and outreach · latino community cardiovascular disease prevention and outreach initiative:...
TRANSCRIPT
LATINO COMMUNITY
CARDIOVASCULAR
DISEASE PREVENTION
AND OUTREACH
INITIATIVE:
BACKGROUND REPORT
U.S. DEPARTMENT OF HEALTH
AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
NATIONAL INSTITUTES OF HEALTH
National Heart, Lung,
and Blood Institute
For Administrative Use
MARCH 1996
ii
iii
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Data Sources and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . 2
Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Population Density . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Composition and Distribution . . . . . . . . . . . . . . . . . . . . . . . . . 3
Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Income and Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Health Care Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Cardiovascular Disease and the Latino Population . . . . . . . . . . . 9
Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
High blood cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Overweight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Physical inactivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Cigarette smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Knowledge, Attitudes, and Behaviors . . . . . . . . . . . . . . . . . . . 21
Community-Based Disease Prevention and HealthPromotion Programs for Latinos . . . . . . . . . . . . . . . . . . . . . . . . . 23
Recommended Strategies and Example Programs . . . . . . . . 25
The NHLBI Latino Community Cardiovascular DiseasePrevention and Outreach Initiative . . . . . . . . . . . . . . . . . . . . . 28
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Appendices
Appendix A: Overview of Selected CVD-RelatedPrevention Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
TABLE OF CONTENTS
iv
Appendix B: The NHLBI Washington, D.C., MetropolitanArea Latino Community Cardiovascular DiseasePrevention and Outreach Initiative . . . . . . . . . . . . . . . . . . . . . 35
Appendix C: Overview of Data . . . . . . . . . . . . . . . . . . . . . . . . 37
List of Figures
Figure 1. U.S. Latino Population by Countryof Origin; 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Figure 2. National Distribution of U.S. LatinoPopulation; 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Figure 3. Percent of U.S. Population Age 25 and OlderWho Have Completed High School, by Origin; 1993 . . . . . . . . . 5
Figure 4. Percent of U.S. Population Living BelowPoverty Level, by Origin; 1992 . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Figure 5. Percent of U.S. Population Age 16 and OlderUnemployed, by Origin; 1993 . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Figure 6. Percent of U.S. Population Under Age 65Who Are Not Covered by Health Insurance,by Origin; 1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Figure 7. Age-Adjusted Death Rates for Heart DiseaseAmong Latinos and All Persons, Age 45 and Older,by Gender, United States; 1985-87 and 1989-91 . . . . . . . . . . . . 9
Figure 8. Age-Adjusted Prevalence of Elevated BloodCholesterol Levels Among U.S. Latinos,Ages 20-74, by Gender; 1982-84 . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure 9. Percent of U.S. Population Age 18 and OlderWho Have Had Their Blood Cholesterol or Blood PressureChecked, Latino and Non-Latino, by Gender; 1990 . . . . . . . . . . 13
Figure 10. Age-Adjusted Prevalence of HypertensionAmong U.S. Adult Latinos, by Gender;1982-84 and 1988-91 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Figure 11. Hypertension Awareness, Treatment, andControl Among U.S. Latinos Ages 18-74,by Gender; 1982-84 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure 12. Age-Adjusted Prevalence of Diabetes AmongU.S. Adults Ages 20-74, by Latino Origin; 1976-84 . . . . . . . . . . 17
Figure 13. Age-Adjusted Prevalence of OverweightAmong U.S. Latinos Ages 20-74, by Gender;1982-84 and 1988-91 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Figure 14. Percent of Latinos and Non-Latinos Age 18 andOlder Who Exercise or Play Sports Moderately, by Gender,United States; 1991. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Figure 15. Prevalence of Cigarette SmokingAmong U.S. Latinos and Non-LatinosAge 18 and Older; 1991 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
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FOREWORD
For nearly five decades, the National Heart,Lung, and Blood Institute (NHLBI) has beenconducting and supporting research, researchtraining, and health education activities relatedto the prevention and control of heart, lung, andblood diseases for all Americans. The NHLBIstrives to translate and disseminate researchknowledge, down to the community level, topromote public health and prevent disease. Toaccomplish this translation and dissemination ofinformation, the NHLBI established its nationaleducation programs. These programs includethe National High Blood Pressure EducationProgram, the National Cholesterol EducationProgram, the National Heart Attack AlertProgram, the National Asthma Education andPrevention Program, and the NHLBI ObesityEducation Initiative. The recommendationsand initiatives of these education programsreflect the efforts of substantial numbers ofhealth professionals who assist the NHLBI insynthesizing and reviewing scientific information.
Through research and clinical studies we havedetermined that many of the risk factors thatinfluence the prevalence and severity ofcardiovascular disease can be modified—primarily by individual choice. These riskfactors include high blood pressure, high bloodcholesterol, cigarette smoking, physical inactivity,obesity, and diabetes.
Despite progress, minority populations in theUnited States have not shared fully in thedramatic reductions in cardiovascular disease(CVD) and other diseases experienced in recentyears by the general population. For example,
specific data show that the rates of obesity anddiabetes are greater among Mexican-Americansthan in the general population. The NHLBIbelieves that the health status of each ethnic andculturally diverse group is integral to the healthand well-being of the Nation. Therefore, one ofthe Institute’s top priorities is to determine bettermethods to reduce the disproportionate burdenof heart, lung, and blood diseases amongminority populations.
The Latino population, a very young and rapidlygrowing segment of our society, now numbers22.4 million, has increased 53 percent over thelast decade, and is still growing. About 66percent of Latinos are younger than 35 yearsof age. However, despite this young age, theleading cause of death among Latinos, as forall Americans, is cardiovascular disease.
Without intervention, CVD morbidity andmortality can be expected to increase as thispopulation ages because the prevalence of CVDand its related risk factors increase with age.To reduce this potential toll, behavioral changeis needed. Unfortunately, studies show thatLatinos are generally unaware of importantlifestyle changes that could help them preventthe development or progression of CVD, and thisknowledge gap transcends socioeconomic status.
This important and challenging prevention andintervention opportunity has led the NHLBI toestablish the Latino Community CardiovascularDisease Prevention and Outreach Initiative. Thisinitiative seeks to promote healthy lifestyles andreduce the prevalence of cardiovascular riskfactors by developing and implementing CVD
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prevention strategies designed specifically forLatinos. The impact of these programs can beconsiderable. The relative youth of the Latinopopulation offers a special opportunity for theprevention of chronic diseases, like CVD, thatincrease in severity and prevalence as peopleage.
This background paper provides an overviewof what is currently known about CVD and itsassociated risk factors among Latinos in theUnited States. It also shares some of theknowledge gained by community projectsacross the Nation about conducting programsdesigned to reduce illness
and death from CVD among Latinos. We hopethat this information sparks ideas to help youand your organization create effective outreachand prevention programs for Latinos in yourcommunity.
The Institute thanks all those who havecontributed to the much-needed LatinoCommunity Cardiovascular Disease Preventionand Outreach Initiative. The success of thisinitiative depends on the involvement of Latinocommunities—and this support has been givenenthusiastically. Together, we will continue ourefforts to improve the health of Latinos in theUnited States.
Claude Lenfant, M.D.
DirectorNational Heart, Lung, and Blood InstituteNational Institutes of Health
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ACKNOWLEDGMENTS
COMMUNITY ALLIANCE WORKING FOR HEART HEALTH
NHLBI L ATINO COMMUNITY CARDIOVASCULAR
DISEASE PREVENTION AND OUTREACH INITIATIVE
Ester AguileraCongressional Hispanic CaucusWashington, D.C.
Cathy Alvarez, R.N.Mayor’s Office on Latino AffairsWashington, D.C.
Zaida ArguedasMontgomery County Health DepartmentRockville, Maryland
Felícita Bernier, R.D.JWK International CorporationAnnandale, Virginia
Patricia Bernstein, R.D.University of Maryland
Cooperative Extension ServiceCollege Park, Maryland
Carmen DuranLatin American Youth CenterWashington, D.C.
Cristina EncinasLatin American Youth CenterWashington, D.C.
Daniel FloresGovernor’s Commission on Hispanic Affairs
for MarylandBaltimore, Maryland
Donna FosterFairfax County Health DepartmentFairfax, Virginia
María Lourdes GarcíaInterAmerican College of Physicians and Sur-geonsWashington, D.C.
María Gómez, R.N., M.P.H.Mary’s Center for Maternal and Child Care, Inc.Washington, D.C.
Nancy GordonFairfax HospitalFalls Church, Virginia
Rudy GuernicaLos Cerezos Broadcasting Co.Univision Channel 48Silver Spring, Maryland
Silvana GutiérrezCommunity EducatorWashington, D.C.
Elmer Huerta, M.D., M.P.H.The Washington Cancer Institute at the
Washington Hospital CenterWashington, D.C.
Enisberto Jaraba-PardoCentro de ArteWashington, D.C.
J. Mark LanglaisCommunity Clinic, Inc.Rockville, Maryland
Eduardo LópezEducational Video in SpanishWashington, D.C.
viii
Everludis López, R.D.JWK International CorporationAnnandale, Virginia
Antonio Melus, Ph.D.Mayor’s Office on Latino AffairsWashington, D.C.
Carmen Moreno, M.P.H., R.D.National Coalition of Hispanic Health andHuman
Services OrganizationsWashington, D.C.
Diana NaranjoNational Council of La RazaWashington, D.C.
Luz Neira, Ph.D.D.C. Commission of Public HealthWashington, D.C.
