Social Work in Public Health

Social Work in Public Health, 25:258–271, 2010

Copyright © Taylor & Francis Group, LLC

ISSN: 1937-1918 print/1937-190X online

DOI: 10.1080/19371910903240605

Latina Women: Health and Healthcare Disparities

BLANCA M. RAMOS School of Social Welfare, University at Albany, State University of New York,

Albany, New York, USA

JANINE JURKOWSKI School of Public Health, University at Albany, State University of New York,

Albany, New York, USA

BLANCA A. GONZALEZ Benedictine University, Lisle, Illinois, USA

CATHERINE LAWRENCE School of Social Welfare, University at Albany, State University of New York,

Albany, New York, USA

This article examines disparities in health and healthcare for

Latina women. It draws on existing literature and descriptive data

from a study with Latinas. Mortality rates, leading causes of death,

and reproductive health are well-documented. Little information

is available on the health and chronic health conditions severely

inflicting Latinas such as heart disease and diabetes. Despite

advances regarding reproductive care and screening procedures,

Latinas still experience inequities in healthcare insurance and

utilization. Study findings indicate higher rates of diabetes and

hypertension than Latinas nationwide and reasons for delaying seeking healthcare. Directions for future research and policy

recommendations are explored.

KEYWORDS Health disparities, healthcare disparities, Latina

women

Research for this paper was supported by the Center for the Elimination of Minority Health Disparities, the New York Latino Research and Resources Network, and the Center for

Social and Demographic Analysis at the University at Albany.

Address correspondence to Blanca M. Ramos, School of Social Welfare, University at Albany, State University of New York, 135 Western Avenue, Albany, NY 12222, USA. E-mail:

[email protected]

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INTRODUCTION

Racial and ethnic health disparities in the United States have been docu- mented as early as 1906 and are a matter of grave public concern in today’s society (Gamble et al., 2006). Racial and ethnic minority groups fare worse overall than Whites on a number of health status and healthcare measures, even after insurance coverage, income, and other socioeconomic factors are statistically controlled (Balsa, Seiler, McGuire, & Bloche, 2003; Jackson et al., 2001). As examples, Latinos (13.3%) are disproportionately more likely to rate their health as fair or poor than are Whites (8.0%) (U.S. Department of Health and Human Services, 2006). Latinos experience higher rates of high blood pressure and stomach cancer and are nearly twice as likely to have diabetes (Office of Minority Health and Health Disparities, 2007). Compared to Whites, Latinos had worse access to care on 7 of 8 core measures and poorer quality of care on 23 of 38 core measures (Agency for Healthcare Research and Quality, 2007). In a national poll, Latinos were more likely (41%) than Whites (22%) to believe that minority group members receive disparate healthcare (Harvard Forums on Health, 2003).

A comprehensive understanding and account of health and healthcare disparities that takes into account gender differences is needed given that health and illness are differentially experienced by men and women cross- culturally (Bird & Rieker, 2008; Pollard & Hyatt, 1999). Although Latinas comprise an important segment of the Latino and U.S. populations, the limited available data on the health and healthcare for the Latino ethnic group are seldom reported separately by gender. Similarly, it is projected that Latinas will represent 25% of the female population in the U.S. by the year 2050, but data specific to women’s health are not always reported by ethnicity (Beckles, 2005; U.S. Census Bureau, 2004). Health information specific to Latinas and distinguished by gender holds promise for a targeted and refined understanding of health disparities.

Research describing health disparities on the basis of ethnicity and gen- der can impact professional and public awareness and raise important con- siderations for health and social policy. More specifically, efforts to eliminate these disparities for the Latino ethnic group can be better informed through gender-specific studies and findings that systematically examine the health and healthcare concerns of Latinas. This article presents descriptive findings from a study that examined the health and healthcare concerns of Latinas re- siding in small cities in upstate New York. Based upon the results and existing literature, implications for policy and program development are explored.

