The Hispanic health paradox: From epidemiological phenomenon to contribution opportunities for psychological science

Abstract

Similar to non-Hispanic Blacks, Hispanics/Latinos experience a range of psychosocial and physical health challenges, including high rates of poverty, neighborhood segregation, discrimination, poor healthcare access, and high rates of obesity, diabetes, and undiagnosed and late-stage diagnosed diseases. Despite such risks, Hispanics generally experience better physical health and lower mortality than non-Hispanic Whites, an epidemiological phenomenon commonly referred to as the Hispanic or Latino health paradox. With the basic phenomenon increasingly well-established, attention now turns to the sources of such resilience. The current aims are to briefly examine the epidemiological paradox and highlight potential sociocultural resilience factors that may contribute to the paradoxical effects. We conclude with presentation of a framework for modeling sociocultural resilience and discuss future directions for psychological contributions.

Keywords

health disparities Hispanic/Latino Hispanic paradox mortality race/ethnicity

Overview

Figure 1 displays an emerging fact supported by increasingly robust data: Hispanics in the United States have a greater life expectancy than non-Hispanics, including non-Hispanic (NH) Whites. This epidemiological phenomenon is commonly referred to as the Hispanic or Latino health paradox, given the significant socioeconomic and psychosocial disadvantages Hispanics experience relative to NH Whites. Contemporary research on Hispanic health reveals that although Hispanics experience higher incidence of diabetes, viral-mediated cancers, and various communicable diseases, they experience significantly lower rates of the major causes of death, including heart disease, stroke, all-site cancers, and infant mortality compared to non-Hispanic Whites (NHW; Heron 2015; Mozaffarian et al., 2015; Siegel et al., 2015). These patterns challenge several basic tenets of minority health, raise questions about the generalizability of existing knowledge from one racial/ethnic group to another, and compel us to investigate the causes of resilience with potential clinical implications for all.

Figure 1.

Racial/ethnic differences in life expectancy (in years) for a person born in 2013. Note that Hispanics have a greater life expectancy among total, men, and women and that the widest disparity is between the life expectancy of Hispanic women and NH Black men (12 years).

With the basic epidemiological patterns increasingly well-established, there is an emerging opportunity for social scientists to contribute to unraveling the associated pathways. Therefore, the current aim is to briefly review the epidemiological evidence, discuss potential explanatory mechanisms, and highlight the potential for psychological sciences to contribute to advancing understanding of the emerging picture.

A quick note on terminology: Hispanics/Latinos may prefer to be referenced by their ancestral country of origin or background (Mexican American, Puerto Rican, etc). However, a majority of the literature omits or fails to measure specific background, instead using the umbrella terms Hispanic and Latino to collectively refer to peoples and countries with historic links to Spain or countries where Spanish is the dominant language (for more information see Humes, Jones, & Ramirez, 2011). These terms also have a long history of use in the biomedical literature including in federally funded research and government data. Therefore, we will use these terms interchangeably and reference specific Hispanic backgrounds where data is clear.

Hispanics and Physical Health Risks

Hispanics are a growing and diverse community representing over 22 countries of origin and with significant heterogeneity in behaviors, diet, and traditions. However, what often binds Hispanics together is a common language and values of collectivism and interpersonal harmony (Oboler, 1995). Collectively, the U.S. Hispanic population exceeds 55 million with 65% native to the US (Lopez & Patten, 2015). With Hispanics accounting for over 50% of the nation’s annual population growth (Colby & Ortman, 2015), they not only represent the future of our national makeup but a critical contributor to, and consumer of, healthcare. It is therefore important to document their health needs to more accurately intervene.

Health behaviors

Critical to understanding Hispanic health is the degree to which they engage in health-damaging behaviors. A handful of behaviors, including smoking, alcohol use, physical activity, and diet are associated with a broad range of health risks (e.g., obesity, poorer management of diabetes, and hypertension). Aggregating the evidence, San Diego County, California, noted that three of these behaviors (smoking, diet, physical activity) account for significant variance in four major diseases (heart disease and stroke, cancer, Type 2 diabetes, lung disease) to account for 50% of all deaths worldwide (“3–4–50” campaign; County of San Diego, Health and Human Services Agency, Public Health Services, & Community Health Statistics Unity, 2010).

Despite other health risks, the prevalence of smoking among Hispanic adults is 12.9% (men: 17.0%; women: 8.6%), a rate far below the national average of 19% and of both non-Hispanic Whites and Blacks (20.6% and 19.4% respectively; Mozaffarian et al., 2015). There is considerable variance in smoking among Hispanics, with the highest rates found among Puerto Rican and Cuban men (35% and 31%) and women (33% and 22%); lowest among Dominican men (11%) and women (12%; Daviglus et al., 2012). As later discussed, this difference is critical to understanding both disease prevalence and outcomes among Hispanics.

In contrast to smoking, most other health behaviors are quite problematic. Hispanics have some of the highest rates of child and adult obesity in the US (Ogden, Carroll, Kit, & Flegal, 2014) with 36.5% of men and 45.8% of women of Mexican descent having a body mass index (BMI) greater than 30, the gold standard for obesity classification. These high rates are due to a cluster of factors, including conceptions of ideal child body size to adult issues of diet and physical activity. As is the case for other minority and lower socioeconomic status (SES) populations, physical activity is difficult to quantify for Hispanics. To illustrate, Hispanics engage in less leisure time physical activity such as walking/running, yoga, or going to a gym compared to non-Hispanics (Marshall et al., 2007). However, Hispanics are more likely to work in physical jobs that are less sedentary than other professions. When physical activity is conceptualized more broadly as a function of daily activity (as opposed to leisure time activity alone) and assessed objectively with activity monitors such as accelerometers, Hispanics are observed to be more active than other groups (Ham & Ainsworth, 2010). Despite these differences, obesity remains a salient problem that needs further study.

Acculturation plays a major health-damaging role for Hispanics and their health behaviors. Growing evidence documents a deleterious, inverse relationship between higher levels of acculturation to the US and worse health behaviors, including higher rates of smoking (Kondo, Rossi, Schwartz, Zamboanga, & Scalf, 2015), obesity (Kaplan, Huguet, Newsom, & McFarland, 2004), and alcohol use (Ramisetty-Mikler, Caetano, & Rodriguez, 2010). These consistent findings inform health projections for this population as they become more interwoven into the blended U.S. culture. At the same time, the findings suggest some protective cultural effects that should be identified to inform potential health interventions.

