Hispanic Paradox Lost: the Health of Puerto Ricans Nathan Hicks

Florida State University Libraries

Honors Theses The Division of Undergraduate Studies

2012 Hispanic Paradox Lost: The Health of Puerto Ricans Nathan Hicks

Follow this and additional works at the FSU Digital Library. For more information, please contact [email protected] ABSTRACT:

Puerto Ricans are a minority group that is severely understudied. Because of this,

we know little about why their mental and physical health is different than other racial

and ethnic groups. This is troubling because Puerto Ricans have high rates for many

different illnesses, diseases and conditions. My aim is to review previous research on the

mental and physical health of Puerto Ricans and mortality risks, and to identify social,

contextual and behavioral risk factors and to offer direction for future research. After

reviewing the available research, I found that the Puerto Rican health profile is poor in

comparison to other non-Hispanic Whites and Blacks. Factors such as segregation and

SES are possibilities that could affect Puerto Ricans health. For future research, I argue

that more emphasis needs to be placed on Puerto Ricans in the U.S. The available

literature is often limited to those on the island of Puerto Rico, which is not applicable to

those the U.S. because the same disadvantages do not exist. Furthermore, research tends

to group Hispanics into a single category which cannot be continued because we risk

stifling what we can actually learn about the individual groups that comprise the Hispanic

group. Puerto Ricans have an overall poor health profile and this causes them to be a

unique group when compared to Hispanics and non-Hispanics. These steps could help

us gain a greater understanding overall of their health and possibly develop new solutions to help them.

Key Words: Hispanic Paradox, Puerto Ricans, Mortality, Physical Health, Mental Health

THE FLORIDA STATE UNIVERSITY

COLLEGE OF SOCIAL SCIENCES

HISPANIC PARADOX LOST: THE HEALTH OF PUERTO RICANS

NATHAN A. HICKS

A Thesis submitted to the Department of Sociology in partial fulfillment of the requirements for graduation with Honors in the Major

Degree Awarded:

Spring, 2012

The members of the Defense Committee approve the thesis of Nathan Hicks defended on

April 20th, 2012.

______

Dr. Terrence Hill Thesis Director

______Dr. Lisa Weinberg Outside Committee Member

______Dr. John Taylor Committee Member

INTRODUCTION

Currently in the United States, there is a phenomenon that is occurring within the

Hispanic community. This group of people is able to enjoy low rates of mortality for many different diseases that rival or are even superior to those of their non-Hispanic counterparts and have strong mental and physical health (Franzini, Ribble and Keddie

2001). In turn, this makes many people in Hispanic population quite healthy in relation to those other racial and ethnic groups with similar SES. This is a surprising occurrence, because many researchers do not understand completely why their health is as pronounced as it is. In theory, they should be a disadvantaged group due to the fact that their SES levels are not as high as non-Hispanic Whites and sometimes are actually even lower than those of non-Hispanic Blacks (Franzini et al 2001). It is a puzzling event and there has been a great deal of research into why this has been happening to such a large portion of people (Franzini et al 2001). Many theories have been developed but none have been proven fully. This exceptional phenomenon is called the Hispanic Paradox.

The Hispanic Paradox is interesting in regards to epidemiology, but what is even more interesting is that Hispanic group does not share these benefits as equally as the others; that is the Puerto Ricans that reside in the U.S (Rivera and Burgos 2010).

Surprisingly, their mental and physical health and mortality risks do not always follow the typical pattern of the “Hispanic Paradox”, and sometimes they are more similar to those of African Americans or even worse (Rivera and Burgos 2010). It would not be uncommon event if they were disadvantaged in perhaps a few areas when it came to physical and mental health. But when you compare them to other racial and ethnic

4 groups, nearly across the board they either have the worst or near worst rates when it comes to rates for diseases, mortality, depression and many other illnesses (Rivera and

Burgos 2010). The reason why this is the case is perplexing and has not been studied to its fullest extent. We currently do not understand why this is happening and there has not been a great deal of research conducted to better explain this either.