LATINA WOMEN

In the United States, there are approximately 17 million Latinas, 52% of the rapidly growing Latino population (U.S. Census Bureau, 2004). Given the

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potential for underreporting, this figure is likely an underestimate. Latinas are a diverse group due primarily to individual sociodemographic characteristics, how they come into contact with U.S. mainstream society, and the Latin American country to which they trace their ancestry, each with its own sociocultural distinctiveness and sociopolitical history. At the same time, Latinas share some common themes including their Hispanic cultural heritage and the social disadvantages that accompany their ascribed gender and minority statuses in U.S. society. These differences and commonalities are important for understanding health status, health behaviors, and healthcare experiences of Latinas.

A Sociodemographic Profile

The gender distribution among Latinos varies by subgroup, with Mexican (59%) and Puerto Rican (10%) women representing the two largest segments of Latinas in the United States. Overall, a large proportion (38%) of Latinas was born outside the continental United States. They tend to be young, with 57% younger than 30 and a median age of 26.6 years. More than half (56%) are married, 59% have children younger than 18, and 83% of those married have the spouse present in the household (U.S. Census Bureau, 2007).

The socioeconomic profile of Latinas reflects multiple social inequalities that place them at high risk for certain health conditions and limit their access to quality healthcare. For example, 43% of Latinas have a 12th-grade education or less, compared to 12% of White women. Only 11% have a bachelor’s degree or higher, contrasted to 26% of White women. Latinas in the workforce are more likely to be employed in low-paying, part-time, or seasonal jobs than their White counterparts and experience twice the rate of unemployment (7.7%) White women do (3.3%). Latinas employed full-time have a median income of $10,862 compared to $15,217 for Whites. Mean- while, 24% live below the poverty line versus 9% of White women. Among female-headed households (23% Latinas, 14% White women), Latinas are more likely (25% versus 9%) to live below the poverty level (Giachello, 2001; U.S. Census Bureau, 2007). Thus, Latinas are economically disadvantaged and vulnerable to poverty-related health conditions and often lack health insurance or financial means to access and pay for needed healthcare.

HEALTH AND HEALTHCARE AMONG LATINA WOMEN

Mortality and Health Conditions

The life expectancy for Latinas (77.1 years) is slightly lower than that of White women (79.6 years) and higher than that of Latino men (69.6 years) (Giachello, 2001). The top three health-related causes of death for Latinas

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are heart conditions, cancer, and cerebrovascular diseases, which are sim- ilar to incidence rates for non-Latina women (Aguirre-Molina, Abesamis, & Castro, 2003). For example, the age-adjusted incidence rates per 100,000 for death from heart and cerebrovascular diseases are 177.3 and 35.4 for Latinas and 172.9 and 47.2 for White women, respectively (U.S. Department of Health and Human Services, 2007). California Latinas show a similar rate of hypertension (25% versus 23.7%) as their White counterparts (Baezconde- Garbanati, Portillo, & Garbanati, 1999).

The mortality rate due to cancer for Latinas is 298 per 100,000. Cancer is the leading cause of death in Latinas aged 25 to 54. Mortality for stomach (9.6 per 100,000) and cervix uteri (12.6 per 100,000) cancers are appre- ciably higher for Latinas than for White women (4.9 and 7.6 per 100,000, respectively). Interestingly, death rates for lung, colon, and ovarian cancers are lower in Latinas than in White women (U.S. Department of Health and Human Services, 2007; Valdez & Posada, 2006). Although the mortality incidence rate for breast cancer is lower for Latinas than for White women (83.9 compared to 125.4 per 100,000), breast cancer is the number one cause of cancer-related deaths among Latinas.

Beyond mortality data, research describing the impact of Latinas’ health problems on death rates and the prevalence of allied health conditions is limited. In a review of the literature on Latinas’ health, Aguirre-Molina et al. (2003) found few studies that pursued these lines of inquiry. For instance, recent efforts to document the gravity of chronic diseases such as diabetes in the Latino population have offered little insight for Latina women. Diabetes is the fourth leading cause of mortality among Latinas and the eighth leading cause of death for the remainder of the female population (Aguirre-Molina et al., 2003). Mortality rate from diabetes for Latinas of all ages is 17.5 per 100,000.

