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FUTURE HEALTH NEEDS OF WOMEN OF COLOR |
Hortensia Amaro is with the Bouve College of Health Sciences, Northeastern University, Boston, Mass. Adela de la Torre is with the Chicana/o Studies Program, University of California, Davis.
Correspondence: Requests for reprints should be sent to Hortensia Amaro, PhD, Bouve College of Health Sciences, Northeastern University, 360 Huntington Ave, Stearns Hall Suite 503, Boston, MA 02115-5000 (e-mail: h.amaro{at}neu.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPUBLIC HEALTH NEEDSCULTURAL TRANSFORMATION AND...SOCIAL STATUS AND HEALTHCONCLUSIONReferences |
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Much of the research on women's health has not deepened our understanding of health issues affecting Latinas. Yet integration of research on Latinas into the women's health agenda is important for at least 2 reasons.
First, critical public health issues facing Latinas must be better understood if effective interventions designed to eliminate racial and ethnic disparities in health are to be developed and implemented. Second, studies on the health of Latinas represent unique opportunities to advance scientific understandings of underlying processes relevant to the health of other populations. Such research can further our knowledge of the processes underlying cultural adaptation and negotiation of changing sex roles and how these issues affect the health of women.
Critical research and empirical approaches that help us to understand how race, ethnicity, sex, and class shape the health of Latinas will inform broader public health issues.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPUBLIC HEALTH NEEDSCULTURAL TRANSFORMATION AND...SOCIAL STATUS AND HEALTHCONCLUSIONReferences |
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The integration of research on Latinas into the women's health agenda is important for at least 2 reasons. First, there are critical public health issues facing Latinas that must be better understood if interventions to eliminate racial and ethnic disparities in health are to be developed and implemented. Second, research on the health of Latinas presents unique opportunities to advance scientific understandings of underlying processes relevant to the health of other populations.
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PUBLIC HEALTH NEEDS |
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TOPABSTRACTINTRODUCTIONPUBLIC HEALTH NEEDSCULTURAL TRANSFORMATION AND...SOCIAL STATUS AND HEALTHCONCLUSIONReferences |
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The public health literature often highlights the "paradox" that Latinos, while sharing many of the demographic risk characteristics of African Americans, exhibit overall life expectancy and mortality rates that compare favorably to those of nonHispanic Whites.7–9 However, a closer look reveals important health disparities not reflected in global and aggregate measures of health status. For example, the age-adjusted mortality rate (255.5 per 100 000) among Latinas is lower than that among non-Hispanic White women (359.1).10 Yet, mortality data specific to Latino subgroups7 show that Mexican American girls younger than 1 year (559.4 per 100 000) and between the ages of 1 and 4 years (29.5) have higher death rates than their non-Hispanic White counterparts (544.6 and 27.0, respectively).
Similarly, death rates among female Puerto Ricans are higher than death rates among their nonHispanic White counterparts in the 5- to 14-year (17.1 vs 14.9 per 100 000), 25- to 34-year (89.0 vs 58.7), 35- to 44-year (167.7 vs 123.7), and 45- to 54-year (353.0 vs 280.5) age groups. Further, more Latinos (15.3%) than non-Hispanic Whites (9.3%) perceive themselves as being in fair or poor health.11 Self-perceptions of health differ among Latino subgroups, with larger percentages of Puerto Ricans (17.5%) and Mexican Americans (16.2%) than members of other Latino groups reporting fair or poor health.11
Both the Latino "paradox" and the higher mortality rates among some Latino age cohorts and subgroups present important opportunities for research. First, the factors responsible for the apparent overall lower mortality among Latinas are not well understood, and research in this area might prove uniquely useful in understanding whether and how contextual and cultural factors have a salutary effect on the overall health status of populations that would otherwise be deemed to be at higher risk. Second, we know little about why some Latino age cohorts and subgroups might have higher mortality risks than others, and investigation of this question could prove important in understanding elevated risks for specific health problems among population subgroups. Research in both of these areas can offer unique scientific opportunities for informing the epidemiology of health problems not only among Latinas but also among other populations.
