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RESEARCH AND PRACTICE |
At the time of this study, Karl Eschbach, Jim P. Stimpson, Yong-Fang Kuo, and James S. Goodwin were with the Department of Internal Medicine, and the Sealy Center on Aging, University of Texas Medical Branch, Galveston.
Correspondence: Requests for reprints should be sent to Karl Eschbach, PhD, Sealy Center on Aging, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0460 (e-mail: kaeschba{at}utmb.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. We sought to determine whether mortality rates among immigrant and US-born Hispanic young adults were higher or lower compared with non-Hispanic Whites. We also sought to identify which causes of death accounted for the differences in mortality rates between groups.
Measures. We used Texas and California vital registration data from 1999 to 2001 linked to 2000 census denominators. We calculated cause-specific, indirectly standardized rates and ratios and determined excess/deficit calculations comparing mortality rates among US- and foreign-born Hispanic men and women with rates among non-Hispanic White men and women.
Results. Mortality rates were substantially lower among Hispanic immigrant men (standardized mortality ratio [SMR]=0.79) and women (SMR=0.59) than among non-Hispanic White men and women. Most social and behavioral and chronic disease causes in Texas and California other than homicide were noteworthy contributors to this pattern. Mortality rates among US-born Hispanics were similar to or exceeded those among non-Hispanic Whites (male SMR=1.17, female SMR=0.91).
Conclusions. Mortality rates among younger Hispanic immigrants in Texas and California were lower than rates among non-Hispanic Whites. This pattern was not observed among US-born Hispanics, however.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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There has been less evidence that mortality rates among younger Hispanic adults (i.e., those aged 18 to 44 years) are also lower than those among younger non-Hispanic White adults. Studies involving the use of survey records linked to the NDI have reported a mortality crossover at approximately 45 years of age, with mortality rates among younger Hispanic adults being higher than those among younger non-Hispanic Whites and rates among older Hispanic adults (i.e., those aged 45 years or older) being lower than those among older non-Hispanic Whites.5 Reduced mortality among older Hispanics is driven by lower death rates from leading chronic causes of death, including heart disease and cancers of most major sites.5,11 At younger ages, causes such as homicide, suicide, substance abuse, and motor vehicle accidents account for a larger share of all deaths. There is evidence that death rates associated with many of these causes are higher among younger Hispanic adults than among younger non-Hispanic White adults.5,12–16
We believe that mortality patterns among younger Hispanics require reexamination. Most of what is known about these patterns is derived from studies, now somewhat dated, using vital statistics linked to the 1980 US census,13,15–18 National Health Interview Survey (NHIS) data from the late 1980s and early 1990s linked to the NDI through 1997,3,5,12,14 and Current Population Survey data linked to the NDI through 1987.11 Mortality rates may have changed since these studies were conducted because of changes in cause-specific rates and because of cohort differences in the attributes of immigrants (e.g., educational attainment and economic performance relative to US natives).19 In most previous studies, stratified analyses of mortality among younger individuals were not conducted or were conducted with data sets involving limited sample sizes.