As a group, Latinos have one of the highest rates of diabetes in the United States and a higher prevalence rate of diagnosed diabetes than Whites across all age groups, and 90% to 95% of Latinos experience type 2 diabetes (Kieffer, Willis, Arellano, & Guzman, 2003; Health, United States, 2007). For Latinos aged 50 or older, between 25% and 30% experience diabetes (National Institute of Diabetes, Digestive, and Kidney Diseases, 2001). Also, the age at onset of diabetes is earlier for Latinos than that of other ethnic groups (Health, United States, 2007). For Latinas aged 45 to 64, the rate of diabetes is 13.5% compared to 7.8% for White women. For Mexican American women, the rate of diabetes (10.9%) is more than double that of White women at 4.5% (National Center for Chronic Disease Prevention, 2004).

Reproductive health is a key area for Latinas given their median age (26.6 years), which places them squarely in their childbearing years. They have the highest birth percentages among women in the United States. Birth rates (live births per 1,000 women) are 24.3 for Latinas compared to 14.6 for White women. Among expecting mothers, Latinas tend to experience

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lower rates of pregnancy-related hypertension (27.7%) compared to their White counterparts (41.0%) and report lower percentages of alcohol con- sumption (1.0 versus 1.2) and smoking (4.0 versus 16.2). Despite these positive indicators, the rate of maternal mortality for Latinas is 1.7 times higher than for Whites; more than 25% do not receive prenatal care (U.S. Department of Health and Human Services, 2007). Latinas are also less apt to receive regular mammograms and Pap tests and, as mentioned before, suffer a disproportionate mortality rate from breast and cervical cancers (Ruskamp- Hatz, 2007).

Less is known about mental health status and mental health conditions such as depression and anxiety among Latinas. The data available are limited and estimates of prevalence reflect considerable variation. These inconsis- tencies can be attributed to methodological and sample differences as well as to the use of assessment instruments that may not be culturally applicable (Ramos & Carlson, 2004).

Healthcare

Disparities in health outcomes have been attributed to the interplay of in- dividual biological and behavioral markers with physical and social envi- ronmental factors (Office of Minority Health and Health Disparities, 2007). Disparate healthcare quality and utilization play a pivotal role (Institute of Medicine, 2002). For Latinos, inequalities in healthcare are apparent for all medical conditions, at all sites of care, and at all points in the process, as documented by the Agency for Healthcare Research and Quality (2002).

Latinos are uninsured at higher rates (34%) than any other U.S. eth- nic group, and preventive and primary care indicators of overall access to care reveal acute disparities between Latinos and non-Latino Whites ( James, Thomas, Lillie-Blanton, & Garfield, 2007). For example, Latinos (30.9%) are less likely than Whites (14.6%) to experience regular continuity of health services or to have had a healthcare visit in the past year (27% versus 14%) even when controlling for income (Health, United States, 2006; James et al., 2007). Compared to other racial and ethnic groups, Latinos have the lowest percentage of adults receiving screening for high blood pressure (83.2%) in the past 2 years and for high cholesterol (68.4%) in the past 5 years ( James et al., 2007).

Although some of the inequalities between Latinas and non-Latina women can be explained by socioeconomic factors, health disparities still persist. For Latina women, the available data on healthcare are largely restricted to services related to reproductive health, such as some cancer screening and timely prenatal care. Trend data that track progress in eliminating healthcare disparities show that despite some advances, when comparing Latinas and White women of similar socioeconomic conditions, inequalities still remain. In 2003, 35% of Latinas were less likely to have

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had a mammogram in the past 2 years than were White women (30%), compared to 48% and 39%, respectively, in 1994 (Health, United States, 2005). During the same time interval, the number of women who did not have a Pap test in the past 3 years declined from 26% to 25% of Latinas and from 23% to 21% of White women ( James et al., 2007; National Center for Health Statistics, 2003). In 2007, 54% of Latinas reported having a Pap test annually and 82% within a 3-year interval (Health, United States, 2007). Among Latinas, 5.4% of live births in 2004 were to mothers who received late or no prenatal care compared to 2.2% for White mothers. Unlike most healthcare data, these statistics are available by Latino subgroup: 5.5% for Mexican Americans, 3.9% for Puerto Ricans, 2.0% for Cubans, 5.1% Central and South Americans, and 5.5% for ‘‘other’’ Latinas (Health, United States, 2006; James et al., 2007).