Research on Latinas also is important because there are clear health conditions that disproportionately affect this population, and studies are needed to inform public health efforts to eliminate such health disparities. For example, relative to nonHispanic White women, Latinas have disproportionately high rates of cervical cancer,12 sexually transmitted diseases,13 HIV/AIDS,14 teenage pregnancy,15 obesity,16 diabetes,17 and violence and unintentional injuries.18,19 At the same time, Latinas face significant obstacles to health care. For instance, they are less likely than women in other racial or ethnic groups to have a regular source of health care20 or to have health insurance coverage.21 Furthermore, they may experience problems in communicating with English-speaking providers, which represents a major deterrent to seeking care.22 Research is needed on the factors that contribute to elevated health risks and disease patterns among Latinas and on effective prevention and intervention strategies for this population.
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CULTURAL TRANSFORMATION AND HEALTH |
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The impact of intergenerational differences in assimilation and identity formation among Latinas is also an important emerging area that must be considered if there is to be a better understanding of the health status of Latinas. Studies focusing on the impact of differentiated trajectories of assimilation will provide needed data on risk factors affecting the health of Latinas. Models such as segmented assimilation theory25 bring attention to the critical interplay of individual, family, and community forces that shape the life opportunities and experiences of Latinos and their adaptation to life in the United States.26
Public health research on Latinas and cultural adaptation has focused largely on acculturation, health status, and health behaviors. In most studies, acculturation has been measured via proxy variables such as place of birth, years of residence in the United States, and language use. Consistently, these studies2,27,28 have demonstrated that as women become more acculturated, they are more at risk for adverse birth outcomes29,30; younger age at first intercourse,31,32 first use of birth control,33 and first pregnancy34; partner violence35–37; tobacco,38–41 alcohol,41,42 and illicit drug41,43–45 use; depression46; sexual activity with multiple partners44,47; and negative attitudes toward condom use.48
While less acculturated Latinas experience fewer health problems and risk factors, they are also less likely to have access to health care services when they need them. In comparison with more acculturated Latinas, those with lower levels of acculturation are less likely to seek prenatal care,34 to use needed mental health services,49 to have had annual Papanicolaou tests or mammograms,50,51 and to have health insurance coverage52 and a regular source of health care.53
Despite the significance of these findings that link levels of acculturation of Latinas to health status and health care access, there still is a dearth of conceptual and empirical attention focused on the mechanisms underlying the relationships between cultural change, risk factors, and health status. Empirical studies readily incorporate existing acculturation variables but do not fully explore the more complex domain of Latina identity formation.
In the case of many Latinas, linear acculturation models fall short of explaining the complex and fluid nature of identity formation and maintenance of bicultural identities despite external assimilation pressures.54 Cultural changes do occur for many of these women and their families, but often these changes are measured primarily through variables such as immigrant status and language of origin. Clearly, these variables do not effectively measure degrees of bicultural identity formation, or shifting identity roles; rather, they merely provide a glimpse of the possible effects of identity formation among Latinas and their children.
Moreover, there is a real danger that we may be confounding narrower acculturation and assimilation variables with items that actually predict economic trajectories of immigrant groups. It is clear that the class position of Latinas affects their overall health status, yet we still need to capture the extent to which these women and their families maintain cultural practices intergenerationally, creating resilient models of bicultural identity formation. We also need to know how these identities and practices may protect Latinas and their children from the degrading effects of racism within American society, as well as the effects on their overall mental and physical health. Both qualitative and quantitative studies on Latina identity formation and health status are needed to further develop this emerging area of scholarship.
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SOCIAL STATUS AND HEALTH |
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With the exception of those advocating purely biological models of women's health, a number of researchers acknowledge the relevance of gender, race, and class to the health of women.1,59 Yet, Reid points out that most feminist theory and research have been "directed to the explication of women's essential experience of gender, as if this could be separated from the confounds of class and race."60(p143) It is critical to build an understanding of health that considers the extent to which Latinas most at risk for health problems are affected by oppression based on gender, race/ethnicity, and class.
The framework of oppression invites us to consider the role of social institutions and their participation in oppression, the dynamics through which social control is exerted at the group and individual levels, and group and individual coping responses to oppression. Amaro and Raj61 described and applied such a framework in the understanding of the disproportionate risk of HIV among African American women and Latinas. They noted the influences of gender bias, racism, and class bias in psychological and health research and public health programs, as evidenced in the history of the eugenics movement and sterilization campaign in Puerto Rico and among women of color in the United States.
More recently, policies that have sought to block access to health care among immigrants, including legal immigrants, have had an impact on use of health care services among some groups of Latinas.21 Yet, with few exceptions,59 research on women who are members of racial and ethnic "minority groups," including Latinas, has lagged in terms of conceptualization and measurement of the effects of socially defined status and oppression.