Lu PalmerNation’s Capital AffiliateAmerican Heart AssociationWashington, D.C.
Cándida RodríguezMigrant Head Start TASCWashington, D.C.
Juan RomagosaLa Clinica del PuebloWashington, D.C.
Elita Rosillo-Christiansen, M.A., M.P.A.Fairfax HospitalFalls Church, Virginia
Sagrario RizoComité Hispano de VirginiaFalls Church, Virginia
Arturo SalcedoEducational Video in SpanishWashington, D.C.
Santiago TávaraEl Pregonero NewspaperWashington, D.C.
Brother Kevin Thompson, R.N.Clinica del Centro Católico HispanoWashington, D.C.
Martha WyattComite Hispano de VirginiaFalls Church, Virginia
NHLBI A D HOC COMMITTEE ON MINORITY POPULATIONS
Rina Alcalay, Ph.D.University of California at DavisDavis, California
Hector Balcazar, Ph.D.Arizona State UniversityTempe, Arizona
Zoila Ortega Harrison, Ph.D., R.N.Fairfield UniversityBeacon Falls, Connecticut
Ariela Rodríguez, Ph.D.Little Havana Activities and Nutrition Center
of Dade CountyMiami, Florida
Louise Villejo, M.P.H.University of TexasM.D. Anderson Cancer CenterHouston, Texas
Carlos Ugarte, M.S.P.H.Program for Appropriate Technology in HealthWashington, D.C.
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NHLBI L ATINO PROJECT TEAM STAFF
REVIEWERS
Gregory J. Morosco, Ph.D., M.P.H.
Nancy J. Poole
Edward J. Roccella, Ph.D., M.P.H.
Thomas J. Thomas
Louise Williams, M.A., M.S.J.
Office of Minority Health
U.S. Public Health Service
Olivia Carter-Pokras, Ph.D., M.P.Hn
National Heart, Lung, and Blood Institute
Glen Bennett, M.P.H.
Rick Bjorklund, D.B.A.
Clarice Brown, M.A.
James I. Cleeman, M.D.
Karen A. Donato, M.S., R.D.
Robinson Fulwood, M.S.P.H.
Mary M. Hand, M.S.P.H., R.N.
Terry Long
National Heart, Lung, and Blood Institute
Matilde Alvarado, R.N., M.S.N.Latino Project Team LeaderMinority Program SpecialistOffice of Prevention, Education, and Control
Carlos Crespo, Dr. P.H., M.S.Public Health AnalystOffice of Prevention, Education, and Control
Robin Hill, Ph.D.Social Science AnalystBehavioral Medicine Research GroupDivision of Epidemiology and Clinical Applications
Claire Lane, M.A.Public Affairs SpecialistOffice of Prevention, Education, and Control
Eileen Newman, M.S., R.D.Nutrition Education AdvisorOffice of Prevention, Education, and Control
Laina PackWriter/EditorOffice of Prevention, Education, and Control
R.O.W. Sciences, Inc.
Samar Debakey, M.D., M.P.H.Epidemiologist
Maxine ForrestTechnical Writer
Iris Harley, M.P.H.Minority Health Specialist
Gloria OrtizMinority Health Specialist
Frederick Rohde, M.A.Biostatistician
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1
Cardiovascular disease (CVD) is the leading causeof death for all Americans, including Latinos.*The Latino community is one of the fastest growingsegments of the American population. It is projectedthat Latinos will become the largest minority popula-tion in the Nation by the year 2000.
Many risk factors associated with CVD arepreventable. A significant portion of morbidityand mortality associated with this disease can bereduced using known health promotion and diseaseprevention strategies. However, many barriersprevent these strategies from being implementedamong Latinos or diminish their effectiveness.
The purpose of this paper is to provide backgroundinformation to support culturally appropriate pro-grams that will help Latinos understand CVDand its risk factors and make behavioral changesto reduce their chances for developing heart disease.This paper provides an overview of the Latinopopulation in the United States and the impact ofCVD and its risk factors on this segment of oursociety.
Specifically, this background paper supports aculturally appropriate program developed bythe National Heart, Lung, and Blood Institute(NHLBI) to prevent CVD among Latinos.The project will promote Healthy People 2000objectives established for the total U.S. population,as well as those specifically set for Latinos.
* In this background paper, the term “Latino” refers to individuals of Central American, Cuban, Mexican, Puerto Rican, SouthAmerican, Dominican, and Spanish ancestry.
To provide a comprehensive picture of CVDamong the Latino population, this backgroundpaper is organized in three sections:
■ Demographic Information. This sectionprovides demographic characteristics of thethree largest Latino populations in the UnitedStates. It focuses on Mexican-Americans,Puerto Ricans, and Cuban-Americans becauseof the dearth of data on other Latino groupssuch as South Americans and CentralAmericans.
■ Cardiovascular Disease and the LatinoPopulation. This section presents informationon each of the major cardiovascular risk fac-tors—high blood pressure (or hypertension),high blood cholesterol, smoking, diabetes,obesity, and physical inactivity—and theireffects on Latinos. This section also discussesknowledge, attitudes, and behaviors that affectthe development and delivery of healthpromotion and disease prevention efforts forLatinos.
■ Community-Based Disease Prevention andHealth Promotion Programs for Latinos.This section offers recommendations forculturally sensitive and language-appropriateCVD prevention programs targeting Latinos.Examples are provided of how some of thesuggested strategies have been employed byprograms targeted to Latinos.
INTRODUCTION
2
data through personal household surveys. Dataobtained from the NHIS are limited because inmost years the survey does not oversample*Latinos.
■ The National Health and Nutrition ExaminationSurveys (NHANES) II and III (phase 1 only)—These surveys were conducted in 1976-80and 1988-91, respectively, by the NCHSto measure and monitor indicators of thehealth and nutrition status of the civiliannoninstitutionalized U.S. population throughinterviews and clinical assessments. Data arelimited because the NHANES II did notoversample Mexican-Americans and theNHANES III oversampled Mexican-Americansbut did not oversample other Latino groups.
■ The Census of the Population—This survey isconducted by the Bureau of the Census, U.S.Department of Commerce, every 10 years toobtain data on the gender, race, age, and maritalstatus of the U.S. population.
■ The Current Population Survey (CPS)—Thissurvey also is conducted by the Bureau of theCensus and provides monthly estimates ofemployment, unemployment, and other generalcharacteristics of the U.S. labor force, theAmerican population as a whole, and subgroupsof that population.
■ Smaller surveys and studies as listed in the textand references.
Some of the data provided in this backgroundpaper also are presented in figures 1-15.Additional data are supplied in tables 1-4 ofappendix C.
* Survey a more-than-proportionate number of participants to ensure representation of all population segments.
Data Sources and LimitationsThe Hispanic Health and Nutrition ExaminationSurvey (HHANES), conducted from 1982 to 1984by the National Center for Health Statistics(NCHS), is considered the largest and mostcomprehensive source of health data on Latinosresiding in the United States. The HHANESexamined the three largest Latino groups (definedby the 1980 census) in selected areas of the coun-try—Mexican-Americans in California, Texas,New Mexico, Arizona, and Colorado; Cuban-Americans in Florida (Dade County); and PuertoRicans living in portions of the States of New York,New Jersey, and Connecticut. Among other healthindicators, the HHANES assessed three sociocul-tural determinants known to affect the utilizationof preventive health services: access to care;acculturation; and sociodemographic factors suchas income, education, age, and gender.
The information provided in this background paperconcerning the prevalence of major cardiovascularrisk factors in the Latino population is based ondata from the HHANES. However, because theHHANES was not designed as a national survey,areas with few Latino residents were not surveyed,and therefore the data are limited. Other sourcesof data used in this paper include the following:
■ The National Vital Statistics System—Thissystem, conducted by the NCHS, collects andpublishes data on births, deaths, marriages, anddivorces in the United States. Data from thissource are limited to States where race orethnicity is coded on death certificates.
■ The National Health Interview Survey (NHIS)—This ongoing nationwide sample survey onpersonal and demographic characteristics gathers
3
POPULATION DENSITY
Latinos are the second largest minority popula-tion in the United States, totaling approximately22.4 million people, or about 9 percent of thetotal U.S. population of about 250 million (U.S.Bureau of the Census, 1993b). Between 1980and 1990, the Latino population increased by53 percent. This rate of growth is more thanfive times that of the total U.S. population(9.5 percent) and about eight times that of non-Latinos (6.6 percent). About half of this growthis attributed to the natural increase in the popula-tion, and the other half is the result of immigra-tion (U.S. Bureau of the Census, 1993b). It isestimated that by the year 2000 Latinos willbecome the largest minority group in the Nationand that by the year 2050 they will representabout 20 percent of the total U.S. population(National Council of La Raza, 1992).
COMPOSITION AND DISTRIBUTION
Latinos are a culturally, demographically, andgeographically diverse population. According tothe 1990 census, persons of Mexican origin formthe largest Latino population group in the UnitedStates, numbering more than 13 million persons,followed by Puerto Ricans, who number close to3 million, and Cuban-Americans, numberingslightly more than 1 million (figure 1). In 1990,more than half of Latinos (64.2 percent) werenative-born Americans and nearly three-quarterswere either native-born or naturalized citizens(U.S. Bureau of the Census, 1993b).
