From Discussions VOL. 9 NO. 2
The Mexican American Health Paradox: The Collective Influence of Sociocultural Factors on Hispanic Health Outcomes
According to recent statistics published by the United States Centers for Disease Control and Prevention in 2011, Hispanics in the United States tend to outlive non-Hispanic whites by almost three years. Specifically, the life expectancy at birth for Hispanic Americans is around 81 years, while non-Hispanic whites on average live to be around 78 years of age. These facts and figures do not represent an isolated phenomenon limited to the recent past; in fact, these distinctive trends in life expectancy and mortality have occupied researchers since 1986, when Dr. Kyriakos Markides and his colleagues at the University of Texas Medical Branch first described this disparity in lifespan between the two groups (Taningco, 2007, p. 213). The consistent finding that most Hispanic ethnic groups live longer than whites has intrigued researchers predominately because of the reality that Hispanic Americans often have the lowest socioeconomic status, income, and education. In most other ethnic groups in the United States, “low socioeconomic status has been universally associated with worse population health and higher death rates” (Franzini and Keddie, 2001, p. 496). As a result of the contradictory nature of Hispanic life expectancy outcomes, researchers have coined the phenomenon as the “Hispanic health paradox,” also known as the Latino health advantage or the epidemiological paradox.
A myriad of explanations for the health paradox exist in the existing literature on the topic. Despite the fact that more than twenty years have passed since the initiation of research, the phenomenon has never been fully explained by any one of these hypotheses. In “Paradox as Paradigm--The Health Outcomes of Mexican Americans,” Richard Scribner (1996) states that “the paradox of Hispanic health represents a group-level correlation between ethnicity and mortality that cannot be explained in terms of an individual-level model” (p. 303). In other words, any factor that is correlated to the paradox must apply to a wider ethnic group of Hispanics, rather than to a narrow community. Based on this research design, the current literature on the topic can be organized into two broad categories. According to Dr. Ana Lanza and Dr. Bruce Dohrenwend (1999) in the article “The Latino Mortality Paradox: A Test of the `Salmon Bias' and Healthy Migrant Hypotheses,” the first category postulates that the lower mortality is not “genuine” but rather is caused by migratory factors. The second category centers on the premise that the lower mortality is “real” and is the result of more favorable health behaviors, risk and genetic factors, and greater family support among Latinos than among non-Latino whites (p. 1543).
Based on a holistic analysis of the multiple rationalizations on the topic, it appears that the paradox is related to observable health-related influences, rather than statistical misrepresentation or misclassification. Focus is narrowed to include only the Mexican American population in the United States, consisting of both foreign-born and native-born individuals, because they comprise the Hispanic subculture that holds the lowest socioeconomic status yet has the highest life expectancy rates. After establishing this context, familial structure is considered as one component that results in better physical health among members of this ethnic group. Still, similar familial bonding in non-Hispanic white, Native American and Cuban American culture must be taken into account, as it has not resulted in similar health outcomes for those groups, thereby indicating additional factors behind the health advantage. Most significantly, the presence of an alternative-health care system with a more emotionally significant practitioner-client relationship is the main factor that separates Mexican Americans from the other ethnic groups, and results in tangible disparities related to sleep and stress levels. In turn, this distinctive system, referred to as curanderismo, has a positive impact on both physical and mental health, and is bolstered by consistent family and community systems.
For the sake of clarity and to provide a workable framework for further discussion in this paper, a clear and applicable definition of the Hispanic health paradox should be restated and the study’s population should be readily defined. The Hispanic health paradox is a data-based finding that indicates that despite low socioeconomic status and decreased access to health care, Hispanic Americans, specifically Mexican Americans, tend to live longer and die later than non-Hispanic whites. Accordingly, any reference to the phenomenon will use a full or abbreviated form of the phrase, “Mexican (American) health paradox.” It is justifiable to use such a broad reference, as the focus of this paper encompasses both immigrants from Mexico and individuals of Mexican descent who were born in the United States, both of who show similar trends in life expectancy and mortality records. Dr. Tillman Farley (2005) further justifies this relative lack of restriction in “Stress, Coping, and Health: A Comparison of Mexican Immigrants, Mexican-Americans, and Non-Hispanic Whites” by noting that it is not necessary to discriminate against foreign-born Mexican Americans and U.S-born Mexican Americans because “it appears that being a U.S born Mexican-American, due to the heightened stressors of acculturation and racism in U.S society, is equally stressful as being a recent immigrant to the United States” (p. 217). Farley also recognizes the fact that “Mexican sociocultural values serve as integral aspects of both groups” (p. 217).