We investigated recent cause-specific mortality rates and patterns among younger foreign-born Hispanic adults and US-born Hispanic adults as compared with non-Hispanic Whites in California and Texas. In addition, we assessed differences from previously reported patterns and sought to identify the factors producing the lower mortality rates observed for certain Hispanic groups.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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We recognize that our classifications are imprecise. Causes that we labeled as social and behavioral may have partial etiology in genetic or organic conditions. Chronic disease deaths may reflect diet, health behaviors, and physiological effects of socially mediated stress. Nonetheless, we believed that it was useful to identify a category of causes of death that are related to social and behavioral causes and that are important causes of death among younger adults. A total of 68 861 deaths were reported among non-Hispanic Whites and Hispanics in California and Texas during the study period (Table 1
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Data Analyses
We compared gender-specific mortality rates for foreign-born Hispanics and US-born Hispanics with those among non-Hispanic Whites. We report cause-specific mortality rates for foreign-born Hispanics and US-born Hispanics. We indirectly standardized these mortality rates using age-specific mortality rates for non-Hispanic Whites of the same ages, categorized into 6 age groups each encompassing 5 years. We made comparisons with mortality rates among non-Hispanic Whites in 2 ways. Initially, we calculated indirectly standardized mortality ratios (SMRs), using non-Hispanic White mortality rates to determine expected numbers of deaths from different causes. Then, to assess the relative contribution of each cause of death to overall differences, we apportioned these differences to specific causes of deaths by calculating the number of excess or deficit deaths compared with the expected number of deaths based on mortality rates for non-Hispanic Whites.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Age-specific all-cause mortality rates are reported in Table 2. Mortality rates were lower among younger foreign-born Hispanic women than among non-Hispanic White women within the entire age range studied. Among foreign-born men, lower mortality rates compared with non-Hispanic White men emerged after the age of 30 years. Mortality rates were higher among US-born Hispanic men than among both foreign-born Hispanic men and non-Hispanic White men throughout the entire age range of 15 to 44 years. Age-specific mortality rates among US-born Hispanic women were similar to those among non-Hispanic White women but higher than those among immigrant Hispanic women.
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(men) and Table 4 (women). An examination of group differences in mortality reveals 3 comparisons of interest: (1) the comparison of mortality rates among foreign-born Hispanics with mortality rates among non-Hispanic Whites, (2) the comparison of mortality rates among US-born Hispanics with those among non-Hispanic Whites, and (3) the comparison of mortality rates among foreign-born Hispanics with those among US-born Hispanics. Although our study emphasized the comparisons with non-Hispanic Whites, we began by comparing immigrant and US-born Hispanic rates with each other. This comparison revealed differing mortality patterns among immigrants and natives.
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Comparisons of mortality rates for immigrant Hispanic men and US-born Hispanic men with non-Hispanic Whites. The standardized all-cause mortality ratio for immigrant Hispanic men versus non-Hispanic White men was 0.79. Relative mortality rates for both social and behavioral (SMR=0.89) and chronic disease (SMR=0.62) causes were lower among immigrant Hispanic men. Of the overall "deficit" of 2424 deaths among immigrant Hispanic men in the 3-year period under study, 35% was attributable to social and behavioral causes. Mortality rates associated with homicide (SMR=2.89) and alcohol use (SMR=1.44) were substantially higher among immigrant Hispanic men than among non-Hispanic White men. These death rates were offset by low rates from suicide and substance use, which were in each case only one third those of non-Hispanic White men. Otherwise, the lower mortality rates among Hispanic immigrant men were not clustered across the disease groups assessed.
In the case of chronic diseases, mortality rates from circulatory diseases and from cancers, especially of the brain (SMP = 0.39) and lung (SMR = 0.37) and malignant melanomas of the skin (SMR = 0.38), were lower among immigrant Hispanic men than among non-Hispanic White men. By contrast, mortality rates associated with intracerebral (SMR = 2.30) and subarachnoid (SMR = 1.76) hemorrhagic stroke and with stomach cancer (SMR = 4.15) were higher among younger immigrant Hispanic men than among younger non-Hispanic White men.
Mortality rates were higher among US-born Hispanic men than among non-Hispanic White men for all causes (SMR = 1.17) and for both social and behavioral (SMR = 1.20) and chronic disease (SMR = 1.11) causes. The excess mortality among US-born Hispanic men relative to expectations based on mortality rates among non-Hispanic Whites was primarily (78%) attributable to social and behavioral causes. US-born Hispanic men had higher mortality rates attributable to substance use, HIV and other sexually transmitted diseases, homicide, and alcohol-related causes. In the case of chronic diseases, their cause-specific mortality patterns were similar to those of non-Hispanic White men. Mortality rates among US-born Hispanic men were significantly higher for endocrine and metabolic diseases (SMR = 1.26) and elevated for fibrosis and cirrhosis of the liver (SMR = 2.95) and other diseases of the liver (SMR = 2.52) than those among non-Hispanic White men.