Health insurance

In addition to individual health behaviors, access to healthcare is an important moderator of health literacy, risk surveillance, early intervention and management, and outcomes (DeVoe, Fryer, Phillips, & Green, 2003; DeVoe, Tillotson, Wallace, Lesko, & Pandhi, 2012; Fryer, Dovey, & Green, 2000; U.S. Department of Health & Human Services, 2011). Prior to enactment of the Affordable Care Act 2010, 84.6% or 263.2 million people in the United States had some form of health insurance coverage (DeNavas-Walt, Proctor, & Smith, 2013). The corresponding uninsured rate was approximately 15%, including 11.1% of non-Hispanic Whites, 15.1% of non-Hispanic Asian Americans, and 19% of non-Hispanic Blacks. In contrast, the uninsured rate among Hispanics was nearly twice the national average at 29.1%. As a consequence, Hispanics have been less able to access important preventative health services, which likely contributes to high rates of undiagnosed and late-diagnosed diseases (Brookfield, Cheung, Lucci, Fleming, & Koniaris, 2009; E. C. Smith, Ziogas, & Anton-Culver, 2013; Valdovinos et al., 2015).

In addition to insurance concerns, one third of Hispanics report not having a usual source of healthcare (Centers for Disease Control and Prevention [CDC], 2007). A consistent source of care is important to understand history, manage chronic illnesses, navigate across services, and address posttreatment adjustment (DeVoe et al., 2003; Fryer et al., 2000; Weiss & Blustein, 1996). Even when Hispanics do receive care, they report significantly lower satisfaction than the national average and particularly non-Hispanic Whites (Phillips, Chiriboga, & Jang, 2012; Saha, Arbelaez, & Cooper, 2003). Several studies document that dissatisfaction with care has negative downstream effects on engagement and treatment adherence (Fiscella, Franks, Doescher, & Saver, 2002; Yang et al., 2009). Hence, Hispanics not only experience significant access disparities, but the lack of a usual source of care and poor quality of care also have additional deleterious effects.

Understanding the Hispanic Paradox

Despite their significant psychosocial and physical health risk profile, Hispanics generally experience better health and live longer than non-Hispanics: an epidemiological phenomenon commonly known as the Hispanic or Latino health paradox. This paradoxical phenomenon is supported not only by overall life expectancy data, but also by apparent advantages in specific health conditions including lower infant mortality rates and lower prevalence for most major diseases.

Life Expectancy

In stark contrast to NH Blacks, Hispanics live longer than NH Whites (CDC, 2015; Heron, 2015). For example, a person of Hispanic ethnicity born in 2013 has a projected life expectancy of 81.6 years, which is roughly 2.5 years longer than NH Whites (78.9 years) and 6.5 years longer than NH Blacks (75.1 years). The Hispanic mortality advantage was first documented by Markides and colleagues in the Southwestern United States in the early 1980s (Markides, 1983; Markides & Coreil, 1986). Several early hypotheses attempted to explain the mortality paradox as a function of data bias. These included the healthy migrant hypothesis (i.e., Hispanics in the US represent a biased, healthy sample of immigrants), the salmon bias hypothesis (i.e., Hispanics registering in the census but returning to their country of origin before death resulting in mortality underestimation), and broader data error problems such as ethnic misclassification on death certificates. Although some critics continue to reference these hypotheses, they have all been directly refuted (see Abraido-Lanza, Dohrenwend, Ng-Mak, & Turner, 1999; Arias, Eschbach, Schauman, Backlund, & Sorlie, 2010), and the mortality advantage has been further validated through a variety of methodological approaches. For example, Arias et al. (2010) estimated relative mortality differences by examining death certificates relative to census counts. Results indicated an approximate 20% mortality advantage for Hispanics relative to non-Hispanics. Importantly, Arias found that ethnic misclassification was comparable between groups, addressing associated data error concerns. In addition, Ruiz, Steffen, and Smith (2013) conducted a meta-analysis of the prospective literature to examine mortality differences. Among 58 studies representing 4.6 million participants, Hispanics were 17.5% more likely than non-Hispanics to be alive at the end of the study (OR = 0.825, p < .001, 95% CI [0.75, 0.91]). Note that both methodologies yielded roughly the same effect size (20% vs. 17.5%), supporting not only the validity of the phenomenon but the magnitude of the effect.

Specific Impacts on Life Expectancy

Infant mortality

Infant mortality rates in the US vary substantially by race/ethnicity, with non-Hispanic Blacks having the highest infant mortality rate at 11.1 per 1,000 live births. In contrast, the infant mortality rate for Hispanics is similar to that of non-Hispanic Whites (5.00 vs. 5.06 deaths per 1,000 live births), despite significant socioeconomic and prenatal healthcare disparities (El-Sayed, Paczkowski, March, & Galea, 2014). Underlying these effects for Hispanics is a reduced incidence of low birth weight infants (i.e., less than 5 pounds, 5 ounces), the primary risk factor for infant mortality (Romero, Duke, Dabelea, Romero, & Ogden, 2012). Despite the overall advantages, there is significant heterogeneity in infant mortality among Hispanics, based on both origin/nativity and social environment. For example, infant mortality rates are lower for foreign-born compared to U.S.-born Hispanics (Collins, Soskolne, Rankin, & Bennett, 2013; Flores, Simonsen, Manuck, Dyer, & Turok, 2012; Hummer, Powers, Pullum, Gossman, & Frisbie, 2007; Powers, 2013). In addition, low infant birth weight and infant mortality rates are lower for Hispanics living in more ethnically dense, Hispanic enclaves or “barrios” (Shaw & Pickett, 2013; Shaw, Pickett, & Wilkinson, 2010). These environments tend to be economically poor but culturally rich, suggesting a sociocultural mechanism for advantages in infant mortality.

Cardiovascular disease (CVD)

Like all other racial/ethnic groups, Hispanics experience significant CVD burden in prevalence, morbidity, and mortality. However, they also are at relative advantage at each stage of the disease course. For example, the prevalence of CVD in Hispanics (8.3%) is significantly lower than for both NH Blacks and Whites (11.1% and 10.3%, respectively), despite a significant risk profile including high rates of obesity, diabetes, and cholesterol (Mozaffarian et al., 2015). In addition, the prevalence of stroke and hypertension among Hispanics (2.6%, 21.6%) is roughly equivalent to that of NH Whites (2.5%, 22.8%) and significantly lower than that of NH Blacks (3.6%, 32.6%). These differences in prevalence contribute, but do not entirely account for an observed CVD-mortality advantage (Heron, 2015). For example, a meta-analysis of 17 cohort studies, involving 22.3 million Hispanics and 88.8 million NH Whites, found that Hispanics were at 33% lower risk of cardiovascular-specific mortality (Cortes-Bergoderi et al., 2013). Moreover, in their meta-analysis of the prospective literature, Ruiz et al. (2013) found that Hispanics held a 25% survival advantage over non-Hispanics among persons with diagnosed heart disease; this finding is suggestive of a survival advantage in the context of heart disease. Together these data support the conclusion that compared to non-Hispanics, Hispanics have lower prevalence of CVD despite greater risk, and lower CVD-specific mortality, which is supported by a survival advantage among persons with CVD.