With all of this in mind, my thesis will critically review previous research to (1) compare the mental and physical health and mortality risks of Puerto Ricans to other race and ethnic groups, (2) identify social, contextual, and behavioral factors that could help to explain the differences, and (3) offer important directions for future research and public health initiatives. Such actions are necessary to help gain a better understanding as to why this group of people is not currently experiencing the same level of benefits like the other Hispanic groups in the U.S. A greater understanding of this could eventually lead to possible solutions to the situation and give Puerto Ricans a better chance at improving their mental and physical health and mortality.

Comparisons in Mental Health

In multiple studies, it has been found that Puerto Ricans are disadvantaged as well in their mental health status (Rivera and Burgos 2010; Ramos 2005). They suffer worse rates of many illnesses, disorders and conditions when compared to other Hispanic groups and their non-Hispanic counterparts. Puerto Ricans have been found to have higher rates of depressive cases and major episodes of depression in comparison to

Cuban and Mexican Americans (Rivera and Burgos 2010). This has been verified through the National Longitudinal Asian American and Latino Study (NLAAS) as well

(Rivera and Burgos 2010). Also, Puerto Rican men and women had the highest rates of overall lifetime and past-year prevalence psychiatric disorders when compared to other

Hispanic groups (Rivera and Burgos 2010). The article cites other studies that have found the same patterns among Puerto Ricans, but that it seemed that those that were on the island had lower rates in comparison to their mainland counterparts (Rivera and

Burgos 2010). It was also found that those Puerto Rican men that were tested to have a high level of acculturation versus lower levels reported high levels of depressive affect/somatic symptoms (Ramos 2005). Those Puerto Ricans that had a low level of acculturation seemed to exhibit higher levels of depression as manifested from low positive affect (Ramos 2005). An explanation for this is that a lack of skills and proficiency in English could cause feelings of low self-worth (Ramos 2005). This means that if Puerto Ricans are more disadvantaged in becoming acculturated then their mental health could be suffering more greatly when compared to other racial and ethnic groups.

These are but a few of the examples that exhibit the poor mental health of Puerto

Ricans. It is possible that there is even more that could be studied to show the disparity between Puerto Ricans health to others. But Puerto Ricans are not merely disadvantaged in just mental health; they are as well in their physical health.

Comparisons in Physical Health

In many areas of physical health, Puerto Ricans have the worst, or near worst, rates for many diseases when compared to other race and ethnic group. For example, heart disease rates are 20% higher for Puerto Ricans than any other Hispanic group

(Rosenwaike 1987). Also, studies that have utilized these same data have reported higher levels of overweight and comparable hypertension rates among Puerto Ricans (especially women) than Cubans and Mexican Americans (Rivera and Burgos 2010). It has also been reported that they have slightly higher prevalence rates of diabetes, hypertension, and asthma when compared to the rates found in other racial and ethnic groups (Rivera and Burgos 2010). Furthermore, there is evidence of higher rates of self-reported bronchitis among Puerto Ricans in comparison to Mexican Americans and Cubans

(Rivera and Burgos 2010).

After viewing the death rates for Puerto Ricans in the New York City area when compared to non-Hispanic Whites, it can be easily surmised that they have a disadvantage when compared to others (Rosenwaike 1983). For both male and female

Puerto Ricans, there was a clear disadvantage (Rosenwaike 1983). For example, for the

25-34 year age group, male Puerto Ricans had a ratio of 2.77 deaths to 1 when compared to non-Hispanic Whites and the rate for females of the same age group was 1.46 deaths to

1 when compared (Rosenwaike 1983). The gaps between the death rates become less pronounced though for each particular age group in both genders (Rosenwaike 1983). In this same study, cerebrovascular disease, diabetes mellitus, cirrhosis of the liver, general accidents and homicide were all compared as well and in nearly every area for each age

7 group and sex, Puerto Ricans had a worse rate (Rosenwaike 1983). While this study was done nearly forty years ago and was only a regional study, it still shows how even at that time Puerto Ricans were disadvantaged with their physical health.