Rate Differences and Comparisons Among Women
Rate differences between foreign-born and US-born Hispanics.
The standardized all-cause mortality rate among immigrant Hispanic women aged 15 to 44 years was 49 per 100 000, the same rate among US-born Hispanic women was 75 per 100 000. Mortality rates were higher for US-born Hispanic women than for immigrant Hispanic women for each of the 12 specific cause groups we assessed. The higher mortaliy rates associated with substance use (0.58 for immigrant Hispanics and 5.22 for US-born Hispanics) were particularly noteworthy.
Comparisons of mortality rates with non-Hispanic Whites. All-cause death rates were lower among immigrant Hispanic women than among non-Hispanic White women (SMR = 0.59), as were rates associated with social and behavioral causes (SMR = 0.44) and chronic diseases (SMR = 0.70). The lower mortality rates for social and behavioral causes accounted for 60% of the mortality "deficit" among immigrant Hispanic women. Immigrant Hispanic women did not have substantially higher homicide mortality rates and had exceptionally low mortality rates from substance use (SMR = 0.08) compared with those among non-Hispanic White women. Immigrant hispanic women also had substantially lower alcohol-related mortality rates and suicide mortality rates.
In addition, mortality rates among immigrant Hispanic women were lower for each chronic disease subgroup than for those among non-Hispanic White women. Immigrant Hispanic women had lower rates of mortality from cancers (SMR = 0.87), especially those of the lung (SMR = 0.31), skin (SMR = 0.31), brain (SMR = 0.87), and breast (SMR = 0.89). However, these lower rates were offset by higher rates for stomach (SMR = 4.21) and cervical (SMR = 1.56) cancers. Younger immigrant Hispanic women had lower mortality rates than did younger non-Hispanic White women for circulatory diseases overall and for most common circulatory causes (SMR = 0.57).
In the case of social and behavioral causes, US-born Hispanic women exhibited a mixed pattern in terms of comparisons with non-Hispanic White women. The mortality rates among US-bon Hispanic women were higher for homicide, HIV, and infectious and parasitic causes but lower for suicide, substance use, and unintentional accidents. As was the case for men, chronic disease mortality rates among US-born Hispanic women were similar to those among non-Hispanic White women.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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We address 3 questions. First, how do our results compare with previously reported findings of studies focusing on mortality among younger Hispanic adults? Second, how do our findings help to explain the so-called Hispanic paradox of lower all-cause mortality in a socioeconomically disadvantaged population? Finally, how did misreports of Hispanic ethnicity affect the results reported here?
Comparison With Previous Findings
Previous studies comparing mortality rates among Hispanics and non-Hispanic Whites have generally reported a mortality crossover occurring for men aged between 40 and 50 years, with mortality rates among Hispanics relatively higher before that age range and relatively lower after that range. In many of these studies, an NHIS–NDI linked file spanning the period 1986 to 1997 has been used, and this linked file includes few deaths among individuals at younger ages.5,12,14 In addition, vital statistics data for Texas and California from the early 1980s showed higher age-adjusted mortality rates associated with homicide, infectious diseases, and unintentional accidents among Hispanics.16–18
We found significantly lower all-cause mortality rates among younger male Hispanic immigrants in California and Texas than among younger non-Hispanic Whites and marginally lower all-cause mortality rates when deaths of foreign- and US-born men were pooled. This difference from previously reported comparisons is attributable in part to the lower homicide and accidental mortality rates in 2000 relative to 1980 and 1990 and a narrowing of the differential between non-Hispanic White rates and Hispanic immigrant rates. Nationwide, motor vehicle mortality rates among men (all ages) dropped from 32.6 per 100 000 during 1979 through 1981 to 20.9 during 1999 through 2001. Homicide mortality rates declined from 15.2 to 9.1 per 100 000.24 Comparisons of immigrant Hispanic and non-Hispanic White men in Texas and California showed that the mortality rate ratios for both causes were narrower in 2000 than in 1980.16
Another factor was the increase in HIV incidence and mortality rates over this period; HIV mortality rates were higher for non-Hispanic White men than for immigrant Mexican American men in Texas and California (although rates were higher for Hispanics from other subgroups and in other regions of the country).25,26 These 3 factors, combined with the continuation of lower mortality rates among Hispanic men with respect to most other causes, have led to the emergence of lower all-cause mortality rates for younger immigrant Hispanic men than for younger non-Hispanic White men in Texas and California.