Cancer

Cancer is the leading cause of death for Hispanics, yet their cancer-specific mortality rates (114.5 deaths per 100,000 persons in 2013) are lower than for non-Hispanic Whites and Blacks (167.7 and 194.4, respectively; CDC, 2015). Underlying this observation is evidence that Hispanics experience significantly lower incidence rates for the most common forms of cancer. Hispanics are 8% less likely to be diagnosed with prostate cancer, nearly 40% less likely to be diagnosed with breast cancer, and more than 90% less likely to be diagnosed with lung cancer compared to NH Whites. Hispanics do have higher rates of stomach, liver, and cervical cancers, but these are relatively less prevalent forms of cancer. Moreover, a portion of these cancers are associated with infections (e.g., helicobacter pylori, Hepatitis B and C, human papilloma virus), indicating that increased prevention (e.g., vaccination, reduced exposure to infectious agents, screening) could reduce these disparities for Hispanics (Siegel et al., 2015).

Diabetes

In contrast to heart disease and cancer, Hispanics experience a disproportionate burden of diabetes. With an estimated prevalence rate of 12.8%, diabetes represents a significant public health challenge for Hispanics. Risk increases with acculturation, as well as overall time in the United States. Hispanics also have a high prevalence of metabolic syndrome (MetSyn), a related condition characterized by a cluster of cardiometabolic abnormalities, including but not limited to high abdominal obesity, high blood pressure, high triglycerides, low HDL cholesterol, high blood glucose levels, and insulin resistance (Grundy et al., 2004). Downstream consequences of these metabolic conditions include end-stage renal disease (ESRD), a condition characterized by kidney failure requiring dialysis or transplant. Hispanics are 1.5 times more likely to be diagnosed with ESRD compared to NH Whites (U.S. Renal Data System, 2010), a disparity which likely reflects differences in access to early care. For example, examination of 321,996 adults in the U.S. Renal Data System revealed that Hispanics were 15% less likely than non-Hispanics to initiate optimal dialysis interventions. Despite these differences, Hispanics appear to survive longer in the context of ESRD (Arce, Goldstein, Mitani, & Winkelmayer, 2013; Frankenfield, Rocco, Roman, & McClellan, 2003; Nicholas, Kalantar-Zadeh, & Norris, 2013).

Summary

Hispanics have a greater life expectancy than non-Hispanics, reflecting specific advantages in infant mortality, lower rates for most major diseases, and reduced disease-specific mortality. These effects tend to be large, consistent, and broadly span multiple unique health conditions. The findings challenge several basic tenets of minority health, raise questions about the generalizability of existing knowledge from one racial/ethnic group to another, contest the validity of existing risk prediction models, and compel us to investigate the causes of resilience.

Sociocultural Resilience and the Hispanic Paradox

Hispanic health advantages may reflect a constellation of factors, including but not limited to genetic/biological advantages, significantly lower rates of smoking, risk overestimation, and/or failure to account for offsetting resilience factors. With a comprehensive review of these pathways beyond the current scope, we will focus here on the issue of sociocultural resilience.

The dominant resilience hypothesis to explain the broad Hispanic health advantages focuses on cultural factors facilitating health-promoting social processes (Campos et al., 2008; Gallo, Penedo, de los Monteros, & Arguelles, 2009; Hovey, 2000; Riosmena & Dennis, 2012). A common iteration of this idea is that Hispanic cultural values for collectivism, family (familismo), interpersonal harmony (simpatía), and valuing of elder community members (respeto) facilitates greater social integration with tighter social connections between members leading to a wealth of social capital/resources and communal coping. Social integration is amongst the most robust psychosocial health moderators (Holt-Lunstad, Smith, & Layton, 2010). In this example, social integration serves as a key health-promoting process which affects health through a variety of social mechanisms (e.g., stress buffering, tangible support, communal coping). The processes described by this “sociocultural hypothesis” may affect health at each point in the disease course from initial susceptibility to survival in the context of advanced disease.

Modeling Sociocultural Resilience

In Figure 2 we illustrate this core conceptual framework for modeling how cultural factors influence health through activation of social networks. Note that although the arrows illustrate the causal direction most germane to this hypothesis, this specificity does not imply that there are not reciprocal relationships.

Figure 2.

The conceptual model of Hispanic sociocultural health resilience illustrating how social networks mediate the association between Hispanic cultural processes and health advantages. Hispanic cultural processes (values, social behaviors, etc.) facilitate larger and more cohesive social networks (family, community) and environments (Path A). Social networks positively moderate health advantages (Path B) and mediate the observed “Hispanic health paradox” represented in Path C.

The model has three key elements: Cultural processes, social networks, and health. Cultural processes refer to the cluster of values, traditions, and knowledge representations that define a cultural group. In this model we refer specifically to those cultural elements that characterize Hispanics. These processes can vary in strength of representation (e.g., degree of acculturation) and specific makeup (e.g., aspects of Hispanic subculture). Social networks refer broadly to social resources, including traditional conceptions of social networks such as family, friends, and acquaintances as well as broader social environments such as neighborhood and community. Like cultural processes, the enacted social network can vary by time and condition. For example, a hospitalized patient might receive emotional support from a visiting family member or through word of a prayer service held for them at a community church. The specific social network actor or actors may vary to activate a basic effect pathway (e.g., emotional, tangible support) to influence health. Finally, health can refer to mental or physical health and, like the other variables, can range on a continuum. In this heuristic, cultural processes modulate engagement of social networks (Path A) with higher network resources then leading to health benefits (Path B). Social networks then serve to mediate the observed relationship between cultural processes and health (Path C). Importantly, this core model is likely moderated by various biopsychosocial factors including biological processes (Dumais & Veenema, 2015), individual differences (T. W. Smith, Ruiz, Cundiff, Baron, & Nealey-Moore, 2013), and proximity of social network members and frequency of contact (Shor, Roelfs, & Yogev, 2013). Although the full model remains largely untested, there is both direct and indirect evidence to support the specific pathways.

Cultural processes and social networks (Path A)

Hispanic cultural processes are associated with a broad array of social network characteristics that distinguish them from the U.S./American culture. Hispanic culture is collectivistic, emphasizing or valuing the importance of group (e.g., family, community) in all respects including its identity, needs, and priorities (Rinderle & Montoya, 2008). Other important values such as familismo (valuing of family), respeto (valuing and including older network members), and simpatía (valuing of interpersonal harmony) may moderate both network size and cohesion. As a result, Hispanics tend to have larger, closer knit, and more proximally distributed social networks relative to non-Hispanics; ethnicity representing a proxy for culture. For example, the median Hispanic household size is significantly larger than non-Hispanic households (3.36 vs. 2.44 persons; U.S. Census Bureau, 2012), with 1 in 4 Hispanics reporting living in a household of five family members or more, compared to just 10.1% of non-Hispanic Whites and 14.4% of non-Hispanic Blacks (Stepler & Brown, 2015). Although Hispanics, Blacks, and Asian Americans are equally likely to live in a multigenerational household, Hispanics are far more likely to live in a household with three or more generations (Taylor et al., 2010).