Comparisons in Mortality

Quite often, mortality rates for Puerto Ricans are poor on all levels of age, gender and ethnicity groups. For example, when comparing age-adjusted death rates, they are higher on average for Puerto Ricans than any other Hispanic group (Rosenwaike 1987).

Age-adjusted death rates from chronic liver disease and cirrhosis are significantly different when compared to other Hispanic groups (Rosenwaike 1987). When compared with Cuban-born and Mexican-born populations, the Puerto Rican-born population exhibits higher mortality rates overall (Rosenwaike 1987). Even when they are being treated for conditions with medical care, they seem to do poorly in comparison. For example, they exhibit higher mortality rates when under dialysis (Frankenfield, Krishnan,

Ashby, Shearon, Rocco and Saran 2009).

Reported age-adjusted mortality rates for Puerto Ricans are higher in comparison than nearly every other racial/ethnicity group in the US. The only group that was higher than them were African Americans (Rivera and Burgos 2010). It was also noted in this article that there was a difference in the rates for Puerto Ricans that were on the island and those that were in the U.S. The Puerto Ricans that lived on the island seemed to have an advantage when it came to CVD mortality versus the Puerto Ricans that were in the

U.S. (Rivera and Burgos 2010). It is possible that the stresses of living in the U.S. could be causing Puerto Ricans there to have worse CVD rates than those on the island.

Another common health condition that afflicts people in the US is asthma; this is especially true for Puerto Ricans. Puerto Ricans age-adjusted annual asthma mortality rate is 40.9 per million (Homa, Mannino, and Lara 2000). In comparison to other

Hispanic groups, it is considerably higher and is actually higher than non-Hispanic blacks which had a rate of 38.1 per million (Homa et al. 2000).

As I mentioned earlier, Puerto Ricans are also disadvantaged for mortality in relation to diabetes. They had a mortality rate of 204 deaths per 100,000 people which was twice the rate of Cuban Americans (101 deaths per 100,000 people) but was not as a great as Mexican Americans (251 deaths per 100,000 people) (Smith and Barnett 2005).

Also, when compared to Mexican and Cuban Americans, Puerto Ricans had the second highest proportion of diabetes related deaths (Smith and Barnett 2005).

Social Factors

There are many different social factors that can play a role in the mental and physical health of Puerto Ricans. For instance, SES levels are an important factor in predicting health. It has been found that across the globe, high SES levels can be attributed to having better chances in life and better health. Among all of the Hispanic groups, Puerto Ricans tend to have some of the lowest levels of education (Rivera and

Burgos 2005). Also, their SES levels are also some of the lowest in comparison (Rivera

9 and Burgos 2005). Both of these factors are possible contributors to explain why Puerto

Ricans overall health is so poor and the lowest of all the Hispanic groups. For example, if the low SES levels cause Puerto Ricans to have a more difficult life and have more stress then this could adversely affect their health. It could cause them to live in poverty more often than other Hispanic groups which brings a multitude of complications. These are but a few examples of how low SES levels could cause a person’s health to be poor.

One study noted that Puerto Rican men were more likely to have a diagnosis of lifetime substance abuse disorder, and attributed the possibility of an increased risk with higher levels of unemployment and underemployment (Caetano et al. 2009). These same authors also suggest that because Puerto Ricans are U.S. citizens, they may have higher expectations for sharing the country’s wealth and are thus more exposed to frustration and stress when facing economic deprivation (Caetano et al. 2009). Increased stress could play a role in a degradation of both their physical and mental health.

Another social factor that is taking place within the Puerto Rican ethnicity is assimilation. Assimilation is defined as the process where different cultural groups merge or share their traits with one another and become more similar to one another. As time progresses, more and more Puerto Ricans are becoming assimilated in culture in the

United States and that is having an impact on many different facets in their life. It has been found that both male and female Puerto Ricans who are first generations within the

United States had less education than those who were second generation (Macisco 1968).