Implications for Explaining the "Hispanic Paradox"
There is a social and behavioral component associated with the lower mortality rates among younger foreign-born Hispanics than among younger non-Hispanic Whites, given our finding that a significant portion of the reduced mortality among the former involved directly behavioral causes, especially sharply lower suicide and substance use mortality rates among both men and women. The lower chronic disease mortality rates among foreign-born Hispanics were broadly distributed across a number of specific causes and were not shared by US-born Hispanics.
Most of the discussion in prior epidemiological studies of the causes of unexpectedly low Hispanic mortality has centered on lower chronic disease mortality rates among older individuals.4–6,8,11 Debates have focused primarily on 3 contrasting explanations of this mortality advantage: (1) that immigrants to the United States are healthier than people who choose not to migrate, (2) that many immigrants return to their home country when they experience a serious illness, and (3) that Hispanic social and behavioral characteristics and practices are somehow healthier than those of non-Hispanic Americans.3,4,7,8 Among those immigrants of younger ages, these 3 explanations are not strongly differentiated. Although health-selective return migration among Hispanic immigrants is frequently characterized as migration in response to late-life illnesses, return migration is in fact most common within the first 2 years of immigration.27,28
The influences on migration selection among individuals at younger ages may be similar for immigration and emigration, reflecting a balancing of the costs and benefits of residing in the country of birth and the United States. Although the factors associated with return migration are complex in the circular migration flows between Mexico and the United States, and in some instances such return migration is planned beforehand,19,27–30 immediate return migration is often attributable to the failure of migrants to adapt to their new environment.31
Health may influence successful adaptation. Individuals whose immigration status is undocumented (a situation characterizing a majority of the recent migrants from Mexico and Central America to Texas and California) and who have early onset of chronic or congenital diseases are poor candidates for international labor migration. Such conditions may increase the risks associated with undocumented migrations across the US–Mexico border.32 Most new Mexican and Central American immigrants to the United States participate in manual and service labor markets, and preexisting morbidities could limit their success in these labor markets.
The lower mortality of immigrants from social and behavioral causes may also be attributable in part to health-selective migration. For example, substance use disorders may be incompatible with successful participation in US labor markets. More generally, a higher sense of internal locus of control (an individual’s sense that his or her own actions determine what will happen to him or her) has been associated with more beneficial health-related behaviors, more beneficial health outcomes,33 and the decision to move across international borders in search of work.34
There is little evidence of a general Hispanic sociocultural pattern spanning immigrants and natives that results in lower mortality associated with social and behavioral causes, with the exception of suicide. With respect to chronic disease patterns, younger US-born Hispanic men and women do appear to have mortality rates comparable to those of younger immigrant men and women for cancers of the lung, brain, and breast and malignant melanomas of the skin, which may reflect in part comparable dietary and other behavioral or occupational exposures. The more general pattern revealed here, however, was that mortality rates associated with both chronic diseases and social and behavioral causes among younger US-born Hispanic men and women residing in California and Texas were similar to or exceeded those of younger non-Hispanic White men and women.
Effects of the Misreporting of Hispanic Ethnicity
There is concern in the public health community that Hispanic ethnicity is underreported on death certificates relative to the census counts that supply the denominators for rate calculations.34,35 This underreporting could occur because death certificate ethnicity data are reported by funeral directors, whereas census ethnicity data are typically reported by respondents or family members, and because of differences in wording of the Hispanic-origin item on death certificates and census forms. Studies have shown that country of origin is more consistently reported and thus is a useful alternative marker of Hispanic ethnicity.2,13,15,17,35 We replicated our analysis for our Mexican-born population (more than 85% of foreign-born Hispanics in Texas and California), and results were virtually identical to those we reported based on death certificate ethnicity.