Consistent with the idea of cultural differences in social cohesion, a novel study objectively compared daily differences in social communication between persons living in the US versus living in Mexico. Ramirez-Esparza, Mehl, Álvarez Bermúdez, and Pennebaker (2009) used the electronically activated recorder (EAR; Mehl, Robbins, & Deters, 2012) to capture snippets of ambient sounds around participants in daily life (i.e., ambulatory audio recordings which are behaviorally coded). Consistent with the idea that Hispanics are more socially integrated than non-Hispanics, Mexican participants were found to spend far less time alone and more time talking with others and engaging in social activities. In fact, Mexican participants were observed to spend 9% or almost a quarter more time talking with others than Americans (43.2% vs. 34.3%). Moreover, Mexican participants spent more time in face-to-face (both dyadic and group) conversations whereas American participants spent more time in remote conversations via phone or computer. Taken together, these findings provide at least preliminary evidence of Hispanic–Anglo cultural differences in everyday social microprocesses germane to social integration.

We would note two caveats in describing the relationships between cultural processes and social networks. First, although our interest is in modeling direction, the association between cultural processes and social networks is likely bidirectional and reciprocal. Culture practices are learned through socialization and many are transmitted across generations and groups (i.e., acculturation). Second, most of the data uses proxies of culture (ethnicity). Future work could seek to disambiguate culture from ethnicity in order to better understand the active ingredients in this relationship. However, the consistency of the relationships and breadth of the data support the validity of Path A.

Social networks and health (Path B)

Social networks and environments represent a well-established set of psychosocial moderators of health and well-being across many demographic factors, including race and ethnicity. From prospective investigations to national cohort studies to meta-analyses, data strongly support the relationship between the size and strength of one’s social ties and a range of health outcomes including morbidity and mortality (Berkman & Glass, 2000; Cohen, 2004; Martire & Franks, 2014; Ruiz, Hutchinson, & Terrill, 2008). These relationships occur for both structural (e.g., marital status, network size, isolation) and functional (e.g., perceived social support, loneliness) aspects of relationships (Cacioppo & Cacioppo, 2014; Holt-Lunstad et al., 2010; Robles, Slatcher, Trombello, & McGinn, 2014; Sbarra, Law, & Portley, 2011) and the magnitude of effect on mortality is comparable to the effects of smoking and alcohol use (Holt-Lunstad et al., 2010).

Evidence from across fields of study demonstrates the importance of social network factors as mediators of a range of relationships including in health contexts. For example, laboratory and ambulatory studies demonstrate that access to social others (including friends, acquaintances, confederates) buffer the effects of psychological stress on acute cardiovascular responses (Birmingham, Uchino, Smith, Light, & Sanbonmatsu, 2009; O’Donovan & Hughes, 2007), pain perceptions (Roberts, Klatzkin, & Mechlin, 2015), cold susceptibility (Cohen, Doyle, Skoner, Rabin, & Gwaltney, 1997; Cohen, Janicki-Deverts, Turner, & Doyle, 2015), and wound healing (Detillion, Craft, Glasper, Prendergast, & DeVries, 2004). Ecological evidence demonstrates that various markers of social networks including marriage and social support mediate the stress effects of socioeconomic disadvantages on subjective and objective indices of health including mortality (Stringhini et al., 2012; Vonneilich et al., 2012). Finally, clinical interventions often manipulate social networks to effect outcomes such as improving medication adherence (Fang & Li, 2015; Simmons et al., 2015), maintaining weight loss in obese adults (Nackers et al., 2015; Turner-McGrievy & Tate, 2013), maintaining sobriety among alcohol users (Bond, Kaskutas, & Weisner, 2003; Kaskutas, Bond, Humphreys, 2002), and reducing stress in caregivers (Gaugler, Reese, & Sauld, 2015; Signe & Elmstahl, 2008). Although these data do not speak directly to the relationship between culture and health, they do support social networks as a common mediational pathway.

Cultural processes and health (Path C)

The association between Hispanic cultural processes and health is supported by robust indirect evidence, including differences in health as a function of ethnicity, nativity, and neighborhood ethnic density. As described earlier, Hispanics as a group experience better health and live longer than non-Hispanics (Ruiz, Campos, & Garcia, in press). In addition, there is variance in the strength of this association among Hispanics. Foreign-born Hispanics are well-documented to experience better health and lower early mortality than U.S.-born Hispanics (Cho, Frisbie, Hummer, & Rogers, 2004; Holmes, Driscoll, & Heron, 2015). Likewise, persons living in more ethnically dense, Hispanic neighborhoods or “barrios” experience a numerous physical health advantages ranging from lower infant mortality (Shaw & Pickett, 2013; Shaw et al., 2010), to disease survival advantages (Keegan, Quach, Shema, Glaser, & Gomez, 2010; Patel, Schupp, Gomez, Chang, & Wakelee, 2013). Presumably, these within-group differences are moderated by differences in cultural processes. Hispanics, particularly foreign-born Hispanics are more acculturated to their country of origin (e.g., Mexico) than are U.S.-born Hispanics and U.S.-born non-Hispanics (Cuellar, Arnold, & Maldonado, 1995; Garcia, Angel, Angel, Chiu, & Melvin, 2015). Similarly, Hispanic enclaves are characterized by stronger cultural representation to the country of origin of its population (e.g., Mexico) including language, foods, customs, and values (Yoder & LaPerrière de Gutiérrez, 2004). Moreover, limited evidence suggests that non-Hispanics living in more ethnically dense Hispanic communities may also experience health advantages (Morenoff, 2003; Shaw & Pickett, 2013), further supporting a more social/cultural hypothesis. Although direct evidence is needed, a strong case can be made for Path C.

Next steps

Despite support for each of the key conceptual pathways, to date there is no published work directly testing the full sociocultural hypothesis nor its moderation by acculturation. Given this hypothesis’ emphasis on interpersonal and group processes, social psychologists are in a unique position to contribute to its unraveling. Testing this sociocultural hypothesis is important to not only unpack these resilience effects, but also to test targeted social integration intervention efforts. More broadly, elucidating these mechanisms could serve as a “blueprint” to foster research on resilience and social network advantages in other underserved populations.