Overall, second generation Puerto Ricans were found to have less unemployment than

10 those from a first generation (Macisco 1968). Puerto Ricans in the second generation were moving more towards clerical, professional and foreman careers and were moving away from the two careers that dominated in the first generation: operatives and service workers (Macisco 1968). For second generation Puerto Ricans, both males and females, they had a higher median income than first generation Puerto Ricans (Macisco 1968).

For all of the things that were measured, second generation Puerto Ricans had higher levels than first generation Puerto Ricans (Macisco 1968). Furthermore, second generation Puerto Ricans averages had begun to move in a direction to where they were more similar to the averages in the United States (Macisco 1968). Just a few of these examples are education levels, income, job placement and employment. As Puerto

Ricans stayed within the United States longer, the outlook for their lives increased as they gained in these areas.

Behavioral Factors

From what I have researched in regards to their physical health, they have some of the worst rates of diseases that are common with high rates of alcoholism. Alcoholism has the potential to lead to a slew of other mortality risks. As was mentioned earlier,

Puerto Ricans have higher rates of certain diseases that can be attributed with heavy alcohol usage and has been identified in numerous studies; chronic liver disease and cirrhosis of the liver. For instance, Puerto Rican woman are the most likely to have two drinks in a period of time in comparison of other Hispanic groups (Caetano et al.

November 2009). Puerto Ricans have high rates of having problems when it comes to

alcohol. In other words, they are more likely to have impaired control, withdrawal

symptoms, a need to drink, etc (Caetano et al. 2009). There was also a difference

between Puerto Ricans that are born in Puerto Rico and those that are born in the US.

Those that are born in the US tend to have much higher levels of alcohol abuse and

dependence. Puerto Ricans that have become highly acculturated to US culture also tend

to have a significant rate of alcohol abuse when compared to other Hispanic groups. As

reported by Caetano, Ramisetty-Mikler, and Rodriguez (2009), risk factors for abuse

include being male and being in the high acculturation group. From this study, risk

factors for alcohol dependence include being male, being Puerto Rican or Mexican

American, having less than a college education, and being U.S.-born (Caetano et al.

2009). Also, alcohol abuse and dependence rates for alcohol were higher among U.S.-

born Puerto Ricans when compared to their counterparts that were foreign-born (Caetano

et al. 2009).

Another interesting factor that could help explain Puerto Ricans mental and

physical health is their diet. If Puerto Ricans have a subpar diet and poor nutrition then

this could certainly lead to numerous health problems if it were to happen over a long

enough time. One thing that I found was the issue of food security within Puerto Ricans

households and how acculturation and social networks tie into it. It has been found that

Puerto Rican households that had low levels of acculturation and that lack a strong social network will have a strong risk of having food insecurity (Dhokarh et al. 2011). Also, if the household is on food stamps and their management skills are poor than this could also

12 play a role in raising their chances of having food insecurity (Dhokarh et al. 2011). This is just one other factor that could play a role in determining their nutrition. If a person’s nutrition is poor, then this could cause their health to deteriorate and worsen over time.

Segregation plays a large role for Puerto Ricans because they are more integrated with Blacks than other Hispanics. There are two theories that could be explanations as to why they are so segregated when compared to other Hispanics; the racial heritage hypothesis and the Anglo prejudice hypothesis. The Anglo prejudice hypothesis is that upwardly mobile Puerto Ricans try to assimilate spatially but are not always able to because of prejudice against them from Whites (Massey and Bitterman 1985). The other theory, racial heritage hypothesis, says that Puerto Ricans are different from other

Hispanic groups because of their heritage (Massey and Bitterman 1985). Due to their

African heritage, many Puerto Ricans may actually be considered as Black because their skin tone is similar to Blacks in the U.S. (Massey and Bitterman 1985). Furthermore, because the mixture of Blacks in the Puerto Rican population is greater, they tend to integrate themselves with Blacks more easily when compared to populations with a smaller Black percentage.

Furthermore, since there is so much variation in the Puerto Rican population due to their mixed heritage, it is possible that just the darker skinned Puerto Ricans who are actually disadvantaged and they are one of the reasons why their mental and physical health profile is poor. This is not to say that they are doing anything in particular to merit the reduced health, but that they could be socially discriminated against like Blacks.