DEMOGRAPHIC INFORMATION
FIGURE 1
U.S. LATINO POPULATION BY COUNTRY
OF ORIGIN; 1990 (IN THOUSANDS)
Latinos live in all 50 States and the District ofColumbia (figure 2), but they are more concen-trated in certain areas. In 1990, nearly 9 out of10 Latinos lived in just 10 States. The four withthe largest proportion of Latino residents wereCalifornia, Florida, New York, and Texas. OtherStates with significant Latino populations wereArizona, Colorado, Illinois, Massachusetts, NewJersey, and New Mexico. According to CurrentPopulation Survey data, more than half of Latinosare concentrated in two States—California andTexas (U.S. Bureau of the Census, 1993b).
519Spanish
13,496Mexican
2,728Puerto Rican
1,044Cuban
520Dominican
269Guatemalan
131Honduran
203Nicaraguan
565Salvadoran
156Other Central American
101Argentinean
379Colombian
191Ecuadorian
175Peruvian
190Other South American
6,489Other* Latino Origin
Source: 1990 Census of Population and Housing.
* Category selected by individuals who consider themselves Latino but do not indicate a more specific origin.
4
The vast majority of Latinos live in urban areas.According to the 1990 census, more than 91percent of Latinos are urban residents, comparedwith about 73 percent of non-Latinos (U.S.Bureau of the Census, 1991).
AGE
Latinos are a young population. CurrentPopulation Survey data for 1993 show that nearly66 percent of Latinos are younger than age 35.The median age for Latinos in the United Statesis 26.7 years—about 8 years less than the medianage of 34.4 years for non-Latinos (U.S. Bureauof the Census, 1993a).
Among the three largest Latino groups, Cuban-Americans are the oldest, with a median age of43.6 years; Mexican-Americans are the youngest,with a median age of 24.6 years; and PuertoRicans fall in between, with a median age of26.9 years. A growing segment of the Latino
population, Central Americans and South Ameri-cans, reported a median age of 28.6 years (U.S.Bureau of the Census, 1993a).
EDUCATION
Overall, educational attainment is lower forLatinos than for non-Latinos. In the UnitedStates, a little more than half of Latinos age 25and older have a high school education; approxi-mately 12 percent have a fifth-grade education orless; and 9 percent have a bachelor’s degree oreducation above that level. Among non-Latinos,more than 80 percent have completed highschool, slightly more than 1 percent have a fifth-grade education or less, and nearly 23 percenthave a bachelor’s degree or education above thatlevel (U.S. Bureau of the Census, 1993a).
The diversity among Latino population groupsalso extends to educational attainment. Inthe United States, 46.2 percent of Mexican-
FIGURE 2
NATIONAL DISTRIBUTION OF U.S. LATINO POPULATION; 1990
AK
HI
WA
ID
UT
WY
MT
OK
KS
NE
SD
ND
MN
WI
IA
MO
AR
LA
IL IN
MI
OH
KY
TN
ALMSGA
SC
NC
VAWV
PA
MEVT
NH
MA
RICT
NJDEMDDC
AZNM
TX
FL
NY
CA
OR
NV
CO
18% and over9 to 17%1 to 8%Less than 1%Source: Bureau of the Census, 1993.
Percent Latinos Among Total Populations by State
5
Americans, 59.8 percent of Puerto Ricans, 62.1percent of Cuban-Americans, and 62.9 percentof Central Americans and South Americans havegraduated from high school. Among those whoclassify themselves as “other Latino,” 68.9percent are high school graduates (figure 3).
INCOME AND EMPLOYMENT
In 1992, 29.3 percent of Latino households livedbelow the poverty level, compared with 13.1percent of non-Latino households. The percent ofLatino families living in poverty varies accordingto country of origin. Puerto Ricans have thehighest percent (36.5 percent) of families livingbelow the poverty level, followed by Mexican-
Americans (30.1 percent), Central Americans andSouth Americans (26.7 percent), and Cuban-Americans (18.1 percent), as shown in figure 4.
Unemployment rates also are higher amongLatinos than non-Latinos and exceed the totalfor the general population (figure 5). In 1993,unemployment rates were 11.9 percent forLatinos, 7.1 percent for non-Latinos, and 7.4percent for the total population. Unemploymentwas highest among Puerto Ricans (14.4 percent),closely followed by Central Americans and SouthAmericans (13.2 percent) and Mexican-Ameri-cans (11.7 percent). Cuban-Americans had thelowest rate of unemployment at 7.3 percent(U.S. Bureau of the Census, 1993a).
FIGURE 3
PERCENT OF U.S. POPULATION AGE 25 AND OLDER WHO HAVE COMPLETED HIGH
SCHOOL, BY ORIGIN; 1993
Source: Current Population Estimates, 1993.
80.2
53.1
82.4
46.2
59.862.1 62.9
68.9
Total Population
Latino Non- Latino
Mexican- American
Puerto Rican
Cuban- American
Central/ South
American
Other Latino
6
FIGURE 4
PERCENT OF U.S. POPULATION LIVING BELOW POVERTY LEVEL, BY ORIGIN; 1992*
FIGURE 5
PERCENT OF U.S. POPULATION AGE 16 AND OLDER UNEMPLOYED, BY ORIGIN; 1993
14.5
29.3
13.1
36.5
18.1
26.723.1
Total Population
Latino Non- Latino
Mexican- American
Puerto Rican
Cuban- American
Central/ South
American
Other Latino
30.1
* Data on income collected in March 1993 refer to income in calendar year 1992.
Source: Current Populations Estimates, 1993.
7.4
11.9
7.1
14.4
7.3
13.210.8
Total Population
Latino Non- Latino
Mexican- American
Puerto Rican
Cuban- American
Central/ South
American
Other Latino
11.7
Source: Current Population Estimates, 1993.
7
Latinos reported that they speak English verywell, about 14 percent said they speak Englishwell, and about 37 percent said that they speakEnglish poorly or not at all (U.S. Bureau of theCensus, 1993b).
HEALTH CARE COVERAGE
Latinos are more likely to be uninsured than“other Americans.” In 1992, slightly more thanone-third did not have health insurance (figure 6).A contributing factor is that programs suchas Medicaid offer limited coverage to the unem-ployed but not to the working poor. Conse-quently, Latinos have less access to preventiveand primary health care. Conditions that canbe prevented or controlled in a doctor’s officeoften are not addressed and can lead to costlyhospitalizations.
Latino men are most likely to be employed asoperators, fabricators, or laborers. The greatestdifference between Latino men and their non-Latino counterparts is in managerial and profes-sional positions (27.4 percent of non-Latino mencompared with 12 percent of Latino men).Latinas (hereafter referred to as Latino women)are most likely to work in technical, sales, oradministrative support positions, and their largestdiscrepancy is in service positions, with 24percent of Latino women working as serviceproviders as opposed to 17 percent of non-Latinowomen (U.S. Bureau of the Census, 1993b).
LANGUAGE
According to the 1990 census, about 78 percentof Latinos over the age of 5 speak a languageother than English in the home. This languageis almost always Spanish. About 49 percent of
FIGURE 6
PERCENT OF U.S. POPULATION UNDER AGE 65 WHO ARE NOT COVERED BY HEALTH
INSURANCE, BY ORIGIN; 1992
17.2
34.0
18.320.1
35.2
Total Population
Latino Mexican- American
Puerto Rican
Cuban- American
Other Latino
37.8
Source: National Health Interview Survey, 1992.
8
9
Cardiovascular disease includes conditions thataffect the blood vessels as well as the heart; hence,cardiovascular disease includes cerebrovasculardiseases as well as heart disease. The most com-mon cardiovascular disorder is coronary heartdisease (CHD*). Heart disease is the leading causeof death in the United States regardless of gender,race, or ethnicity. In 1992, 24 percent of all deathsamong Latinos were attributed to heart disease(National Center for Health Statistics, 1994a).
Age-adjusted heart disease death rates are loweramong Latinos than among the general population;however, considering prevalence and mortalityrates alone could underestimate the impact andpotential impact of CHD in this growing segmentof the population. For example, the decline inheart disease mortality rates observed in thegeneral population in recent years has occurred toa much lesser extent among Latinos than in thetotal population. Figure 7 illustrates this disparity.
CARDIOVASCULAR DISEASE AND
THE LATINO POPULATION
*CHD is defined as diseases bearing ICD codes 410-414, “ischemic heart disease.”
FIGURE 7
AGE-ADJUSTED DEATH RATES FOR HEART DISEASE AMONG LATINOS* AND ALL
PERSONS, AGE 45 AND OLDER, BY GENDER, UNITED STATES; 1985-87 AND 1989-91
394.4
Both Sexes Men Women Both Sexes Men Women
Source: Vital Statistics of the United States.
366.6
518.6485.4
296.1271.2
631.0
546.2
739.9
862.3
451.4394.7
Latino All Persons
* Rate shown only for States that list ethnic origin on death certificate.
1985-87 1989-91
Rate per 100,000 Population
10
CHD and other chronic diseases are expected toincrease among Latinos over the next 20 years,as this population ages (Keenan et al., 1992).In 1990, mortality due to CHD was about eighttimes higher among Latino men age 65 and olderthan among those 45 to 64 years of age. Latinowomen in the 65-plus age category are about17 times more likely to die of CHD than thoseages 45 to 64 years (Keenan et al., 1992).
In addition to age, other risk factors are knownto increase the risk of developing cardiovasculardisease in general and CHD in particular.Although some of these risk factors (e.g., age,gender, heredity) cannot be controlled by theindividual, others can be prevented or treated,thus greatly reducing a person’s chances ofdeveloping CHD. In some instances, preventingor controlling one risk factor will decrease thechances of developing another. Modifiablerisk factors include high blood cholesterol,hypertension, diabetes, obesity, physical inactiv-ity, and smoking (National Heart, Lung, andBlood Institute, 1992).