Latinas are also at a disadvantage with regard to healthcare quality and utilization. They have a high rate of being uninsured—37% compared to 16% for White women and 34% for Latinos as a whole—and they are less likely (24%) to have a regular care provider than are White women (11%). While most Latinas receive healthcare in a doctor’s office (51%), this rate falls well below the national average (75%) for all women (Aguirre-Molina et al., 2003). When Latinas do seek medical care, they are more likely to encounter multiple barriers when compared to non-Latinas (Kaiser Family Foundation, 2001). They report difficulty receiving care due unavailability of physicians or clinics, unwillingness of their physicians to take time to answer questions, and concern with the quality of services. Latinas also report delaying healthcare in the past year due to lack of transportation (18% versus 5% for White women), affordability (31% compared to 22% for White women), and, among mothers, lack of child care (15% versus 9% for White women). Only 52% of Latinas reported feeling ‘‘comfortable’’ at a family planning clinic (Health, United States, 2007).

In sum, Latina women represent an appreciable and rapidly growing segment of the U.S. population. As a group, Latinas experience multiple social disadvantages and disparities involving health and healthcare. Data on Latinas’ health and healthcare, especially mental health, issues are scarce. Mortality rates and causes of death are well-documented, but literature link- ing health status and chronic health conditions to well-being for Latinas is sparse. The picture of reproductive health is somewhat clearer and more positive, perhaps as an indirect gain of persistent advocacy efforts calling attention to health concerns specific to women. Despite a few advances in reproductive care and screening procedures, it is clear that Latinas continue to face a number of barriers related to healthcare and experience inequities in health insurance coverage and utilization. The study presented below examined health and healthcare concerns in a sample of Latinas in small cities in upstate New York focusing on specific health and healthcare indi- cators.

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STUDY METHODS

Sample and Procedures

This study used a purposive sampling method. Nonprobability sampling techniques are commonly used in exploratory studies with difficult-to-reach populations such as members of minority groups who historically have not been adequately represented in research (Kreuger & Neuman, 2006; Rubin & Babbie, 2008).

The sample was drawn from a three-county area in upstate New York where the Latino population varies between 3% and 9% (U.S. Census Bureau, 2002; Ramos, 2004). Potential participants were recruited through referrals, community-based organizations, English as a second language classes, churches, and workplaces that were known to have Latina employ- ees. Women aged 18 and older who self-identified as Latina or Hispanic completed a 30- to 40-minute healthcare survey in English or Spanish. A bilingual researcher assisted women with low literacy. Participants received a $10 gift card as compensation for their time.

Survey

A survey, which included items on the respondents’ health, mental health, healthcare, and demographics, was developed and pretested. For example, we asked about their health with the question ‘‘Have you ever been told by a doctor or health professional that you have : : : ?’’ which was followed by a list of 12 of the most prevalent health conditions among Latinas. For mental health, we asked ‘‘Do you currently experience : : : ?’’ and listed depression, anxiety, and panic attack. Respondents also had the option to complete an ‘‘other’’ category for both health and mental health. We asked respondents about their health insurance coverage and their experiences with the healthcare system. The demographic and screening questions were drawn from the National Health Interview Survey or/and the Behavioral Risk Factor Surveillance Survey.

Analytic Strategy and Results

The study used a cross-sectional survey design. Data were entered into STATA 9.0 for storage and analysis. Data were reviewed to check for errors. Descriptive statistics for frequencies and percentages were conducted.

