Nelda Mier, Ph.D.Assistant Professor

School of Rural Public HealthSocial and Behavioral Health Department

South Texas Center

The U.S. Census Bureau uses 5 race categories:

American Indian and Alaska Native Asian Black or African American White Native Hawaiian and Other Pacific

Islander

Race and Hispanic origin are separate and distinct concepts.

Hispanic" or "Latino" are those who classify themselves as: Mexican Puerto Rican Cuban “Other Spanish, Hispanic, or Latino."

U.S. Bureau Census: Origin can be considered as the heritage,

nationality group, lineage, or country of birth of the person or the person’s parents or ancestors before their arrival in the United States.

People who identify their origin as "Spanish," "Hispanic," or "Latino" may be of any race.

In 2000, the total population: 281,421,906.

98% of the population reported only one race, with a majority reporting to be White.

U.S. Bureau Census

BY 2050….

More than 1 in 8 people are Hispanic

2 in 5 Hispanics are foreign born

The Hispanic population became the largest minority group by increasing 67% --22.4 million in 1990 to 37.4 million in 2002, excluding Puerto Rico and other islands

U.S. Bureau Census 2000

U.S. Bureau Census 2000; Total population: 11 million

% of the Population that are White alone (2006)

% of the Population that are Black alone (2006)

% of the Population that are Asian alone (2006)

% of the Population that are American Indian and Alaska Native alone (2006)

% of the Population that are Native Hawaiian and other Pacific Islander alone (2006)

HOW MUCH DIVERSITY TO YOU SEE AROUND?

Minorities experience a disproportionate burden of preventable disease, death, and disability compared with non-Hispanic Whites

Williams DR, Collins C. U.S. socioeconomic and racial differences in health. In: LaVeist TA, editor. A public health reader. Race, ethnicity, and health. San Francisco, CA: Jossey-Bass; 2002. p. 391-431.

Asthma mortality Rate

(per million; northeast U.S. 1993-1995)

Hispanics/Latinos 34

whites 15.1

HIV/AIDS mortality rate per 100,000 (1999)

Puerto Ricans living on the U.S. mainland 32.7

non-Hispanic whites 2.4

national average 5.4

Adult immunization, 65+ years (2002)

Influenza vaccination

Hispanics/Latinos 46.7%

whites 70.2%

Millard AV, Graham MA, Mier N, Flores I, Carrillo-Zuniga G, & Sánchez ER. Addressing Health Disparities: The Hispanic Perspective. In S. Kosoko‑Lasaki, R.L. O'Brien & C.T. Cook [Eds.]. Promoting Cultural Proficiency in Eliminating Health Disparities. Boston: Jones & Bartlett Publishers. (In Press.)

Cancer of the cervix (2000)

Hispanic incidence higher than that of non- Hispanic whites by: 152%

Cancer of the stomach (2000)

Males: Hispanic incidence higher by: 63%

Females: Hispanic incidence higher by: 150%

Overweight among Hispanics 20 to 74 years of age

Males: Hispanic incidence higher than in non-Hispanic whites by: 11%

Females: Hispanic incidence higher by: 26%

Obesity, 20 to 74 years of age

Males: Hispanic incidence higher by: 7%

Females: Hispanic incidence higher by: 32%

Millard AV, Graham MA, Mier N, Flores I, Carrillo-Zuniga G, & Sánchez ER. Addressing Health Disparities: The Hispanic Perspective. In S. Kosoko‑Lasaki, R.L. O'Brien & C.T. Cook [Eds.]. Promoting Cultural Proficiency in Eliminating Health Disparities. Boston: Jones & Bartlett Publishers. (In Press.)

CDC, 2005

Millard AV, Graham MA, Mier N, Flores I, Carrillo-Zuniga G, & Sánchez ER. Addressing Health Disparities: The Hispanic Perspective. In S. Kosoko‑Lasaki, R.L. O'Brien & C.T. Cook [Eds.]. Promoting Cultural Proficiency in Eliminating Health Disparities. Boston: Jones & Bartlett Publishers. (In Press.)

Hispanics whites

Those under the age of 65 years with health insurance 66% 87%

Those with a regular source of ongoing health care 77% 90%

Vaccinations

Children aged 19-35 months who are fully vaccinated (2002) 73% 78%

Millard AV, Graham MA, Mier N, Flores I, Carrillo-Zuniga G, & Sánchez ER. Addressing Health Disparities: The Hispanic Perspective. In S. Kosoko‑Lasaki, R.L. O'Brien & C.T. Cook [Eds.]. Promoting Cultural Proficiency in Eliminating Health Disparities. Boston: Jones & Bartlett Publishers. (In Press.)

Why is important to understand cultural diversity and eliminate health disparities?

For health professionals, there is an ethical and moral dilemma that must be addressed. Their ethical standards demand fairness and compassion.