Going Forward

Hispanic physical health is a mix of significant risk, yet paradoxical advantages for a wide range of major diseases as well as early mortality. These findings likely represent a constellation of factors, with one of the strongest contenders being sociocultural resilience. In this paper, we propose a sociocultural model that posits relationships between cultural processes, social networks, and health outcomes. Much work is needed to test this model and elucidate specific mechanisms. Social scientists, including social psychology researchers, will be vital to these endeavors. These investigations will span the range of research contexts from community and population-based studies, to psychosocial laboratory manipulations, to targeted interventions. With expertise in research methods and in human behavior, psychological scientists have an opportunity to not only disentangle questions about Hispanic health, but also inform these resilience effects with targeted social integration intervention efforts for and beyond the Hispanic population.

Multidisciplinary collaborations will be essential to meeting many of these needs. Indeed, the historic “silo-ing” of fields has contributed to existing gaps in knowledge and perceptions of Hispanic health as paradoxical. This lack of integration likely reflects long-standing differences between the medical/disease community and psychological sciences regarding the determinants of disease and understanding of psychosocial factors in the disease process (Engel, 1977). To effectively pursue multidisciplinary collaborations, social scientists, including psychologists, will need to have a working knowledge of the disease of interest and familiarity with the culture of medicine in order to effectively communicate with medical collaborators. Social scientists should also strive to improve the reporting of their work. In particular, benchmarking results and reporting relative effect sizes to known disease moderators will help to contextualize the relative weight of the contribution. Moreover, multidisciplinary collaborations may open up new funding and dissemination options for social scientists, as well as advancing our understanding of the Hispanic paradox.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References

Abraido-Lanza

A. F.

Dohrenwend

B. P.

Ng-Mak

D. S.

Turner

J. B.

(1999). The Latino mortality paradox: A test of the “salmon bias” and healthy migrant hypotheses. American Journal of Public Health, 89, 1543–1548. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1508801/pdf/amjph00010-0085.pdf

Arce

C. M.

Goldstein

B. A.

Mitani

A. A.

Winkelmayer

W. C.

(2013). Trends in relative mortality between Hispanic and non-Hispanic Whites initiating dialysis: A retrospective study of the US renal data system. American Journal of Kidney Diseases, 62, 312–321. doi:10.1053/j.ajkd.2013.02.375

Arias

Eschbach

Schauman

W. S.

Backlund

E. L.

Sorlie

P. D.

(2010). The Hispanic morality advantage and ethnic misclassification on US death certificates. American Journal of Public Health, 100, S171–S177. doi:10.2105/AJPH.2008.135863

Berkman

L. F.

Glass

(2000). Social integration, social networks, social support, and health. In Berkman

L. F.

Kawachi

(Eds.), Social epidemiology (pp. 137–173). New York, NY: Oxford University Press.

Birmingham

Uchino

B. N.

Smith

T. W.

Light

K. C.

Sanbonmatsu

D. M.

(2009). Social ties and cardiovascular function: An examination of relationship positivity and negativity during stress. International Journal of Psychophysiology, 74, 114–119. doi:10.1016/j.ijpsycho.2009.08.002

Bond

Kaskutas

L. A.

Weisner

(2003). The persistent influence of social networks and Alcoholics Anonymous on abstinence. Journal of Studies on Alcohol, 64, 579–588. doi:10.15288/jsa.2003.64.579

Brookfield

K. F.

Cheung

M. C.

Lucci

Fleming

L. E.

Koniaris

L. G.

(2009). Disparities in survival among women with invasive cervical cancer: A problem of access to care. Cancer, 115, 166–178. doi:10.1002/cncr.24007

Cacioppo

J. T.

Cacioppo

(2014). Social relationships and health: The toxic effects of perceived social isolation. Social and Personality Psychology Compass, 8, 58–72. doi:10.1111/spc3.12087

Campos

Schetter

C. D.

Abdou

C. M.

Hobel

C. J.

Glynn

L. M.

Sandman

C. A.

(2008). Familialism, social support, and stress: Positive implications for pregnant Latinas. Culture, Diversity, and Ethnic Minority Psychology, 14, 155–162. doi:10.1037/1099-9809.14.2.155

10.

Centers for Disease Control and Prevention. (2007). No usual source of health care among adults. Retrieved from http://www.cdc.gov/nchs/health_policy/adults_no_source_health_care.htm

11.

Centers for Disease Control and Prevention. (2015). Deaths: Final data for 2013, Table 7. Retrieved from http://www.cdc.gov/nchs/fastats/life-expectancy.htm

12.

Cho

Frisbie

W. P.

Hummer

R. A.

Rogers

R. G.

(2004). Nativity, duration of residence, and the health of Hispanic adults in the United States. International Migration Review, 38, 184–211. Retrieved from https://scholar.google.com/citations?view_op=view_citation&hl=en&user=rfgSZsAAAAAJ&citation_for_view=rfgSZsAAAAAJ:W7OEmFMy1HYC

13.

Cohen

(2004). Social relationships and health. American Psychologist, 59, 676–684. doi:10.1037/0003-066X.59.8.676

14.

Cohen

Doyle

W. J.

Skoner

D. P.

Rabin

B. S.

Gwaltney

J. M.

Jr. (1997). Social ties and susceptibility to the common cold. Journal of the American Medical Association, 277, 1940–1944. doi:10.1001/jama.1997.03540480040036

15.

Cohen

Janicki-Deverts

Turner

R. B.

Doyle

W. J.

(2015). Does hugging provide stress-buffering social support? A study of susceptibility to upper respiratory infection and illness. Psychological Science, 26, 135–147. doi:10.1177/0956797614559284

16.

Colby

S. L.

Ortman

J. M.

(2015). Projections of the size and composition of the U.S. population: 2014 to 2060. Population estimates and projections. U.S. Department of Commerce Economics and Statistics Administration, U.S. Census Bureau. Retrieved from https://www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf

17.

Collins

J. W.

Jr. Soskolne

G. R.

Rankin

K. M.

Bennett

A. C.

(2013). Differing first year mortality rates of term births to White, African American, and Mexican-American US-born and foreign-born mothers. Maternal Child Health Journal, 17, 1776–1783. doi:10.1007/s10995-012-1197-2

18.

Cortes-Bergoderi

Goel

Murad

M. H.

Allison

Somers

V. K.

Erwin

P. J.

. . .Lopez-Jimenez

(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, 24, 791–799. doi:10.1016/j.ejim.2013.09.003

19.

County of San Diego, Health and Human Services Agency, Public Health Services, & Community Health Statistics Unity. (2010). 3–4–50 chronic disease deaths in San Diego County. Retrieved from http://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/phs/documents/CHS-3–4–50SanDiegoCounty2010.pdf

20.

