data likely underestimate mortality rates because of misclassification of Hispanic ethnicity on death certificates (Sorlie, Rogot, and Johnson, 1992). A somewhat lower advantage is shown with data from large population surveys linked to the National Death Index where misclassification of ethnicity on death certificates is not an issue, though completeness of record linkage may be (Hummer, Benjamins, and Rogers, 2004). The advantage is further reduced—but remains substantial—among older people when data are taken from the Social Security Administration’s Master Beneficiary record and the NUMIDENT file (Elo et al., 2004). While there is a lively debate about the source of a Hispanic mortality advantage that persists into old age (Abraido-Lanza, Dohrenwend, Ng-Mak, and Turner, 1999; Franzini et al., 2001; Markides and Eschbach, 2005; Palloni and Arias, 2004), it is generally accepted that the advantage is real and is also present at older ages. The data appear to show that the advantage is greatest among immigrants from Mexico, as well as among immigrant members of the residual category that the U.S. statistical system labels “other Hispanics” (Palloni and Arias, 2004). “Other Hispanics” are a diverse group that includes Dominicans, Spaniards; Central and South Americans, some Mexicans, Puerto Ricans, and Cubans who do not disclose a specific national origin; and persons of mixed ancestry. If indeed Hispanic populations experience low mortality rates—including at older ages—one would expect that they would also enjoy other health advantages; for example, in self-ratings of health. However, what may be most paradoxical about the Hispanic paradox is that this expectation is not what the data show. While

Mortality of Foreign-Born and US-Born Hispanic Adults at Younger Ages: A Reexamination of Recent Patterns

OBJECTIVES We sought to determine whether mortality rates among immigrant and US-born Hispanic young adults were higher or lower compared with non-Hispanic Whites. We also sought to identify which causes of death accounted for the differences in mortality rates between groups. Measures. We used Texas and California vital registration data from 1999 to 2001 linked to 2000 census denominators. We calculated cause-specific, indirectly standardized rates and ratios and determined excess/deficit calculations comparing mortality rates among US- and foreign-born Hispanic men and women with rates among non-Hispanic White men and women. RESULTS Mortality rates were substantially lower among Hispanic immigrant men (standardized mortality ratio [SMR]=0.79) and women (SMR=0.59) than among non-Hispanic White men and women. Most social and behavioral and chronic disease causes in Texas and California other than homicide were noteworthy contributors to this pattern. Mortality rates among US-born Hispanics were similar to or exceeded those among non-Hispanic Whites (male SMR=1.17, female SMR=0.91). CONCLUSIONS Mortality rates among younger Hispanic immigrants in Texas and California were lower than rates among non-Hispanic Whites. This pattern was not observed among US-born Hispanics, however.

Trends In Health Care Spending For Immigrants In The United States

The suspected burden that undocumented immigrants may place on the U.S. health care system has been a flashpoint in health care and immigration reform debates. An examination of health care spending during 1999-2006 for adult naturalized citizens and immigrant noncitizens (which includes some undocumented immigrants) finds that the cost of providing health care to immigrants is lower than that of providing care to U.S. natives and that immigrants are not contributing disproportionately to high health care costs in public programs such as Medicaid. However, noncitizen immigrants were found to be more likely than U.S. natives to have a health care visit classified as uncompensated care.