A common hallmark of oppression is ascription by the dominant group of the oppressed group's negative and disempowering characteristics.61 The characteristics ascribed to socially subordinate groups both reflect and reinforce the lower power status of these groups. Because these dynamics can pervasively define the life experiences of lower status groups, they are likely to be relevant to our understanding of the context of Latinas' health. The work of Williams and colleagues,58,62,63 Krieger,59 and Leveist64 has begun to document the relationship between discrimination and jeopardized health. However, much of this work has focused on African Americans, with few studies documenting the role of discrimination in the health status of Latinas.65,66
Research is needed that investigates the nature of discrimination experienced by Latinas through the process of cultural adaptation and the resulting effects on health and experiences in the health care delivery system. One important line of research involves stereotypes held by service providers and their impact on the health care received by Latinas. Scrimshaw et al.67 found that stereotypes held by medical providers negatively affect the obstetrical and gynecological care received by Latinas. Further research is needed to assess the frequency of negative ascriptions of Latinas among health care providers and the effects on quality of care.
Latinas' development of an ethnic identity as a "minority" group within US society has been overlooked as a facet of oppression that may have an impact on their health. A number of researchers who study development of racial and ethnic identity among US "minority" groups have documented that, in early stages of ethnic identity development, members of oppressed racial and ethnic groups internalize negative views of their groups that have been prescribed by the larger, dominant group. This negative internalization may result in a desire of individuals to distance themselves from their racial or ethnic group.68–71
Alternatively, exploration, knowledge, and acceptance of one's cultural group have been linked to healthier psychological development. Studies on the health of Latinas have generally categorized these women solely in terms of their reported ethnic identification. However, we know relatively little about the ways in which Latinas cope with the meaning of being a member of a socially defined subservient group and how varying coping responses are related to health behaviors and risk factors. The responses of groups ascribed lower social status in a society are complex and depend on many historical and situational contextual factors.
Berry72 proposed 4 strategies adopted by members of nondominant cultural groups in response to domination: integration, assimilation, separation, and marginalization. These strategies have important implications for identity, values, attitudes, and abilities, and they are expressed in behaviors and social relations. Marginalization, which involves disengagement from one's culture of origin as well as lack of integration into one's new culture, has been associated with the most negative outcomes. In a study of illicit drug use, Amaro and colleagues43 found that Latinos who were highly acculturated but were not integrated into the US mainstream (as reflected in their poverty status) had by far the highest rates of illicit drug use. The literature suggests that marginalization might be a health risk factor deserving attention in future studies on Latinas.
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CONCLUSION |
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TOPABSTRACTINTRODUCTIONPUBLIC HEALTH NEEDSCULTURAL TRANSFORMATION AND...SOCIAL STATUS AND HEALTHCONCLUSIONReferences |
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1. Although aggregate and global measures of Latina health may provide useful benchmarks of Latinas vis-à-vis other groups, these measures mask important differences that could explain the Latino "paradox" in health as well as differential mortality rates among some Latina age cohorts and subgroups. Developing research studies that address the impact of contextual and cultural factors on the health status of Latina age cohorts and subpopulations may prove valuable in identifying the health needs of this rapidly growing group.
2. The impact of Latina identity formation and cultural transformation on health behaviors, health risks, and protective coping strategies represents an emerging area of study that requires further conceptual and empirical development. There is a significant amount of public health research primarily addressing the impact of acculturation on health status and health behaviors; thus, there is a real opportunity to disentangle aggregate acculturation measures that focus on immigrant status or language of origin and to expand them to include variables that measure identity formation, perceived discrimination, and cultural negotiation. The representation of both US-born and immigrant populations among Latinas provides an additional opportunity for this type of research.
3. Methods of measuring the impact of oppression and power dynamics based on how Latinas experience the intersections of gender, race, and class must be developed if there is to be a full understanding of the health status and access issues faced by this group. For example, by developing research on discrimination, coping, and resistance strategies, researchers could shed light on how these affect the health status of Latinas.
4. Finally, given a broader conceptual framework of oppression for assessing Latina health, researchers may develop a better understanding of the negative effects of social institutions, as well as of actors within these institutions, on access to health care services.
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Footnotes |
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Accepted for publication December 27, 2001.
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