Table 1 presents sociodemographic characteristics of the participants (N D 287). Ages ranged from 18 to 81 with an average age of 45. Consistent with the geographic distribution of Latino subgroups in New York State, the majority (56.6%) self-identified as Puerto Rican and 18.2% as Dominican. About 79% were born outside the continental United States, either in Puerto

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TABLE 1 Demographic Characteristics of the Participants (N D 286)

Characteristic n %

Birthplace United States 59 20.6 Puerto Rico 122 42.7 Dominican Republic 47 16.4 Mexico 12 4.2 Other 46 16.1

Age <25 33 11.7 >25 to <35 60 21.3 >35 to <65 151 53.6 >65 38 13.5

Age at immigration <15 48 24.0 >15 152 76.0

Education Less than high school 121 42.5 High school diploma 69 24.2 Associate 49 17.2 Bachelor plus 46 16.1

Marital status Married/lives with partner 147 51.4 Single 54 18.9 Divorce/separated 63 22.0 Widow 20 7.0

Health insurance Private 91 35.6 Medicaid 114 39.8 Medicare 36 12.7 None 34 12.0

Rico (43%) or in 1 of 14 Latin American countries. In this sample, the propor- tion of respondents born outside the U.S. mainland were double the national figure (79% compared to 38%), with 76% immigrating at age 16 years or older. Interestingly, although an appreciable portion (42.3%) had less than a high school education, compared to more than 60% nationally, a considerable proportion had some college education (33.2%). Most participants (51.4% compared to 56% nationally) were married or living with someone, whereas 19% reported being single and 22% divorced. Most women, 51.4%, indicated being married or living with someone, whereas 19% reported being single and 22% divorced. Respondents born in the United States tended to use both English and Spanish. In this sample, 12% were uninsured.

As shown in Table 2, 33.6% of the respondents reported hypertension, 27.6% high cholesterol, and 14.3% diabetes. Nationally, Latinas report rates of 22% for hypertension and 13.5% (ages 45 to 64) for diabetes (Health, United States, 2007; National Center for Chronic Disease Prevention, 2004). For mental health conditions, respondents reported 39.2% depression and

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TABLE 2 Percentage of Participants Who Answered ‘‘Yes’’ to Specific Health Condition

Health condition %

Hypertension 33.6 High cholesterol 28.0 Diabetes 14.3 Depression 39.2 Anxiety 42.3

TABLE 3 Percentage of Participants Answering ‘‘Yes’’ to Healthcare Questions

Question %

Delayed seeking healthcare past year 69.7 Pap test within last 3 years 85.3 Mammogram within last 2 years 84.2 Cholesterol test within last 2 years 83.8 Blood pressure test within last 2 years 94.2 Uncomfortable asking questions 33.3

42.3% anxiety. These findings are somewhat inconsistent with the limited evidence on the mental health status of Latinas at the national level indicating a depression rate of 53% for adult Latinas (U.S. Department of Health and Human Services, 2007).

Table 3 presents sample data on healthcare utilization. Here, 69.7% reported delaying seeking healthcare during the past year and 83.3% have had a Pap test within the past 3 years. For other screening procedures, 84.2% have had a mammogram, 83.8% a cholesterol check, and 94.2% a blood pressure test within the past 2 years. Each of these figures is above the national rate for Latinas ( James et al., 2007; Health, United States, 2007). Reasons for delaying healthcare in the past 12 months were related to cost, transportation, accessibility and availability of services, and child care or family responsibilities. Respondents also reported communication barriers, not feeling comfortable asking questions to their physicians, and difficulties understanding insurance or government programs.

DISCUSSION AND IMPLICATIONS

The results and interpretations presented need to be considered in the con- text of the methodological limitations of the study. The sample was not randomly selected, and therefore it is not representative of all Latinas. It was biased toward younger, slightly more educated Latinas born in Puerto Rico. We also collapsed the sample into one category, which might have obscured important subgroup differences. As with any study based on self-reporting,

Latina Women: Health and Healthcare Disparities 267

the potential for recall bias is increased. Thus, the findings are primarily descriptive and may have only limited generalizability to all Latinas.

Despite these limitations, this study adds to the limited literature on the health and healthcare of Latinas. Furthermore, it provides a glimpse into these concerns among Latinas living in small cities, a subpopulation seldom studied. The findings can inform the development and implementation of action-oriented strategies that will eliminate health disparities for Latinas.