Death certificates may underreport Hispanic ethnicity among US-born Hispanics as well. Recent studies2,37 and unpublished comparisons of survey and death certificate classifications in matched records from the National Longitudinal Mortality Study suggest the need for upward adjustments of between 5% and 10% in terms of rates for US-born Hispanics. Adjustments of this magnitude would sharpen the patterns reported here but would not change our basic conclusion: for most causes, mortality rates among US-born Hispanics are equal to or higher than mortality rates among Whites in the same age groups.
Limitations
In this study, we used data for California and Texas. More than 80% of both the foreign-born and US-born Hispanic populations of these 2 states reported Mexican American origin on the US census, and these states together accounted for two thirds of the Mexican American population of the United States. The majority of the non-Mexican Hispanic residents of these states were immigrants from Central America (7%) or did not report a specific Hispanic origin (5%). Only 2% reported Cuban or Puerto Rican ancestry.22 Thus, the mortality profile reported here predominantly reflects the experience of a Mexican American population and should not be generalized to other Hispanic groups.
A second limitation is that causes of death were based on data reported on death certificates. Death certificate coding of underlying causes of death has been found to be inaccurate in some instances and does not reflect all contributing causes. There may be less concern with regard to this issue among younger individuals and in the case of accidents and other social and behavioral causes.38 The low suicide rate for Hispanics may be partly attributable to differential reporting of suicide deaths. However, this hypothesis seems to imply ethnic differentials in misclassification of suicides as either traffic accident or homicide deaths, because these are the only external accident and injury categories with sufficient numbers to affect materially our reported suicide rates. It seems unlikely that such classification effects would entirely explain the suicide differentials reported here.
A third limitation is that we did not adjust our results for differential ethnicity-specific census undercounts. In 2000, the Census Bureau estimated an undercount for Hispanics of 0.71% and an overcount for non-Hispanic Whites of 1.13%.39 The Census Bureau did not publish Hispanic-specific assessments of differential undercounting according to immigrant status or age in the 2000 census. Results from evaluations of past census data suggest that undercounts are likely to be higher among younger adults and immigrants. These considerations suggest that the mortality rates reported here for Hispanic immigrants may be slightly overstated.
Conclusions
Our findings highlight several points. First, declines in mortality resulting from external accidents and injuries in recent decades have contributed to the emergence of relatively low mortality rates among Hispanic immigrants. Researchers should not assume that ethnic differentials in mortality are invariant in time and across cohorts. Second, the relatively low mortality rates among younger Hispanic immigrants are compatible with patterns of health-selective in-migration and out-migration. Further research seeking to explain Hispanic immigrant mortality patterns should focus on specific mechanisms that contribute to large ethnic differentials. It may be difficult to differentiate cultural explanations of these patterns from explanations rooted in migration selection because the latter may also influence psychosocial and behavioral characteristics. Finally, cause-specific mortality patterns are distinct for younger immigrant and US-born Hispanics, reaffirming the usefulness of disaggregating these groups in studies of Hispanic mortality.
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Acknowledgments |
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Human Participant Protection
This study was approved by the institutional review board of the University of Texas Medical Branch, Galveston.
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Footnotes |
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Contributors
K. Eschbach originated the study and supervised all aspects of its implementation. J. P. Stimpson and Y. F. Kuo contributed to the statistical analysis. All of the authors participated in interpreting findings and reviewing drafts of the article.
Accepted for publication September 5, 2006.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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2. Eschbach K, Kuo YF, Goodwin JS. Errors in ascertainment of Hispanic ethnicity on the California death certificate: implications for the explanation of the Hispanic mortality advantage. Am J Public Health.2006; 96:2209–2215.
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