Cuellar

Arnold

Maldonado

(1995). Acculturation Rating Scale for Mexican Americans-II: A revision of the original ARSMA scale. Hispanic Journal of Behavioral Sciences, 17, 275–304. doi:10.1177/07399863950173001

21.

Daviglus

M. L.

Talavera

G. A.

Aviles-Santa

M. L.

Allison

Cai

Criqui

M. H.

. . .Stamler

(2012). Prevalence of major cardiovascular risk factors and cardiovascular diseases among Hispanic/Latino individuals of diverse backgrounds in the United States. Journal of the American Medical Association, 308, 1775–1784. doi:10.1001/jama.2012.14517

22.

DeNavas-Walt

Proctor

B. D.

Smith

J. C.

(2013). Income, poverty, and health insurance coverage in the United States: 2012 (Current population reports). Washington, DC: U.S. Government Printing Office. Retrieved from http://www.census.gov/prod/2013pubs/p60-245.pdf

23.

Detillion

C. E.

Craft

T. K.

Glasper

E. R.

Prendergast

B. J.

DeVries

A. C.

(2004). Social facilitation of wound healing. Psychoneuroendocrinology, 29, 1004–1011. doi:10.1016/j.psyneuen.2003.10.003

24.

DeVoe

J. E.

Fryer

G. E.

Phillips

Green

L. A.

(2003). Receipt of preventive care among adults: Insurance and usual source of care. American Journal of Public Health, 93, 786–791. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447840/

25.

DeVoe

J. E.

Tillotson

C. J.

Wallace

L. S.

Lesko

S. E.

Pandhi

(2012). Is health insurance enough? A usual source of care may be more important to ensure a child receives preventive health counselling. Maternal Child Health Journal, 16, 306–315. doi:10.1007/s10995-011-1762-4

26.

Dumais

K. M.

Veenema

A. H.

(2015). Vasopressin and oxytocin receptor systems in the brain: Sex differences and sex-specific regulation of social behaviors. Frontiers in Neuroendocrinology, 40, 1–23. doi:10.1016/j.yfme.2015.04.003

27.

El-Sayed

A. M.

Paczkowski

M. M.

March

Galea

(2014). Trends in the Mexican infant mortality paradox over the past two decades. Annals of Epidemiology, 24, 831–836. doi:10.1016/j.annepidem.2014.09.005

28.

Engel

G. L.

(1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136.

29.

Fang

(2015). Electronic messaging support service programs improve adherence to lipid-lowering therapy among outpatients with coronary artery disease: An exploratory randomized control study. Journal of Clinical Nursing, 25, 664–671. doi:10.1111/jocn.12988

30.

Fiscella

Franks

Doescher

M. P.

Saver

B. G.

(2002). Disparities in health care by race, ethnicity, and language among the insured: Findings from a national sample. Medical Care, 40, 52–59.

31.

Flores

M. E.

Simonsen

S. E.

Manuck

T. A.

Dyer

J. M.

Turok

D. K.

(2012). The “Latina epidemiologic paradox.” Contrasting patterns of adverse birth outcomes in U.S.-born and foreign-born Latinas. Women’s Health Issues, 22, e501–e507. doi:10.1016/j.whi.2012.07.005

32.

Frankenfield

D. L.

Rocco

M. V.

Roman

S. H.

McClellan

W. M.

(2003). Survival advantage for adult Hispanic hemodialysis patients? Findings from the end-stage renal disease Clinical Performance Measures Project. Journal of the American Society of Nephrology, 14, 180–186. doi:10.1097/01.ASN.0000037400.83593.E6

33.

Fryer

G. E.

Dovey

S. M.

Green

L. A.

(2000). The importance of having a usual source of health care. American Family Physician, 62, 477.

34.

Gallo

L. C.

Penedo

F. J.

de los Monteros

Arguelles

(2009). Resiliency in the face of disadvantage: Do Hispanic cultural characteristics protect health outcomes? Journal of Personality, 77, 1707–1746. doi:10.1111/j.1467-6494.2009.00598.x

35.

Garcia

M. A.

Angel

J. L.

Angel

R. J.

Chiu

C. T.

Melvin

(2015). Acculturation, gender, and active life expectancy in the Mexican-origin population. Journal of Aging and Health, 27, 1247–1265. doi:10.1177/0898264315577880

36.

Gaugler

J. E.

Reese

Sauld

(2015). A pilot evaluation of psychosocial support for family caregivers of relatives with dementia in long-term care: The Residential Care Transition Module. Research in Gerontological Nursing, 8, 161–172. doi:10.3928/19404921-20150304-01

37.

Grundy

S. M.

Brewer

H. B.

Jr. Cleeman

J. I.

Smith

S. C.

Jr. Lenfant

National Heart, Lung, and Blood Institute, & American Heart Association. (2004). Definition of metabolic syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation, 109, 433–438. doi:10.1161/01.CIR.0000111245.75752.C6

38.

Ham

S. A.

Ainsworth

B. E.

(2010). Disparities in data on Health People 2010 physical activity objectives collected by accelerometry and self-report. American Journal of Public Health, 100, S263–S268. doi:10.2105/AJPH.2009.180075

39.

Heron

(2015). Deaths: Leading causes for 2012 (National Vital Statistics Report 64). Hyattsville, MD: National Center for Health Statistics.

40.

Holmes

J. S.

Driscoll

A. K.

Heron

(2015). Mortality among US-born and immigrant Hispanics in the US: Effects of nativity, duration of residence, and age at immigration. International Journal of Public Health, 60, 609–617. doi:10.1007/s00038-015-0686-7

41.

Holt-Lunstad

Smith

T. B.

Layton

J. B.

(2010). Social relationships and mortality risk: A meta-analytic review. PLoS Medicine, 7, e1000316. doi:10.1371/journal.pmed.1000316

42.

Hovey

J. D.

(2000). Psychosocial predictors of acculturative stress in Mexican immigrants. Journal of Psychology, 134, 490–502. doi:10.1037/1099-9809.8.3.274

43.

Humes

K. N.

Jones

Ramirez

(2011). Overview of race and Hispanic origin: 2010 (2010 Census Briefs). Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf

44.

Hummer

R. A.

Powers

D. A.

Pullum

S. G.

Grossman

G. L.

Frisbie

W. P.

(2007). Paradox found (again): Infant mortality among the Mexican-origin population in the United States. Demography, 44, 441–457. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2031221/

45.

Kaplan

M. S.

Huguet

Newsom

J. T.

McFarland

B. H.

(2004). The association between length of residence and obesity among Hispanic immigrants. American Journal of Preventive Medicine, 27, 323–326. doi:10.1016/j.amepre.2004.07.005

46.