Healthcare is a resource that is associated to social justice, opportunity, and quality of life. Health status is linked to productivity.

Institute of Medicine, 2002

From the perspective of public health, racial and ethnic disparities threaten efforts to improve the nation’s health.

Racial and ethnic disparities in healthcare pose a significant dilemma to a society that is still dealing with a legacy of racial discrimination.

Institute of Medicine, 2002

Studies examining disparities Studies implementing culturally

sensitive interventions

Race, ethnicity, and cultural are consistently used interchangeably in health promotion research, even though they are not synonymous terms.

Integrated patterns of human behavior that include: language, thoughts, communications, actions, customs, beliefs, values and institutions of racial, ethnic, religious or social groups” (16)

Unique shared values, beliefs, and practices that are:- Directly associated with a health-related behavior- Indirectly associated with that behavior- Influencing acceptance and adoption of the health education message or activity. (15)

15.Pasick RJ DOC, Otero-Sabogal, R. Similarities and differences Across Cultures: Questions to Inform a Third Generation for Health Promotion Research. Health Education Quarterly 1996;23(Suppl):S142-S161.16.Assuring cultural competence in health care: Recommendations for national standards and outcomes-focused research agenda. In: Health USDoHaHSOoM, editor.: Washington, DC: U.S. Government Printing Office; 2000.

Race, ethnicity, language, nationality, and even geographic location are most commonly used as proxies for culture.

African Americans have a perception that “eating healthy” means giving up part of their cultural heritage and trying to conform to the dominant culture.(18)

Compared with White women, African American women are more satisfied with their weight and, if overweight, are more likely to feel attractive.(19)

18. James DC. Factors influencing food choices, dietary intake, and nutrition-related attitudes among African Americans: application of a culturally sensitive model. Ethnicity & health 2004;9(4):349-67.19. Eyler AA, Matson-Koffman D, Vest JR, Evenson KR, Sanderson B, Thompson JL, et al. Environmental, policy, and cultural factors related to physical activity in a diverse sample of women: The Women's Cardiovascular Health Network Project--summary and discussion. Women & health 2002;36(2):123-34.

Another study found that Latina women believe that sports are for men and that family and children come before personal needs (such as being physically active). (20)

Other studies found that Hispanics believe that diabetes is caused by emotional trauma .

(21) 20. Evenson KR, Sarmiento OL, Macon ML, Tawney KW, Ammerman AS. Environmental, policy, and cultural factors related to physical activity among Latina immigrants. Women & health 2002;36(2):43-57.21. Arcury TA, Skelly AH, Gesler WM, Dougherty MC. Diabetes meanings among those without diabetes: explanatory models of immigrant Latinos in rural North Carolina. Soc Sci Med 2004;59(11):2183-93.

Studies examining disparities Studies implementing culturally

sensitive interventions

The extent to which ethnic or cultural characteristics, experiences, norms, values, behavior patterns, and beliefs of a target population, and relevant historical, environmental, and social forces are incorporated in the design, delivery, and evaluation of targeted health interventions.

Resnicow K, Braithwaite RL, Dilorio C, Glanz K. Applying theory to culturally diverse and unique populations. In: Glanz K, Rimer BK, Lewis FM, editors. Health behavior and health education: theory, research, and practice. 3rd ed. San Francisco, CA: Joseey-Bass; 2002. p. 485-509.

Cultural Competence Multicultural Culturally appropriate, relevant, congruent,

specific.

Targeting denotes a process of identifying a population subgroup for the purpose of insuring exposure to the intervention by that group. E.g. targeting an ethnic group.

Tailoring implies adapting the intervention to best fit the needs and characteristics of a target population. (15)

Cultural tailoring is the development of interventions, strategies, messages, and materials to conform with specific cultural characteristics.(15)

Innovate?

Adopt an evidence-based program?

Literature review of RCTs testing nutrition and exercise interventions tailored for Hispanics

Principles and components of these interventions.

Mier N, Ory MG, Medina AA. Anatomy of Culturally Sensitive Interventions Promoting Nutrition and Exercise in Hispanics: A Critical Examination of Existing Literature Submitted to Health Promotion Practice. In review.

(1) described an intervention that was tailored for Hispanics; (2) the intervention aimed at modifying knowledge, beliefs, or behavior related to nutrition or exercise; (3) the intervention was tailored for Hispanics of any age group; (4) the study was based on the randomized controlled trial research design; (5) the study was published in a peer review journal, (6) the study was conducted in the United States; and (7) the study was published between 1990 and 2006.