The relatively young age of Latinos presents anopportunity to use health promotion measuresto prevent these modifiable risk factors andpositively alter the progression of cardiovasculardisease in this population.
The following section discusses the most com-mon modifiable CHD risk factors and their effecton Latinos residing in the United States. Becauselifestyles, attitudes, geographic factors, culturalinfluences, length of residency, education levels,and other sociodemographic characteristics affectindividual health and disease patterns (Keenan etal., 1992), information is provided on the threemajor Latino groups—Mexican-Americans,Puerto Ricans, and Cuban-Americans—whenit is relevant and when data are available.
RISK FACTORS
High blood cholesterol levels cause plaquesto form in the arteries. These plaques can slowor block the flow of blood to the heart, brain,or other vital organs and cause a heart attack,stroke, or other life-threatening condition.The National Cholesterol Education Program(NCEP) has determined ranges of blood choles-terol levels that define desirable, borderline-high, and high blood cholesterol. For adults, ablood cholesterol level lower than 200 mg/dLis desirable. Cholesterol levels from 200 to 239are considered borderline-high, and high bloodcholesterol is defined as levels of 240 mg/dLor greater (National Heart, Lung, and BloodInstitute, 1993c).
Among the Latino groups, between 48 and57 percent of men have blood cholesterol levelsabove the desirable level. For Latino women,between 43 and 52 percent have blood choles-terol above the desirable level. Latino menhave a lower percent of borderline-high bloodcholesterol levels than Latino women; however,Latino women have a higher percent of highblood cholesterol levels than men (figure 8).
Blood cholesterol levels are influenced byheredity and by modifiable factors including dietand level of physical activity (see box on page 12for details). Studies consistently indicate thatdietary factors, particularly the intake of saturatedfat, strongly affect the blood cholesterol levelsof individuals and populations (National Heart,Lung, and Blood Institute, 1993b). For Ameri-cans, the percent of daily calories derived fromfat exceeds recommended levels. About 12percent of our total daily calories are derivedfrom saturated fat alone, with no differencesnoted among gender or race/ethnicity groups(McDowell et al., 1994).
11
Between 1982-84 (HHANES) and 1988-91(NHANES III, phase 1), the mean dietary choles-terol intake for Mexican-American womendecreased from 317 mg per day to 267 mg perday—bringing that group within the recom-mended daily allowance. Mexican-Americanmen also decreased their dietary cholesterolintake from 479 mg per day in 1982-84 to 378mg per day in 1988-91, although this remainsabove recommended levels (Loria et al., 1995).
Plaque formation tends to begin in childhood oradolescence and worsen with age (NationalHeart, Lung, and Blood Institute, 1993c); hencehealth education and primary prevention areimportant. Because borderline-high bloodcholesterol levels are more prevalent than highblood cholesterol levels (figure 8), an opportunityexists to initiate the lifestyle changes needed toprevent these levels from progressing to the highrange as the population ages.
FIGURE 8
AGE-ADJUSTED PREVLAENCE OF ELEVATED* BLOOD CHOLESTEROL LEVELS AMONG
U.S. LATINOS, AGES 20-74, BY GENDER; 1982-84
Mexican-American
High Blood Cholesterol†
*
Men
38.2%
18.8%
32.4%
20.0%
Cuban-American
35.6%
16.1%
Puerto Rican
17.7%22.7%
26.1%
31.7%
16.9%
26.5%
Borderline-High Blood Cholesterol‡
High Blood Cholesterol†
WomenBorderline-High Blood Cholesterol‡
60
50
40
30
20
10
Elevated blood cholesterol levels include high and borderline-high levels.
† High blood cholesterol is defined as 240 mg/dL or greater.
‡ Borderline-high blood cholesterol is defined as 201-239 mg/dL.
Perc
ent
Source: Hispanic Health and Nutrition Examination Survey, 1982-84.
12
High blood cholesterol levels cause no symp-toms. Screening is an important interventionused to identify and monitor individuals withelevated blood cholesterol. From 1983 to 1990the percent of people screened for blood choles-terol levels increased from 35 to 65 percent(Schucker et al., 1991), and from 1978 to 1990the average blood cholesterol level decreasedfrom 213 to 205 mg/dL (Johnson et al., 1993).
However, the National Health Interview Surveyindicates that fewer Latinos reported having theirblood cholesterol level checked than non-Latinos.Among adults, 30.0 percent of Latino men and43.9 percent of Latino women reported havinghad their blood cholesterol level checked, com-
pared with 51.5 percent of non-Latino men and56.3 percent of non-Latino women (NationalCenter for Health Statistics, 1990; see figure 9).
Hypertension is the medical term for high bloodpressure. With hypertension, there is resistanceto blood flow through the arteries and the hearthas to exert excessive pressure to carry blood tothe vital organs and muscles. Hypertension cancause heart attack, heart failure, stroke, or kidneyor eye damage. Hypertension also is a risk factorfor a number of other diseases; the higher thepressure, the greater the risk for disease.
Blood pressure is reported in two numbers. Thefirst number represents pressure when the heartcontracts to propel the blood through the arteries.
LIMITING DIETARY FAT TO LOWER BLOOD CHOLESTEROL
The Adult Treatment Panel (ATP II) guidelines, recently updated by the National CholesterolEducation Program, were established by the Expert Panel on Detection, Evaluation, and Treatmentof High Blood Cholesterol in Adults to improve detection and treatment of high blood cholesterol.These guidelines reflect the latest scientific knowledge concerning blood cholesterol and can beused to assist health care professionals in choosing the best therapy for patients. Cholesterol levelsusually can be controlled by lifestyle modification and, in severe cases, by drug treatment (NationalHeart, Lung, and Blood Institute, 1993b). According to the ATP II, more than three-quarters ofthose who require some type of therapy for high blood cholesterol can be helped by diet andexercise, and fewer than one-quarter require drug treatment (Sempos et al., 1993).
To establish or maintain an acceptable blood cholesterol level, the NCEP recommends that people:
■ limit the number of calories derived from saturated fatty acids to less than 10 percent of totalfat intake,
■ limit total fat to no more than 30 percent of total daily calories, and
■ limit total dietary cholesterol to less than 300 mg per day (National Heart, Lung, and BloodInstitute, 1993a).
13
This is called systolic pressure. The secondnumber, called diastolic pressure, reflects thepressure in the arteries when the heart relaxes.A reading of 120/80 mm Hg is considered optimalblood pressure (National Heart, Lung, and BloodInstitute, 1993d). Persons with systolic bloodpressure measurements of 140 mm Hg or higheror diastolic blood pressure measurements of90 mm Hg or higher are considered to havehypertension if the elevation occurs at two ormore separate visits (National Heart, Lung,and Blood Institute, 1993a).
Even persons with high normal blood pressure(a systolic blood pressure measurement of 130to 139 mm Hg or a diastolic blood pressuremeasurement of 85 to 89 mm Hg) are consideredat increased risk for disease (National Heart,Lung, and Blood Institute, 1993a). However,available data show that even modest loweringof blood pressure levels can have a favorableimpact. For example, data in the report onprimary prevention of hypertension indicate thata downward shift in the average national systolicblood pressure of only 2 mm Hg could decrease
FIGURE 9
PERCENT OF U.S. POPULATION AGE 18 AND OLDER WHO HAVE HAD THEIR BLOOD
CHOLESTEROL OR BLOOD PRESSURE CHECKED, LATINO AND NON-LATINO, BY
GENDER; 1990
Men Women
Source: National Health Interview Survey, 1990.
Latino Non-Latino
30.0
51.5
43.9
56.3
Men Women
73.3
83.4
88.390.9
Cholesterol Blood Pressure
14
annual U.S. mortality from stroke, heart disease,and all causes by 6, 4, and 3 percent, respectively(National Heart, Lung, and Blood Institute,1993d).
Hypertension among Latinos varies by genderand by country of origin (Pappas et al., 1990).Latino men tend to have higher prevalence ratesthan Latino women. Mexican-Americans havehigher age-adjusted hypertension prevalencerates than Cuban-Americans or Puerto Ricans(figure 10). The prevalence of hypertensionamong Mexican-American men increased by7.6 percent between 1982-84 (HHANES) and1988-91 (NHANES III, phase 1).
A family history of hypertension places a personat increased risk for this disease. The followingfactors also contribute to hypertension but canbe modified: being overweight, being physicallyinactive, having a high sodium intake, or consum-ing excessive amounts of alcohol (National Heart,Lung, and Blood Institute, 1993d). Data fromHHANES and NHANES III indicate that Latinoshave a higher prevalence of overweight and aremore likely to report a sedentary lifestyle thannon-Latinos. Although sodium intake is similaramong Latinos and non-Latinos, both groupsexceed the recommended daily intake (see boxon page 15 for details). Among Latino women,
FIGURE 10
AGE-ADJUSTED PREVALENCE OF HYPERTENSION* AMONG U.S. ADULT LATINOS,BY GENDER; 1982-84 AND 1988-91
1982-84
25.0
Mexican-American
* Defined as the average of two blood pressure measurements greater than or equal to 140/90 mm Hg or currently taking antihypertensive medication.