The Salmon Bias and Healthy Migrant Theories: Popular Yet Limited
Within the group of explanations for the health paradox that focus on misrepresentation of census statistics, two main theories have been highly regarded by researchers over the past decade. The first is the healthy migrant effect, which holds that the migration of healthy Latinos from their respective countries of origin accounts for the life expectancy differences. As a result, the group of Mexican Americans who originally migrated from Mexico, as well as the generations following them, constitutes a notably healthy group of individuals, relatively free from prevalent health conditions. The second sub-theory is the “salmon bias” or the “moribund migrant effect which, according to the article ”The Latino Mortality Paradox: A Test of the `Salmon Bias' and Healthy Migrant Hypotheses” by Lanza and Dohrenwend, “proposes that many Latinos return to their country of birth after employment, retirement, or illness because of the desire to die in one’s birthplace” (p. 1543). Foreign deaths are not included in U.S mortality statistics, thus resulting in the documentation of an artificially low mortality rate (because those individuals move prior to their death).
Though among the most popular of the initial hypotheses, both the salmon bias and the healthy migrant effect are insufficient as exclusive factors contributing to the health advantage. A study conducted by the aforementioned Lanza and Dohrenwend demonstrated that even Puerto Ricans, whose deaths are recorded in U.S mortality statistics, exhibit a significant health advantage compared to non-Hispanic whites, suggesting an inadequacy to the widespread applicability of the theory. More specific to Mexican Americans, the presence of familiar and tightly knit community systems might stymie the desire to return to one’s homeland. As noted by Lanza and Dohrenwend, this effect is most likely reinforced by patterns of immigration from Mexico, as families that are part of an extended family unit tend to immigrate in consecutive fashion (p. 1544). Consequently, the need to return home to die in one’s birthplace is reduced when provided with such a vast amount of available familial support and care in the United States. Therefore, it is highly probable that there has been a significant body of Mexican Americans in the country on which census studies report. With regard to the healthy migrant effect, Anne Sanders (2010) contends in “A Latino Advantage in Oral Health-Related Quality of Life is Modified by Nativity Status” that “studies have shown that Mexican migrants to the United States were not any healthier or better educated than those who did not migrate” (p. 205). In addition, even U.S-born Mexican Americans show higher life expectancies compared to non-Hispanic whites, with a CDC-reported lifespan greater by about 2.5 years (80.3 years from birth, compared to 78 years for non-Hispanic whites). This points to other factors playing a role in sustaining the health paradox. In fact, “group cultural explanations are likely to explain this phenomenon more so than individual characteristics or behaviors” (Sanders, p. 210).
Familism: A Cultural Boon for Mexican Americans
As the most common element of social structure in any society, a family unit holds great potential and power in shaping the views, actions, and behaviors of individual constituents. This transformational influence can extend far into the well-being of family members, traversing the physical, mental, spiritual, social, and emotional realms of health. According to “The Effects of Family Composition, Health, and Social Support Linkages on Mortality” written by Richard G Rogers (1996), family living arrangements can influence mortality. This is largely due to the fact that “the family rearranges itself to deal with ill health and disability among its members” (p. 326). In addition, familial units strive to promote health, prevent disease, and encourage economic security (p. 326). Dr. Toni Antonucci (1990) extends this notion by suggesting that “living with other family members can promote compliance with group norms, encourage health practices, and provide emotional reassurance or helpful appraisals of difficult situations” (p. 205).