Kaskutas

L. A.

Bond

Humphreys

(2002). Social networks as mediators of the effect of Alcoholics Anonymous. Addition, 97, 891–900. doi:10.1046/j.1360-0443.2002.00118.x

47.

Keegan

T. H.

Quach

Shema

Glaser

S. L.

Gomez

S. L.

(2010). The influence of nativity and neighborhoods on breast cancer stage at diagnosis and survival among California Hispanic women. BMC Cancer, 10, 603. doi:10.1186/1471-2407-10-603

48.

Kondo

K. K.

Rossi

J. S.

Schwartz

S. J.

Zamboanga

B. L.

Scalf

C. D.

(2015). Acculturation and cigarette smoking in Hispanic women: A meta-analysis. Ethnicity and Substance Abuse, 15, 46–72. doi:10.1080/15332640.2014.1002878

49.

Lopez

Patten

(2015). The impact of slowing immigration: Foreign-born share falls among 14 largest U.S. Hispanic origin groups. Washington, DC: Pew Hispanic Center. Retrieved from http://www.pewhispanic.org/files/2015/09/2015-09-15_hispanic-origin-profiles-summary-report_FINAL.pdf

50.

Markides

K. S.

(1983). Mortality among minority populations: A review of recent patterns and trends. Public Health Reports, 98, 252–260.

51.

Markides

K. S.

Coreil

(1986). The health of Hispanics in the Southwestern United States: An epidemiologic paradox. Public Health Reports, 101, 253–265. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477704/pdf/pubhealthrep00183-0027.pdf

52.

Marshall

S. J.

Jones

D. A.

Ainsworth

D. A.

Reis

J. P.

Levy

S. S.

Macera

C. A.

(2007). Race/ethnicity, social class, and leisure-time physical inactivity. Medicine and Science in Sports and Exercise, 39, 44–51. doi:10.1249/01.mss.0000239401.16381.37

53.

Martire

L. M.

Franks

M. M.

(2014). The role of social networks in adult health: Introduction to the special issue. Health Psychology, 33, 501–504. doi:10.1037/hea0000103

54.

Mehl

M. R.

Robbins

M. L.

Deters

F. G.

(2012). Naturalistic observation of health-relevant social processes: The electronically activated recorder methodology in psychosomatics. Psychosomatic Medicine, 74, 410–417. doi:10.1037/hea0000103

55.

Morenoff

J. D.

(2003). Neighborhood mechanisms and the spatial dynamics of birth weight. American Journal of Sociology, 108, 976–1017. Retrieved from https://www-jstor-org.web.bisu.edu.cn/stable/10.1086/374405

56.

Mozaffarian

Benjamin

E. J.

A. S.

Arnett

D. K.

Blaha

M. J.

Cushman

. . . American Heart Association Statistics Committee and Stroke Statistics Subcommittee. (2015). Heart disease and stroke statistics—2015 update: A report from the American Heart Association. Circulation, 131, e29–e322. doi:10.1161/CIR.0000000000000152

57.

Nackers

L. M.

Dubyak

P. J.

Anton

S. D.

Dutton

G. R.

Perri

M. G.

(2015). Group dynamics are associated with weight loss in the behavioral treatment of obesity. Obesity (Silver Spring), 23, 1563–1569. doi:10.1002/oby.21148

58.

Nicholas

S. B.

Kalantar-Zadeh

Norris

K. C.

(2013). Racial disparities in kidney disease outcomes. Seminars in Nephrology, 33, 409–415. doi:10.1016/j.semnephrol.2013.07.002

59.

Oboler

(1995). Ethnic labels, Latin lives: Identity and the politics of (re)presentation in the United States. Minneapolis: University of Minnesota Press.

60.

O’Donovan

Hughes

B. M.

(2007). Access to social support in life and in the laboratory: Combined impact on cardiovascular reactivity to stress and state anxiety. Journal of Health Psychology, 13, 1147–1156. doi:10.1177/1359105308095968

61.

Ogden

C. L.

Carroll

M. D.

Kit

B. K.

Flegal

K. M.

(2014). Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA, 311, 806–814. doi:10.1001/jama.2014.732

62.

Patel

M. I.

Schupp

C. W.

Gomez

S. L.

Chang

E. T.

Wakelee

H. A.

(2013). How do social factors explain outcomes in non-small-cell lung cancer among Hispanics in California? Explaining the Hispanic paradox. Journal of Clinical Oncology, 31, 3572–3578. doi:10.1200/JCO.2012.48.6217

63.

Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 (2010).

64.

Phillips

K. L.

Chiriboga

D. A.

Jang

(2012). Satisfaction with care: The role of patient–provider racial/ethnic concordance and interpersonal sensitivity. Journal of Aging and Health, 24, 1079–1090. doi:10.1177/0898264312453068

65.

Powers

D. A.

(2013). Paradox revisited: A further investigation of racial/ethnic differences in infant mortality rates by maternal age. Demography, 30, 495–520. doi:10.1007/s13524-012-0152-6

66.

Ramírez-Esparza

Mehl

M. R.

Álvarez Bermúdez

Pennebaker

J. W.

(2009). Are Mexicans more or less sociable than Americans? Insights from a naturalistic observation study. Journal of Research in Personality, 43, 1–7. doi:10.1016/j.jrp.2008.09.002

67.

Ramisetty-Mikler

Caetano

Rodriguez

L. A.

(2010). The Hispanic Americans Baseline Alcohol Survey (HABLAS): Alcohol consumption and sociodemographic predictors across Hispanic national groups. Journal of Substance Use, 15, 402–416. doi:10.3109/14659891003706357

68.

Rinderle

Montoya

(2008). Hispanic/Latino identity labels: An examination of cultural values and personal experiences. The Howard Journal of Communications, 19, 144–164. doi:10.1080/10646170801990953

69.

Riosmena

Dennis

J. A.

(2012). Importation, SES-selective acculturation, and the weaker SES-health gradients of Mexican immigrants in the United States. Social Science Journal, 49, 325–329.

70.

Roberts

M. H.

Klatzkin

R. R.

Mechlin

(2015). Social support attenuates physiological stress responses and experimental pain sensitivity to cold pressor pain. Annals of Behavioral Medicine, 49, 557–569. doi:10.1007/s12160-015-9686-3

71.

Robles

T. F.

Slatcher

R. B.

Trombello

J. M.

McGinn

M. M.

(2014). Marital quality and health: A meta-analytic review. Psychological Bulletin, 140, 140–187. doi:10.1037/a0031859

72.

Romero

C. X.

Duke

J. K.

Dabelea

Romero

T. E.

Ogden

L. G.

(2012). Does the epidemiologic paradox hold in the presence of risk factors for low birth weight infants among Mexican-born women in Colorado? Journal of Health Care for the Poor and Underserved, 23, 604–614. doi:10.1353/hpu.2012.0065

73.