Men Women
1988-91
26.9
1982-84
21.8
1988-91
20.8
1982-84•
20.5
13.8
1982-84•
19.718.0
Cuban-American Puerto Rican
Hispanic Health and Nutrition Examination Survey, 1982-84. National Health and Nutrition Examination Survey III (Phase 1), 1988-91.
• Data are for ages 18-74 years.
Percent
Source:
15
the self-reported prevalence of chronic drinkingis similar to that of women not of Latino origin.However, gender differences in the prevalenceof chronic drinking do exist. Chronic drinkingis about seven times higher for Latino men thanfor Latino women (Keenan et al., 1992).
Interventions conducted in community-based andpractice-based settings indicate that the lifestylechanges needed to prevent hypertension arefeasible. Although the studies did not specificallytarget Latinos, the efficacy of four interventions—weight loss, reduced sodium intake, reducedalcohol consumption, and increased physicalactivity—has been documented (National Heart,Lung, and Blood Institute, 1993d).
For blood pressure levels, as for high cholesterollevels, adequate screening also is essential.Data from the NHIS also indicate that Latinosare less likely than non-Latinos to have eithertheir blood cholesterol levels or blood pressurechecked (figure 9). In all three Latino groupssurveyed by the HHANES, women were moreaware of having hypertension than men and weremore likely to have their hypertension treatedor controlled (figure 11). Further, a substantialproportion of Puerto Rican and Mexican-American men determined by the HHANESto have hypertension (21.3 and 32.1 percent,respectively) were not aware of their conditionand therefore were not receiving treatment.
Diabetes mellitus is a group of disorders charac-terized by high blood glucose levels. The vastmajority of diabetics die from some type ofcardiovascular disease. This is partly becausediabetes affects cholesterol levels. Thus, diabetesis related to lipoprotein metabolism and athero-sclerosis as well as obesity and hypertension.Diabetes is an independent risk factor for CHD,and the risk is doubled when hypertension ispresent (National Heart, Lung, and Blood Insti-tute, 1994a).
An excessive intake of salt and sodiummay lead to increases in blood pressure.Salt and sodium occur naturally in foodand are added in some form to almost allprocessed foods. The Joint NationalCommittee on Detection, Evaluation, andTreatment of High Blood Pressure, con-vened by the National High Blood PressureEducation Program, recommends limitingdietary sodium intake to no more than2,300 mg per day (National Heart, Lung,and Blood Institute, 1993a). This is theequivalent of a little more than one tea-spoon of table salt (a teaspoon of saltcontains 2,000 mg of sodium).
The most current data on dietary sodiumintake and discretionary salt use are fromthe NHANES III, phase 1 (1988-91).Overall, these data show that salt intake isvery similar for all the racial/ethnic groupsstudied—non-Latino whites, non-Latinoblacks, and Mexican-Americans—and thatall these groups exceed the recommendeddaily intake level (Briefel et al., 1994).According to NHANES III data, meansodium intake for individuals age 20 orolder is 3,395 mg for non-Latino whites,followed by 3,242 mg for Mexican-Americans, and 3,303 mg for non-Latinoblacks (Briefel et al., 1994).
DIETARY SODIUM AND HYPERTENSION
Diabetes is a very serious health problem forLatinos. Data from the HHANES estimate that1.3 million adult Latinos (nearly 10 percent) havediabetes (Flegal et al., 1991). As shown in figure12, the prevalence of diabetes was two to threetimes as great for Mexican-Americans and PuertoRicans surveyed in the 1982-84 HHANES as for
16
non-Latino whites surveyed in NHANES II(1976-80).
The mortality rate due to diabetes is 42 percentgreater among Latinos ages 45 to 64 than amongnon-Latinos. The rate among Latinos 65 yearsand older is about 66 percent higher than amongnon-Latinos (Keenan et al., 1992).
Studies comparing the prevalence of diabetesamong individuals with similar genetic
susceptibility and different lifestyles indicate thatbehavioral factors may be capable of overriding agenetic predisposition to diabetes (U.S. PublicHealth Service, 1993a). Lifestyle changes thathelp control and may help prevent diabetesinclude dietary modifications and exercise. Forindividuals with diabetes, reducing other healthrisks, such as cigarette smoking and hyperten-sion, also reduces the chances of complications(Zonszein, 1993).
FIGURE 11
HYPERTENSION* AWARENESS, TREATMENT, AND CONTROL† AMONG U.S. LATINOS
AGES 18-74, BY GENDER; 1982-84
Percent
Mexican- American
Men
Source: Hispanic Health and Nutrition Examination Survey, 1982-84.
Aware Treated
67.9
49.3
22.6
87.2
70.1
26.1
78.7
41.0
11.9
Puerto Rican
Mexican- American
Women
95.0
86.0
43.6
95.1
79.1
96.1
85.5
41.6
Cuban- American
Puerto Rican
29.5
Controlled
* Hypertension is defined as either blood pressure of 160/95 mm Hg or greater or reported taking antihypertensive medication.
† Control is defined as a threshold of 140/90 mm Hg.
Cuban- American
17
Overweight* is an independent risk factor forCHD that also is associated with high bloodpressure, high blood cholesterol levels, anddiabetes (National Heart, Lung, and BloodInstitute, 1994b).
Overweight is common among Latinos.HHANES data for 1982-84 showed that amongLatino women, ages 20 to 74, 41.4 percent ofMexican-Americans, 39.8 percent of PuertoRicans, and 31.9 percent of Cuban-Americanswere overweight. Latino men had lower preva-lence rates than Latino women, but more thanone of every four—31.2 percent of Mexican-Americans, 25.7 percent of Puerto Ricans, and28.5 percent of Cuban-Americans—were over-weight (figure 13). More recent data from
NHANES III show the age-adjusted prevalenceof overweight to be 48 percent among Mexican-American women and 40 percent among Mexican-American men (National Heart, Lung, and BloodInstitute, 1994b).
The San Antonio Heart Study not only revealeda high level of overweight among Mexican-Americans (Stern et al., 1990), but determinedthat, in this geographic area, overweight wasmore prevalent among Mexican-Americans thanamong their non-Latino white counterparts,regardless of gender (Mexican-American men,65.7 percent; non-Latino white men, 51.9 percent;Mexican-American women, 59.5 percent;non-Latino white women, 31.5 percent).
FIGURE 12
AGE-ADJUSTED PREVALENCE OF DIABETES AMONG U.S. ADULTS AGES 20-74,BY LATINO ORIGIN; 1976-84
* Overweight is defined as having a body mass index (weight in kilograms divided by height in meters squared) equal toor greater than 27.8 for men and 27.3 for women (National Center for Health Statistics, 1990).
Mexican-American
1.9
Note: Data for Latinos are from HHANES; data for non-Latinos are From NHANES.
Ages 20-44 Ages 45-74
14.3
Cuban-American
1.5
5.9
Puerto Rican
2.0
14.3
Non-Hispanic White
0.9
5.9
Non-Hispanic Black
2.3
10.1
Hispanic Health and Nutrition Examination Survey (HHANES), 1982-84.National Health and Nutrition Examination Survey (NHANES) II, 1976-80.
Percent
Source:
18
The prevalence of overweight varies amongLatino groups. Mexican-Americans have ahigher prevalence of overweight than PuertoRicans or Cuban-Americans of the same gender(National Center for Health Statistics, 1989).Data collected through the Behavioral RiskFactor Surveillance System in Maricopa County,Arizona, also show a propensity among Mexican-Americans toward central obesity, which isadversely associated with increased insulin,glucose, and triglyceride levels (McGinnis andBallard-Barbash, 1991).
Weight loss among adults is difficult to attain andeven more difficult to maintain; however, even
small losses have been shown to have positiveeffects on cardiovascular risk. Five-year datafrom the Coronary Artery Risk Development inYoung Adults (CARDIA) study show that aninitial loss of 5 pounds without regain of morethan 5 pounds over 5 years raised high densitylipoprotein cholesterol levels and also reducedblood pressure (National Heart, Lung, andBlood Institute, 1994b).
A strong argument for overweight prevention isthat obese children have a much higher relativerisk of becoming obese adults than nonobesechildren (National Heart, Lung, and BloodInstitute, 1994b). Studies also indicate that
FIGURE 13
AGE-ADJUSTED PREVALENCE OF OVERWEIGHT* AMONG U.S. LATINOS AGES 20-74,BY GENDER; 1982-84† AND 1988-91‡
1982-84
31.2
Mexican-American
* Overweight is defined as a body mass index (weight in kilograms divided by height in meters squared) of 27.8 for men and 27.3 for women, * which is equal to the 85th percentile for persons 20-29 years of age examined in the Second National Health and Nutrition Examination Survey.
Men Women
1988-91
39.5
1982-84
41.4
1988-91
47.9
1982-84
28.5
31.9
1982-84
25.7
39.8
Cuban-American Puerto Rican
† Hispanic Health and Nutrition Examination Survey, 1982-84.‡ National Health and Nutrition Examination Survey III (Phase 1), 1988-91.
Percent
Source:
19
prevention of overweight in children may bemore efficacious than attempts to lose weight andmaintain weight loss among adults. Data fromfour 10-year family-based treatment studiesshowed a high correlation between weightchanges in parents and children over the shortterm. However, there was less correlation overtime. After 5 to 10 years, parents tended to goback to their original weight, even when theirchild maintained the weight loss (National Heart,Lung, and Blood Institute, 1994b).