As with many Hispanic ethnic groups, Mexican American culture places a substantial degree of emphasis on family and familial values. A particular concept known as familismo represents the notable importance of family within this ethnic group. Also known as familism, this model refers to a collective loyalty to extended family that promotes ties, obligations, and interdependence among Mexican Americans (Sanders, 2010, p. 206). In support of this notion, Dr. Flavio F. Marsiglia and Dr. Cecilia Ayon (2010), both Professors of Social Work at Arizona State University, claim in “Latino Family Mental Health: Exploring the Role of Discrimination and Familismo” that Latino families are often described as close knit with extended family networks that offer a great deal of support (p. 744). Consequently, “the solid ties between Mexican American family members can be associated with helping newly immigrated individuals adjust and confront social inequalities and prejudices in the United States” (p. 744). This trend also applies to U.S- born Mexicans, as community studies indicate that compared with their immigrant counterparts, U.S-born Mexicans have even more extensive social networks and interact more with intergenerational family members and friends in the United States (p. 744). As a result, the protective effects of family on health can be found within this population as well. Evidence suggests that familismo is a protective factor for Latino families as it has been linked to positive health outcomes including “lower levels of substance and drug abuse, increase likelihood of seeking out mammogram exams, and decreased likelihood of child maltreatment” (p. 745). In “A Latino Advantage in Oral Health-Related Quality of Life is Modified by Nativity Status,” Anne Sanders further notes that the protective effects of family on Latino health, including oral health-related quality of life, diet, reciprocity, social ties and attachments, are well recognized (p. 210). Accordingly, a logical theory is that the Mexican health advantage may essentially stem from the strong socio-centric values instilled at the familial level, primarily because these tenets support the development and continuation of sound long-term health behaviors and habits.
Nevertheless, the depth and breadth of research on familial structure and health confound the use of the familial hypothesis as a singular explanation for the health paradox. The limitations of such a viewpoint are readily observable through a cross-cultural analysis of familial strength in non-Hispanic white, Native American, and Cuban American societies. First, the prevalence of family values and potential protective effects similar to those of Mexican Americans were studied in these other cultures, as described in existing research. Even in non-Hispanic white families, the close, personal structure and organization of the family unit can also express itself positively in the health of both young and older adults. This idea is supported by the findings of Edward L. Schor, the senior Vice President for the Lucile Packard Foundation for Children’s Health, and his colleagues in the article “Family Health: Utilization and Effects of Family Membership.” Schor and his team (1987) note that for non-Hispanic whites, “membership in a family has a powerful influence on one’s health care-seeking behavior; it accounts for nearly one third of the variance of individual utilization” (p. 624). Furthermore, the white family can stabilize beneficial health-related behaviors, much like a family can in a Mexican American context. Similarly, both Native American and Cuban American families demonstrate a strong, resilient form of bonding. Among American Indian families, the extended family unit is of paramount importance as it is responsible for the safe development of children and adolescents. In fact, according to Randall C. Swaim and his colleagues (1993) in “American Indian Adolescent Drug use and Socialization Characteristics: A Cross-Cultural Comparison,” the Native American family may take precedence over the peer group as the most powerful contributor to alcohol use or non-use among youth (p. 54). Due to their Hispanic roots, Cuban Americans also place a significant degree of importance on familismo, sharing many components of familial structure and customs with Mexican Americans. As described by authors Monica McGoldrick, Joseph Giordano, and Nydia Garcia-Preto in their book, Ethnicity and Family Therapy, “the role of the nuclear and extended family is central to Cubans; familismo is a cultural attitude and value that is the crucial basis of traditional family structure” (p. 207).
After establishing the similarities in familial composition and authority between Mexican American families and those of the other three cultures, life expectancy and mortality trends of different ethnic groups were compared. The current literature suggests that familial strength has not been associated with similar health outcomes for all three ethnic groups (compared to Mexican Americans). A look at the life expectancy statistics described in the introduction of this paper indicates that familial aid in protecting health has not resulted in longer lives for non-Hispanic whites, despite similarities in family membership and influence. With regard to Native Americans, Dr. Paul Spicer (2008) explains in “Poverty and Health Disparities for American Indian and Alaska Native Children” that:
The age-adjusted death rate for American Indian and Alaska Native adults exceeds that of the general population by almost 40%, with deaths due to diabetes, chronic liver disease and cirrhosis, and accidents occurring at least three times the national rate, and deaths due to tuberculosis, pneumonia and influenza, suicide, homicide, and heart disease also exceeding those of the general population. (p. 128)
Lastly, Leo Morales and his research team (2002) point out in “Socioeconomic, Cultural, and
Behavioral Factors Affecting Hispanic Health Outcomes” that a similar trend exists for Cuban Americans, who have mortality rates that are greater than those of Mexicans and similar to those of whites (p. 495).
If consistent familial strength between the groups has not resulted in consistent lifespans, then there must be other factors involved with the more positive health outcomes for Mexican Americans. Hence, though a vital and relentless aspect of Mexican culture, familismo cannot be used to singlehandedly explain the Mexican American health paradox in its entirety. From this conclusion, it appears that a primary explanation for the health paradox would most likely be linked to a beneficial factor that is largely unique to members of the Mexican American population.Continued on Next Page »
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