Not much detail Settings:

Community agencies Churches Schools Media

Theory-driven, yes. But…1st Determine a specific health issue for which an

intervention is needed2nd Identify the theories from a socioecological

perspective and select the most appropriate one for understanding causal factors and processes of specific health-behaviors

3rd Determine potential points of interventions suggested by the selected theory or framework

4th Consider the collective wisdom on what interventions work with what populations under what conditions

http://www.lgreen.net/precede.htm

PRECEED-PROCEED model

Influenced by the health belief model, theory of reasoned action, and PRECEED-PROCEED model

Culture is the core of health promotion and disease prevention programs

Used to assess cultural eating patterns and to develop AIDS prevention programs.(18)

(Airhihenbuwa 1995); 18. James DC. Factors influencing food choices, dietary intake, and nutrition-related attitudes among African Americans: application of a culturally sensitive model. Ethnicity & health 2004;9(4):349-67.

PositiveExistentialNegative

PerceptionsEnablersNurturers

PersonExtended FamilyNeighborhood

CULTURAL EMPOWERMENT RELATIONSHIPS &EXPECTATIONS

CULTURAL IDENTITY

PEN-3 MODEL

Acknowledges the role of social and cultural influences in health behavior

Emphasizes the transactions between individual and the environment at different levels: individual, family, community, environment.

It uses a consumer orientation, audience analysis and segmentation, and aspects of exchange theory.

Reaim.org

It emphasizes the idea that communities themselves can achieve social and behavioral outcomes and that social forces influence behaviors.

Formative research plays an important role in the design and implementation of an intervention for Hispanics.

Health assessments, focus group discussions, literature searches, and interviews are tools for tailoring an intervention by identifying attitudes, beliefs, language use, and other opinions of the priority population in relation to specific health issues or behaviors

The diversity of the Hispanic population must be acknowledged in intervention design

Consider immigration and contextual factors in intervention design

Consider acculturation, but also understand that it is a complex phenomenon and more research is needed to better assess its impact on health outcomes.

Level of immersion in the new culture or how far people have deviated from their cultural origins in adopting features of the new or dominant culture

Conflicting evidence about the influence of acculturation on health behaviors (see table).

Lara M, Gamoa C, Kahramanian MI, Morales LS, Hayes Bautista DE. (2005). Annu Rev Public Health, 26, 367-97.Millard AV, Graham MA, Mier N, Flores I, Carrillo-Zuniga G, & Sánchez ER. Addressing Health Disparities: The Hispanic Perspective. In S. Kosoko‑Lasaki, R.L. O'Brien & C.T. Cook [Eds.]. Promoting Cultural Proficiency in Eliminating Health Disparities. Boston: Jones & Bartlett Publishers. (In Press.)

Salient culturally sensitive intervention components are Bilingual and bicultural facilitators and

materials Family-based activities Literacy-appropriate materials Social support. Having a clear understanding of Hispanic

cultural values is also required.

Evidence-based programs must use a program structure and curriculum that have been proven through prior research to be beneficial for participants.

Incorporate measurable goals so that program managers can further evaluate and document their benefits in different settings and populations.

Mary Altpeter, Ph.D., “Healthy Aging Briefing Series: The Basics of Evidence-Based Health Promotion Programming,” July 20, 2006.

Pilot study A walking program for low-income women

of Mexican origin living in areas known as “colonias” in the Texas-Mexico border region.

Stages of Change Model Community-based Participatory Research

SOURCE: The Rio Grande Valley Partnership/Chamber of Commerce

1.2 million people (U.S. Census

2006)

(US Census Bureau, 2006)

(US Census Bureau, 2006)

EDUCATION LEVEL (< HS)EDUCATION LEVEL (< HS)

(US Census Bureau, 2006)

Unincorporated, impoverished settlements located along the U.S.-Mexico international boundary (Ward, 1999)

Texas: 1,524 colonias (N=400,000) (Ward, 1999); 60% of these colonias are located in Hidalgo County (Federal Reserve Bank of Dallas (FRBD), 1995; Housing Assistant

Council, 2000; Ward, 1999).

Average household income > $834 month 70% of residents have less than high

school education High unemployment rates (20% - 60%,

compared to 7% at the state level) and a lack of medical services (FRBD).

50% of colonia residents are immigrants, mostly from Mexico (Dutton, Weldon, Shannon, Bowcock, Tackett-Gibson,

Blakely et al., 2000).

-Non-expensive- Feasible activities-Included topics

of diabetes and exercise- Addressed dogs problem- Social activities- Certificate- Children’s issue

The duration of the program was 12 weeks Program based on PA recommendations and

encouraged participants to incorporate walking activities into their lifestyle.

The groups met separately every week for 1-hour

The promotoras worked with participants using a problem-solving, self-management approach to discuss physical activity behavior change strategies.

Addressed challenges

Ninety-three percent of participants attended 88% of the sessions

According to the program fidelity assessment we conducted, the promotoras delivered every lesson of the program as planned

Acceptance of the program was assessed through feedback sessions with participants.

Theory driven and use of the community-based participatory research

Feasibility issues: cost, setting, training, language.

Acculturation? Evaluation issues