Sociocultural factors may be the most importantinfluence on prevalence patterns of overweight.Sociocultural factors influence food consump-tion, activity patterns, and attitudes toward bodyweight (National Heart, Lung, and Blood Insti-tute, 1994b). For example, in some Latinocultures overweight is frequently considered asign of health and thinness is associated withillness (National Heart, Lung, and Blood Insti-tute, 1994a). Experts convened by the NHLBIfor the Strategy Development Workshop forPublic Education on Weight and Obesity stressedthe importance of targeted interventions tosupport weight control strategies (National Heart,Lung, and Blood Institute, 1994b). These expertsrecommended (1) that programs for minoritypopulations begin with target audience segmenta-tion that considers country of origin and degreeof acculturation and (2) that message content,communication channels, and motivationalfactors vary according to population groupand age.
Physical inactivity can double an individual’schance of developing heart disease (NationalHeart, Lung, and Blood Institute and AmericanHeart Association, 1993), whereas physicalactivity of the proper duration and intensityimproves the fitness of the heart and lungsand helps control blood cholesterol levels,high blood pressure, diabetes, and obesity.
Data from the NHIS show that a smallerpercent of Latinos engage in regular moderatephysical activity than non-Latinos (20.1 versus24.0 percent, respectively), and this disparityholds true for both men and women (unpublisheddata from the National Center for Health Statis-tics, National Health Information Survey, 1991)(figure 14). Although many Latinos hold jobsthat require physical labor, the activities involvedin the jobs may not be of the type or duration thatimprove cardiovascular health (National Councilof La Raza, 1992; Nieman, 1995).
Researchers have indicated that interventionsto encourage physical activity among Latinosshould be culturally based and tailored forspecific geographic regions (Keenan et al., 1992).Local studies have indicated that Latinos aremore motivated to participate in activities thatare family-centered (National Heart, Lung, andBlood Institute, 1994b).
Cigarette smoking is an independent risk factorfor heart disease that also acts synergistically withother risk factors. Even light smoking can causeadverse effects. Cigarette smoking is associatedwith each of five interrelated processes that havebeen determined to contribute to the developmentof myocardial infarction—atherosclerosis, throm-bosis, coronary artery spasm, cardiac arrhythmia,and reduced blood oxygen delivery (U.S. PublicHealth Service, 1990).
Smoking appears to increase atherosclerosis bypromoting the adherence of platelets to the liningof the arteries (U.S. Public Health Service, 1990).Smoking also increases the level of the clottingenzyme fibrinogen, which is strongly related toheart disease and stroke (Whitney and Harris,1994). In addition, smoking raises the heart rateand blood pressure, which increases oxygendemand and concurrently decreases the capacityof the blood to deliver oxygen by elevating carbon
20
monoxide levels. The resulting imbalancebetween oxygen need and delivery increases thechance of myocardial infarction (U.S. PublicHealth Service, 1990).
According to the NHIS, the overall prevalenceof cigarette smoking is lower among Latinos(20.2 percent) age 18 and older than amongnon-Latinos (26.1 percent). Consistent with thegeneral population, data also show that a muchhigher percent of Latino men smoke than Latinowomen (figure 15). Both Latinos and non-Latinowhites show a changing pattern in smokinginitiation, with women developing smokingbehaviors similar to those found among men, andLatino women are experiencing steeper increasesin smoking prevalence than their counterparts in
the general population (Gregory and Clark,1992). Another important observation is thatPuerto Rican and Cuban-American men are notexperiencing the same steep decline in smokingrates that is observed in non-Latino whites(Gregory and Clark, 1992).
Although a lower percent of adult Latinossmoke than other population groups, a majority(75 percent) of Latino high school students haveexperimented with cigarettes, and 6.8 percentalready smoke frequently (American CancerSociety, 1992). Tobacco products are beingextensively marketed in regions with highconcentrations of Latinos, which may also resultin an increase in smoking among Latino youth(Keenan et al., 1992).
FIGURE 14
PERCENT OF LATINOS AND NON-LATINOS AGE 18 AND OLDER WHO EXERCISE OR
PLAY SPORTS MODERATELY, BY GENDER, UNITED STATES; 1991
Total Both Sexes
20.1
Latino Non-Latino
24.0 23.626.7
16.9
Source: National Health Interview Survey, 1991.
21.6
Men Women
21
KNOWLEDGE, ATTITUDES, AND BEHAVIORS
Based on the limited data concerning the levelsof knowledge about cardiovascular disease andits risk factors among Latinos, it appears thatmany Latinos are not aware of lifestyle changesthat can prevent or control many of the riskfactors for cardiovascular disease. Much of theavailable data are from local studies that includedonly a single Latino group; however, these studiescommonly show that Latinos know less aboutCVD and its risk factors compared with non-Latinos. For example, when the San Diego HealthProject surveyed knowledge on the effects ofdietary fat, exercise, and salt consumption, scoresacross each of these areas were higher for whitechildren and parents than for Mexican-Americanchildren and parents (Vega et al., 1987).
To significantly improve the primary healthof a community, major behavioral changes arerequired. Research has revealed that knowledgealone is not sufficient to invoke this degree ofbehavioral change. A market research studyconvened focus groups of low-income adultsto examine how hard-to-reach segments of theAmerican public perceive the roles of diet,exercise, and weight control in preventing orcontrolling certain chronic diseases. Responsesfrom these groups, which included six Latinogroups, suggest that people frequently fail to seehow information about risk factors and diseaseapplies to them personally. They may professto know that healthy behaviors are linked todisease reduction, while retaining the beliefthat disease is largely out of their own control(U.S. Public Health Service, 1993b).
FIGURE 15
PREVALENCE OF CIGARETTE SMOKING AMONG U.S. LATINOS AND NON-LATINOS
AGE 18 AND OLDER; 1991
Latino
20.2
Both Sexes Men
25.2
15.5
26.128.3
Source: National Health Interview Survey, 1991.
24.2
Non-Latino
Women
Percent
22
Indeed, many factors can affect people’s desireand ability to modify their lifestyle. The healthpromotion and planning model PRECEDE(Green and Kreuter, 1991) established threecategories of factors that influence healthbehaviors. These categories are beneficial toconsider when planning, developing, imple-menting, and evaluating health programs forspecific communities. They are:
■ Predisposing factors that include knowl-edge, values, cultural beliefs, perceivedneeds, perceived abilities, and existing skills;
■ Enabling factors that include conditions ofthe environment (such as access to healthcare) and the ability to perform new tasksthat constitute a health-related behavior; and
■ Reinforcing factors that include family andsocial support, peer influence, and real orperceived positive or negative consequencesof the behavior.
Knowledge concerning all of these factors, asthey apply to a specific target group, may helpto maximize the effect of health promotionmessages. Values placed on health, meaningsattached to disease, health priorities, level ofacculturation, language preferences, literacylevels, economic status, and demographics allinfluence the outcomes of interventions (NationalHeart, Lung, and Blood Institute and The JohnsHopkins Medical Institutions, 1992)
The next section provides examples of howselected health promotion and disease preventionprograms targeting Latinos have used these kindsof information to develop culturally competentcardiovascular disease prevention programs.
23
Culture is a complex social phenomenon thatinfluences every aspect of a person’s life.Culture consists of the shared beliefs andvalues within a group of people that guidetheir accepted and patterned ways of behavior(Kreps and Kunimoto, 1994). Cultural valuesalso influence an individual’s attitudes towardmedications, illness, and death and beliefsconcerning the individual’s control over his orher health (Kavanaugh and Kennedy, 1992).
When developing disease prevention programs,cultural values and norms can be used tostrengthen and facilitate the efficacy of theintervention. It has been suggested that positivesocial and cultural factors may explain whypoverty, poor access to primary care, and a lackof health insurance have not created a highermortality rate among Latinos living in theUnited States (Sorlie et al., 1993).
Cultural values differ among Latinos accordingto country of origin, educational attainment,and acculturation level (National Coalition ofHispanic Health and Human Services Organiza-tions, 1990). However, most Latinos share corevalues and beliefs that differentiate them fromother cultural groups (Marin, 1989) and that canbe used to improve the efficacy of the healthpromotion and disease prevention interventions.Latino values and beliefs that may influencehealth include:
■ familismo—the significance of the family tothe individual;
■ colectivismo—the importance assigned tofriends and members of the extended family;
■ simpatía—the need for positive, smoothinterpersonal relations;
■ personalismo—the preference for friendly andpersonal relationships with members of thesame ethnic group;
■ fatalismo—the belief that there is little that anindividual can do; and
■ respeto—deferential behavior toward othersbased on factors such as age and positionof authority. Doctors, teachers, and otherprofessionals may be awarded respect byvirtue of healing functions or education.
Because these factors vary from one communityto another, there is no single best way to design ahealth promotion and disease prevention cam-paign. Some programs involve communityleaders and community volunteers. Volunteersalso may be referred to as promotoras/promotoresor consejeras (see box, page 24). Some programsuse community resources such as churches,schools, community centers, local health clinics,social clubs, and local businesses as partners forcommunity-based outreach efforts. Thesecommunity resources also may have ties tonational organizations with even stronger, moreextensive networks (National Heart, Lung, andBlood Institute, 1987). Other programs use thelocal media to enhance some program outreachefforts.