Ruiz

J. M.

Campos

Garcia

J. J.

(in press). Latino physical health: Disparities, paradoxes, and future directions. Journal of Latina/o Psychology.

74.

Ruiz

J. M.

Hutchinson

J. G.

Terrill

(2008). For better and worse: Social influences on coronary heart disease. Social and Personality Psychology Compass, 2, 1400–1414. doi:10.1111/j.1751-9004.2008.00108.x

75.

Ruiz

J. M.

Steffen

Smith

T. B.

(2013). The Hispanic mortality paradox: A systematic review and meta-analysis of the longitudinal literature. American Journal of Public Health, 103, e52–60. doi:10.2105/AJPH.2012.301103

76.

Saha

Arbelaez

J. J.

Cooper

L. A.

(2003). Patient–physician relationships and racial disparities in the quality of health care. American Journal of Public Health, 93, 1713–1719.

77.

Sbarra

D. A.

Law

R. W.

Portley

R. M.

(2011). Divorce and death: A meta-analysis and research agenda for clinical, social, and health psychology. Perspectives in Psychological Science, 6, 454–474. doi:10.1177/1745691611414724

78.

Shaw

R. J.

Pickett

K. E.

(2013). The health benefits of Hispanic communities for non-Hispanic mothers annd infants: Another Hispanic paradox. American Journal of Public Health, 103, 1052–1057. doi:10.2105/AJPH.2012.300985

79.

Shaw

R. J.

Pickett

K. E.

Wilkinson

R. G.

(2010). Ethnic density effects on birth outcomes and maternal smoking during pregnancy in the US linked birth and infant death data set. American Journal of Public Health, 100, 707–713. doi:10.2105/AJPH.2009.167114

80.

Shor

Roelfs

D. J.

Yogev

(2013). The strength of family ties: A meta-analysis and meta-regression of self-reported social support and mortality. Social Networks, 35, 626–638. doi:10.1016/j.socnet.2013.08.004

81.

Siegel

R. L.

Fedewa

S. A.

Miller

K. D.

Goding-Sauer

Pinheiro

P. S.

Martinez-Tyson

Jemal

(2015). Cancer statistics for Hispanics/Latinos, 2015. CA: A Cancer Journal for Clinicians, 65, 457–480. doi:10.3322/caac.21314

82.

Signe

Elmstahl

(2008). Psychosocial intervention for family caregivers of people with dementia reduces caregiver’s burden: Development and effect after 6 and 12 months. Scandinavian Journal of Caring Sciences, 22, 98–109. doi:10.1111/j.1471-6712.2007.00498.x

83.

Simmons

Prevost

A. T.

Bunn

Holman

Parker

R. A.

Cohn

. . .Graffy

(2015). Impact of community based peer support in Type 2 diabetes: A cluster randomized controlled trial of individual and/or group approaches. PLoS One, 10, e0120277. doi:101371/journal.pone.0120277

84.

Smith

E. C.

Ziogas

Anton-Culver

(2013). Delay in surgical treatment and survival after breast cancer diagnosis in young women by race/ethnicity. JAMA Surgery, 148, 516–523. doi:10.1001/jamasurg.2013.1680

85.

Smith

T. W.

Ruiz

J. M.

Cundiff

J. M.

Baron

K. G.

Nealey-Moore

J. B.

(2013). Optimism and pessimism in social contexts: An interpersonal perspective on resilience and risk. Journal of Research in Personality, 47, 553–562.

86.

Stepler

Brown

(2015). Statistical portrait of Hispanics in the United States, 1980–2013. Retrieved from http://www.pewhispanic.org/2015/05/12/statistical-portrait-of-hispanics-in-the-united-states-2013-key-charts/

87.

Stringhini

Berkman

Dugravot

Ferrie

J. E.

Marmot

Kivimaki

Singh-Manoux

(2012). Socioeconomic status, structural and functional measures of social support, and mortality: The British Whitehall II Cohort Study, 1985–2009. American Journal of Epidemiology, 175, 1275–1283. doi:10.1093/aje/kwr461

88.

Taylor

Passel

Fry

Morin

Wang

Velasco

Dockterman

(2010). The return of the multi-generational family household. Retrieved from http://www.pewsocialtrends.org/files/2010/10/752-multi-generational-families.pdf

89.

Turner-McGrievy

G. M.

Tate

D. F.

(2013). Weight loss social support in 140 characters or less: Use of an online social network in a remotely delivered weight loss intervention. Translational Behavioral Medicine, 3, 287–294. doi:10.1007/s13142-012-0183-y

90.

U.S. Census Bureau. (2012). America’s families and living arrangements: 2012: Average number of people (AVG Table Series). Retrieved from https://www.census.gov/hhes/families/data/cps2012AVG.html

91.

U.S. Department of Health and Human Services. (2011). HHS action plan to reduce racial and ethnic health disparities: A nation free of disparities in health and healthcare. Washington, DC: Author. Retrieved from http://minorityhealth.hhs.gov/npa/files/plans/hhs/hhs_plan_complete.pdf

92.

U.S. Renal Data System. (2010). Annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases.

93.

Valdovinos

Penedo

F. J.

Isasi

C. R.

Jung

Kaplan

R. C.

Espinoza Giacinto

. . .Greenlee

H. A.

(2015). Perceived discrimination and cancer screening behaviors in US Hispanics: Hispanic community health study/study of Latinos sociocultural ancillary study. Cancer Causes and Control. Advance online publication. doi:10.1007/s10552-015-0679-0

94.

Vonneilich

Jockel

K. H.

Erbel

Klein

Dragano

Siegrist

. . . Heinz Nixdorf Investigator Group. (2012). The mediating effect of social relationships on the association between socioeconomic status and subjective health – Results from the Heinz Nixdorf Recall cohort study. BMC Public Health, 12, 285.

95.

Weiss

L. J.

Blustein

(1996). Faithful patients: The effect of long-term physician–patient relationships on the cost and use of health care by older Americans. American Journal of Public Health, 86, 1742–1747. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380727/pdf/amjph00523-0064.pdf

96.

Yang

Thumula

Pace

P. F.

Banahan

B. F.

III Wilkin

N. E.

Lobb

W. B.

(2009). Predictors of medication nonadherence among patients with diabetes in Medicare Part D programs: A retrospective cohort study. Clinical Therapeutics, 31, 2178–2188. doi:10.1016/j.clinthera.2009.10.002

97.

Yoder

M. S.

LaPerrière de Gutiérrez

(2004). Neighborhoods: Distinctiveness and diversity in a majority-Hispanic place. In Arreola

D. D.

(Ed.), Hispanic spaces, Latino places (pp. 55–76). Austin: University of Texas Press.