When examined in the context of national data, Latinas in the sample reported nearly double the rate of diabetes than White women and a higher percentage of hypertension compared to Latinas in California (Baezconde- Garbanati et al., 1999). This is concerning particularly given respondents’ relatively young age (mean of 45 years). The high number of respondents re- porting depression and anxiety is intriguing and differs from national norms, indicating that further research is needed. Data from representative samples to document these and other health concerns as well as risk and protective factors among Latinas in small cities are sorely needed.

Not surprisingly, compared to White women, Latinas in this sample were more likely to be uninsured. Interestingly, for respondents the rate of being uninsured was lower and the rates of screening practices were higher than for Latinas nationally. Yet, respondents reported delaying healthcare due to personal and systemic barriers. Although most of these barriers were similar to those previously found among Latinas nationwide (Kaiser Family Foundation, 2001; Health, United States, 2007), respondents also reported difficulties in understanding how their health insurance works to pay for the cost of care. Respondents also reported feeling uncomfortable when asking questions of their physicians and difficulties understanding insurance or government programs, suggesting specific areas that need to be addressed.

Future research needs to examine in greater depth the specific barri- ers to healthcare encountered by Latinas in small cities. It is apparent, at least for this sample of Latinas, that simply having healthcare coverage is often insufficient. Studies could focus on the dynamics of patient-physician interactions where patients’ literacy and physicians’ communication styles and sensitivity to linguistic and cultural nuances play crucial roles. Evidence- based, culturally responsive interventions that could effectively offset some of these healthcare barriers for this population of Latinas need to be identified. Perhaps strategies shown to be successful in augmenting screening practices could be expanded to ensure follow-up and regular care. Recommendations for relevant health and social policies are provided below.

Policy Recommendations

Recommendations for policy that are both specific to the population studied and Latinas as a whole can be drawn from the study findings and the literature. First, additional data collection, analyses, and reporting, under

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Department of Health and Human Services data systems, on the health and healthcare of Latinas in small cities are needed to adequately monitor dispar- ities and better understand their etiology. Environmental variations between small and large cities may differentially impact their health and healthcare (Center for the Elimination of Minority Health Disparities, 2007). Latinas in small cities may be embedded in environments with fewer economic resources where they constitute a small number of the local population, are less visible, and hold less political leverage. These differences may translate into fewer health programs, limited or no public transportation, greater alienation and marginalization, and fewer social supports from culturally prescribed sources. In small communities, family and social networks derived from the Latino community are often limited.

Second, federal and state funding should support research with Latinas in small cities to increase our understanding of risk and protective factors associated with health outcomes, identify individual and systemic barriers to healthcare, and test interventions specific to this population to inform policy and program development and implementation. Third, existing and future national health and healthcare data on the Latino ethnic group must be disaggregated by gender and place of residence with a concerted effort to oversample small cities. It is important to be able to distinguish between the healthcare experiences of Latinas and larger and smaller settings. This type of information should be included in periodically published Latino health fact sheets.

Fourth, public resources should be made available to foster and support Latino coalitions seeking to promote health and eliminate health and health- care disparities through partnerships. Here, a coalition works in tandem with policy makers; local, state, and federal health agencies; universities; nonprofit and professional organizations; and businesses, civil leaders, consumers, and advocates. A recent project that drew upon this type of partnerships to address healthcare disparities in small cities found their use especially suitable. The partners’ enthusiasm and commitment as well as the relatively short traveling distances facilitated the sharing of expertise and resources, regular personal interactions, meeting attendance, and sustainability (Ramos, Smith, & Jurkowski, 2008).

Fifth, a necessary policy priority is to fully actualize policy recommen- dations targeted to address the health and healthcare concerns of the Latino population, paying special attention to those concerns that are specific to Latina women in small cities. These carefully crafted recommendations have been generated from technical reports, summits, studies, task forces, and special national initiatives during the last 2 decades (Aguirre-Molina, Falcon, & Molina, 2001). For example, scholars have called for policies to reduce the distressingly high numbers of uninsured Latinos, increase healthcare access and utilization, and put in place me