COMMUNITY-BASED DISEASE PREVENTION AND
HEALTH PROMOTION PROGRAMS FOR LATINOS
24
Data suggest that Latinos can be reached effec-tively through public health intervention programsthat are media based and culturally appropriate.Spanish-language television and radio are bothexcellent methods for promoting prevention andcontrol messages to Latinos. Research hasrevealed that on a typical day, 67 percent ofLatinos in the United States watch Spanish-language television; 47 percent listen toSpanish-language radio; 21 percent readSpanish-language newspapers; and 19 percentread Spanish-language magazines (Ramirez andMcAlister, 1988). According to 1990 censusdata, more than 17 million people age 5 and olderspeak Spanish, and 8.3 million of these speakEnglish poorly or not at all (U.S. Bureau of theCensus, 1993b).
Program planners also must keep in mind that asegment of the Latino population speaks onlyEnglish. A need also exists for culturally sensitivemessages presented in English and disseminatedthrough the mainstream media.
Community involvement has proven to be a keyelement in planning, developing, implementing,and evaluating programs. Community involve-ment enhances a program’s credibility andvisibility and helps ensure broader communityparticipation. Overall, it is evident that a com-munity-based approach of project implementa-tion offers distinct advantages, including theability to gain the community’s support, theprospect of decreasing the community’s depen-dence on external resources, the ability to betterassess needs and tailor interventions, and thepotential to achieve behavioral change throughactive participation in the project (Alcalay andTaplin, 1989). Community-based health promo-tion programs also have the opportunity toconduct needs assessments in the form of popula-tion-based surveys or focus groups in the target
LATINO COMMUNITY PARTNERS
Community leaders are typically activein local churches, schools, social clubs, andother community resources and are recog-nized as opinion leaders. These individualshave access to information that is unavail-able to outsiders. They understand thehealth priorities of the Latino communityas well as the daily challenges they face.Community leaders are familiar with locallanguage preferences, health beliefs, andhealth practices, and they know whatcommunity health care resources areavailable and how they are used. They alsocan identify other community opinionleaders, communication networks, andlocal experts who may be useful to theprogram (National Heart, Lung, and BloodInstitute, 1987).
Community volunteers, consejeros/consejeras, or promotoras/promotores arerespected and responsible members of thetarget communities who not only sharehealth information and materials butalso model appropriate health behaviorsin their own lives. In many instances,these volunteers become agents of socialchange in their communities, rising toleadership positions and inspiring othersto accept personal responsibility for takingcontrol of their own health (University ofCalifornia—San Diego, 1990).
communities. A sound needs assessment can helpprogram planners determine the level of knowledgewithin the community concerning relevant healthissues and how these issues are perceived.
25
RECOMMENDED STRATEGIES AND EXAMPLE
PROGRAMS
This section discusses some key elements toconsider in the design of community-based healthpromotion programs targeted to Latinos. Thestrategies are based on findings from interventionstudies of Latinos, the experiences of actualprograms, and the demographic and epidemio-logical reality of the Latino community asestablished in this background paper. Thesehighlighted strategies are not presented in orderof priority and are not meant to represent theuniverse of successful program strategies.
The health promo-tion and diseaseprevention programscited are examplesof interventions that
have employed one or more of the recommendedstrategies. Some of the programs reviewed werenot designed to reduce cardiovascular disease;however, their approach and outreach strategieshave significant relevance and applicability toCVD prevention for Latinos. An overview of theprojects used as examples appears in table formatin appendix A.
Involving community members in the programlends credibility. Family and friends are re-spected sources of information among Latinosand an essential part of their support system.Encouraging people to share their personal storiesand give testimonies of simple lifestyle changesthey have made to prevent CVD and contributeto overall improved health status can be veryeffective. Recruiting volunteers from the com-munity to share health information and to modeldesirable health behaviors is a viable method.Focus groups composed of members of the targetcommunity also provide valuable insights into thetarget audience’s health beliefs and practices aswell as its level of knowledge about specifichealth issues.
Recruiting community members assists programplanners in various ways. Community memberscan be enlisted to conduct their own communityneeds assessment. Working groups also can beestablished to assist with the development ofconcepts, messages, and images to ensure cultur-ally appropriate CVD prevention and educationmaterials. Working groups lend credibility andvisibility to program efforts, and given trainingand support, they can evolve over time into acommunity coalition to address not only CVDprevention and education but other health issuesas well.
A Su Salud, a smoking prevention and cessationprogram that targeted Mexican-Americans,recruited and trained more than 400 volunteersfrom its target communities (Ramirez andMcAlister, 1988). These volunteers distributededucational materials and served as role modelsfor behavior modification.
The Ayude Su Corazón project also trainedcommunity volunteers (Oto-Kent et al., 1991).More than 50 people were taught how to takeblood pressure measurements and completesurvey questionnaires. This project also involvedthe area stores, schools, churches, and Spanish-language newspapers and radio stations inactivities designed to increase awareness ofhigh blood pressure, high blood cholesterol, andother heart disease risk factors. For example,a bilingual education campaign was conductedin five major grocery stores.
Direct input fromthe community canenable a programto design materialsbased on the specificneeds of the targetaudience.
For some target audiences, the novela may be aneffective way to deliver health messages. In other
Gain communitysupport.
Develop culturallyappropriate andlanguage-specificmaterials.
26
cases, a colorful poster with one simple messagemay be the best approach. Selected formatsshould attract the target group and be understoodby them.
It is usually best to develop Spanish-languagematerials in Spanish from the beginning. IfEnglish-language materials are translated intoSpanish, use only experienced translators whounderstand that direct translations generally arenot successful in communicating the intendedmessage and may offend the target audience.
Recognizing the diversity within each Latinocommunity ensures reaching more individuals.One approach will not be appropriate for all.Developing and implementing interventionsto target different age groups, socioeconomiclevels, and acculturation levels are desirable.
It is important to obtain an accurate assessment ofthe general educational level, literacy level, andlanguage preference of the target audience beforedeveloping written materials and messages. Forlow-literacy audiences, materials using simplewords, short sentences, and concrete concepts aremost successful. The use of graphic illustrationsmaximizes ease of understanding key messages.Public service announcements should be producedusing the preferred language of the target popula-tion. Messages and materials need to have apresent-time orientation. Themes that focus onthe future may not be as effective as those thatemphasize the importance of making healthbehavior changes now. Pamphlets and brochuresshould be pretested for readability and appeal.
The Checkerboard Cardiovascular Curriculum isan example of a program that showed respect forcultural values (Harris et al., 1988). This programwas designed to help Native American and Latinochildren in rural New Mexico develop healthiereating and exercise habits. The program invitedrespected elders to the classroom to talk about thecultural importance of physical activity and to
demonstrate how traditional heart-healthy foodsare prepared. Materials used in this programwere relevant to the American Indian and Latinocultures.
As a result of this program, all of the studentsshowed significant increases in their knowledgeabout the cardiovascular system, exercise,nutrition, obesity, tobacco use, and how behaviorcan be changed to enhance heart health.
The San Diego Family Health Project illustratesanother possible impact that materials andtechniques can have on outcomes among ethnicpopulations (Nader et al., 1989). This projectwas designed to encourage families to decreasetheir intake of high-salt and high-fat foods andincrease their physical activity levels. BothMexican-American and white families partici-pated in the program. As expected, the experi-mental group gained more knowledge than thecontrol group during the specified time period.However, a greater change was found amongwhites in the experimental group than among theMexican-Americans. Several factors may haveinfluenced this discrepancy. Because participantswere required to record behaviors using diariesand questionnaires, it has been suggested that thequality of translation of the questionnaires andthe literacy level of the target audience may haveneeded more consideration.
When possible,attaching a newhealth promotion ordisease preventionprogram to existinghealth programs inthe target commu-
nity will allow the newer program to utilizeinfrastructures and viable local networks thatthe ongoing services and programs have alreadyestablished. Collaborative efforts can signifi-cantly expand the reach of the combined
Involve existingcommunityorganizations andservices.
27
programs beyond what either of the singleprograms could accomplish alone.
A program’s planning process should take intoaccount the role, patterns of use, and impact ofthe local mainstream health care system on thetarget community. This information may beobtained from private physicians, local healthclinics, hospital emergency departments, andother health care providers and facilities.
The Washington Heights-Inwood Healthy HeartProgram combined a community interventionwith an ongoing media campaign sponsored bythe New York State Healthy Heart Program (Sheaet al., 1992). This project determined ways toadapt the statewide intervention to a specificurban area. Strategies included adapting thematerials for the linguistic and cultural diversityof the target population and involving communityleaders and organizations to lend legitimacy tothe efforts.
Local media canassist with theplanning andimplementation
of the program. This ensures more communityinvolvement and also can reduce certain costs.Sponsoring television and radio stations mayprovide air time free of charge or at a nominalfee. Local media channels may include localtelevision and radio stations, community news-papers and magazines, and newsletters publishedby community-based organizations. Enlistingthe cooperation of a local media personality toserve as a spokesperson for the CVD preventionprogram facilitates immediate program recogni-tion and can lend credibility and visibility toprogram efforts.
The A Su Salud project included local media atan early stage of the program implementation(Ramirez and McAlister, 1988). This stepresulted in increased community involvement.
It also reduced program costs because the spon-soring stations provided production time free ofcharge and air time at a nominal fee.
Interventions thatcomplement theirdaily activities andpreferences may bebetter accepted bya target audience.For example,
Latinos find family-centered activities moreappealing than solitary activities. To encourageLatinos to increase their physical activity, judi-cious choices would be walking, hiking, dancing,swimming, or other activities that can be enjoyedin a group setting.
Some programs have found it more effective tofit new health information into an old frame ofreference. For example, program strategies canbe incorporated into traditional healing practices.To reach certain segments of the Latino commu-nity, this approach is more successful thanignoring or trying to eliminate such beliefs.
Interpersonal communication also is importantin transmitting health messages. Interpersonalcommunication may come from health experts orimmediate family members. Latino women oftenserve as channels to the entire family and cansuccessfully transmit messages to less accessiblefamily members.
Por la Vida, a program designed to increaseLatino women’s knowledge of heart disease andhelp them develop skills to prevent heart diseaseand stroke, used existing social networks in thecommunity to encourage women to participatein the program (University of California—SanDiego, 1990). A unique feature of Por la Vidais that it provided child care during its trainingsessions, which was a major incentive for womento take the time to learn how to care for them-selves and others.
Select influentialmedia.
Incorporatecommunitylifestyle, values,and beliefs.
28
THE NHLBI L ATINO COMMUNITY
CARDIOVASCULAR DISEASE PREVENTION
AND OUTREACH INITIATIVE
Implementation of the NHLBI Latino CVDprevention and outreach initiative follows athorough study of the prevalence of cardiovascu-lar risk factors among Latinos residing in theUnited States, the sociodemographics of theLatino community, and the community’s knowl-edge base concerning CVD and its prevention.
The first NHLBI-sponsored initiative will targetCentral and South Americans living in theWashington, D.C., metropolitan area. Theeffectiveness of specific strategies for develop-ing and implementing other health promotionand disease prevention programs for the Latinocommunity also was carefully reviewed inpreparation for this program. A report follows(appendix B) that outlines the goals and objec-tives of the Washington, D.C., metropolitan areaprogram.
29
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APPENDIX AOVERVIEW OF SELECTED CVD-RELATED
PREVENTION PROGRAMS
PROJECT TARGET AUDIENCE LOCATION GOALS AND OBJECTIVES METHODOLOGY
A Su Salud Mexican-American Texas-Mexico – Reduce number of smokers – Use of role models fromadults border area by encouraging current community.
smokers to quit and preventing – Distribution by volunteers ofothers from initiating the habit. culturally specific materials,
– Promote other healthy such as a self-help booklet.behaviors. – Use of media to disseminate
information and personaltestimonies.
Ayude Su Rural residents Yolo County, – Increase knowledge of CVD risk – Blood pressure screening byCorazón (predominantly CA factors and ways to prevent and trained volunteers.
Latino) control these risk factors. – Cholesterol screening by a– Enable community to sustain local hospital.
program after intervention is – Quarterly newsletter,over. newspaper articles, PSAs.
– Toll-free question line.– Promotions in stores.– Classes conducted by area
teachers.
Checkerboard Native American and Rural New – Teach children heart-healthy – Interviews with grandparentsCardiovascular Latino children Mexico behaviors, such as selecting about traditional diet andCurriculum low-fat food and being activities.
physically active. – Cooking demonstrations and– Test a pilot curriculum designed talks by elders.
to accomplish the goal stated – Culturally relevant materialsabove. on exercise and diet.
Por la Vida Latino women San Diego, CA – Prevent heart disease and stroke. – Trainings conducted by– Provide skills and knowledge to women from the Latino
Latino women to help them community (consejeras).improve their own health and – Games and culturally specificthe health of their families. handout materials.
– Child care to allowparticipation.
– Small group sessions ofrelatives and friends.
San Diego Mexican-American San Diego, CA – Decrease cardiovascular heart – Education.Family Health and white families disease and related conditions. – Aerobic activity.Project – Teach children and parents how – Self-report of dietary and
decreasing salt and fat intake activity behaviors.and increasing activity levels canprevent CVD and various riskfactors.
Washington Low SES urban Northern – Reduce risks of CVD. – Adapted model for inner-cityHeights- residents Manhattan, – Test the diffusion of a setting.Inwood (predominantly New Y/rk community-based disease – Used community volunteers.Healthy Heart Latino) prevention program. – Involved communityProgram organization and leaders.
34
35
APPENDIX BTHE NHLBI WASHINGTON, D.C., METROPOLITAN AREA
LATINO COMMUNITY CARDIOVASCULAR DISEASE PREVENTION
AND OUTREACH INITIATIVE
The initial effort of the NHLBI Latino Commu-nity Cardiovascular Disease Prevention andOutreach Initiative is taking place in the Wash-ington, D.C., metropolitan area. The intendedgoals of this project include:
■ increasing the awareness of cardiovascular riskfactors and their impact on heart health in theLatino community,
■ establishing an alliance of community groupsto become partners with the NHLBI in thedevelopment and implementation of theproject,
■ developing a series of health messages andsupport materials in collaboration with theLatino community, and
■ monitoring and assessing the effect of theproject’s awareness and outreach efforts inthe Latino community.
Strategies for attaining these goals includeconducting public education through use of themedia and through community outreach efforts.The NHLBI and community members are
working together to develop health educationproducts specifically designed for the Latinocommunity.
Widespread community involvement in theendeavor is being emphasized through thedevelopment and implementation of this project.Latino health care professionals, communityleaders, community-based organizations, clinics,and health centers as well as Latino businessesand media have been invited and encouragedto participate as partners with NHLBI healtheducators and researchers to develop and provideactivities that will promote healthier lifestylesand reduce the risk of CVD among Latinos.
In addition, this effort is intended to serve asa model for future projects elsewhere in theNation. Planning sessions are being conductedin the Latino community. The first communityplanning session was held September 12, 1994.
For more information on this project, pleasecontact the NHLBI Information Center at(301) 251-1222, fax (301) 251-1223.
36
37
APPENDIX COVERVIEW OF DATA
List of Tables
Table 1. Percent of U.S. Population by SelectedGroups and Socioeconomic Factors . . . . . . . . . . . . . . 38
Table 2. Selected Behaviors Among the TotalU.S. Population and the U.S. LatinoPopulation by Gender . . . . . . . . . . . . . . . . . . . . . . . . . 39
Table 3. Age-Adjusted Prevalence of SelectedFactors Among Latinos by Ethnicityand Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Table 4. Age-Adjusted Death Rates for Heart Diseasefor the Total U.S. Population and the U.S.Latino Population by Gender . . . . . . . . . . . . . . . . . . . . 41
38
TABLE 1. PERCENT OF U.S. POPULATION BY SELECTED GROUPS
AND SOCIOECONOMIC FACTORS
Selected Groups
Central/Total Non- Mexican- Puerto Cuban- South Other
Socioeconomic Factors Population Latino Latino American Rican American American Latino
Percent
Completed high school 19931 80.2 82.4 53.1 46.2 59.8 62.1 62.9 68.9
Living below poverty line 19931 14.5 13.1 29.3 30.1 36.5 18.1 26.7 23.1
Unemployed 19931 7.4 7.1 11.9 11.7 14.4 7.3 13.2 10.8
Under age 65 and notcovered by healthinsurance 19922 17.2 — 34.0 37.8 18.3 20.1 — 35.2
1 Current Population Estimates2 National Health Interview Survey
— Data not available
39
Total Population Latinos
Behaviors Total Men W omen Total Men Women
Percent
Exercise or play sports moderately 19911 24.0 26.7 21.6 20.1 23.6 16.9
Currently smokes cigarettes 19901 26.1 28.3 24.2 20.2 25.2 15.5
Ever checked cholesterol 19901 52.7 51.5 56.3 37.5 30.0 43.9
Checked blood pressurewithin year 19901 87.0 83.4 90.9 81.8 73.3 88.3
1 National Health Interview Survey
TABLE 2. SELECTED BEHAVIORS AMONG THE TOTAL U.S. POPULATION
AND THE U.S. LATINO POPULATION BY GENDER
40
Mexican-American Puerto Rican Cuban-American
Selected Factors Men Women Men Women Men Women
PercentHypertension
Prevalence 1982-841 25.0 21.8 19.7 18.0 20.5 13.8
Awareness 1982-841 67.9 95.0 78.7 96.1 87.2 95.1
Treatment 1982-841 49.3 86.0 41.0 85.5 70.1 79.1
Control 1982-841 22.6 43.6 11.9 41.6 26.1 29.5
Prevalence 1988-912 26.9 20.8 — — — —
High Blood Cholesterol
Prevalence high 1982-841 18.8 20.0 17.7 22.7 16.1 16.91988-912 20.3 19.4 — — — —
Prevalence borderline-high 1982-841 38.2 32.4 31.7 26.5 35.6 26.1
Overweight
Prevalence 1982-841 31.2 41.4 25.7 39.8 28.5 31.91988-912 39.5 47.9 — — — —
Diabetes*
Prevalence ages 20-44 1982-841 1.6 2.3 1.2 2.5 1.0 1.8
Prevalence ages 45-74 1982-841 13.4 15.2 11.3 16.2 5.2 6.6
1 Hispanic Health and Nutrition Examination Survey2 National Health and Nutrition Examination Survey* Crude prevalence
— Data not available
TABLE 3. AGE-ADJUSTED PREVALENCE OF SELECTED FACTORS
AMONG LATINOS BY ETHNICITY AND GENDER
41
TABLE 4. AGE-ADJUSTED DEATH RATES FOR HEART DISEASE
FOR THE TOTAL U.S. POPULATION AND THE U.S. LATINO
POPULATION BY GENDER
Total Population Latinos
Behaviors Total Men W omen Total Men Women
1985-871 631.0 862.3 451.4 394.4 518.6 296.1
1988-911 546.2 739.9 394.7 366.6 485.4 271.2
1 Vital Statistics of the United States
42