There is research to support that darker skinned men in the Puerto Rican population have higher age-adjusted mortality rates than those who are lighter skinned (Borrell, Crespo and Garcia-Palmieri 2007). This means that racism and social discrimination can be playing a role in the health of Puerto Ricans that are darker skinned.

Contextual Factors

Much of the time, Puerto Ricans live in neighborhoods that are close in proximity or the same as Blacks (Massey and Bitterman 1985). It has been found on numerous occasions that Puerto Ricans are more highly segregated against Whites than Blacks in comparison to other Hispanics groups (Massey and Bitterman 1985). In doing so, Whites tend to segregate themselves from Puerto Ricans because of the similarities between them

(Massey and Bitterman 1985). With Puerto Ricans being segregated from Whites, it could alienate them from important opportunities to improve their SES. This reduced ability to improve their SES could have negative effects on their mental and physical health. It was found in a study that segregation for Puerto Ricans is associated with more health problems when compared to other Hispanic groups. If this is true, then it means that segregation hurts Puerto Ricans in two distinct ways. First, they are disadvantaged in general in comparison to other Hispanic groups when it comes to segregation and second, that it may keep them from increasing their life chances (SES). The element of segregation could play an integral role in Puerto Ricans and their health profile.

Also, the area of where the men were living at had a factor in their health as well

(Borrell et al. 2007). For men living in an urban setting, they had higher all-cause mortality if they were dark skinned rather than light skinned individuals (Borrell et al.

2007). This did not hold true though if they were living in a rural setting. Living in an urban or rural setting held no difference when comparing cardio vascular disease mortality (Borrell et al. 2007). It is possible that the stresses of living in a city could be affecting the health of the individuals who are darker skinned more abjectly than those with lighter skin.

There is also a peculiar phenomenon for cancer rates for the entire Puerto Rican populace. Cancer rates for Puerto Ricans that live on the island of Puerto Rico itself have a much lower rate of cancer nearly across the board in comparison to Puerto Ricans that are in the United States (Torre-Feliciano, Figueroa-Vallés, Ho, Jiménez-Velázquez,

Ortiz-Martínez and Rivera 2009). For the cancer rates that were observed, only two out of thirteen different types of cancer were found more often Puerto Ricans that were on the island than in the U.S (Torre-Feliciano et al. 2009). While this is only one area of differences, it is possible that there could be more areas where Puerto Ricans in Puerto

Rico are advantaged against those in the U.S.

POSSIBILITIES FOR FUTURE RESEARCH

Puerto Ricans are a group of people that are set apart from others due to their poor overall health profile. They are unique in that the benefits that are attributed to other

Hispanics do not apply to them. Thus, we cannot say that the Hispanic Paradox can be applied to them. This has not been fully explained with current research and so my goal was to review the available literature to find social, behavioral and contextual factors that could help explain their health. Some of the most important factors that I found were the ways that acculturation affects them, the fact that they have some of the lowest levels of

SES and that they may sometimes be met with racism and social discrimination due to their darker skin color. After researching about the generally poor health profile of

Puerto Ricans and the many viable contributing factors, I believe that a more concerted effort should be taken in order to bring a greater understanding of what the reason for this is. I argue that there are many new avenues available for new research and data collection in regards to this issue and I will highlight some of the main areas that I believe are of particular importance.

Also I believe that, while the emphasis on Blacks is merited of course, we should also focus on the individual groups that comprise the Hispanic category. In particular, we need to focus on the overall mental and physical health of Puerto Ricans and what exactly is the cause of their disadvantaged health profile. Some research has been conducted in the past on their health and how in comparison they do have a health profile that is worse than other Hispanic groups, but there does not seem to be a focus on finding the actual reasons for this and conducting new theories. For instance, when searching for research in regards to Puerto Ricans mental health, I was unable to find much research that was focused specifically on them. Much of the time if there was any research, they grouped all of the Hispanics into a single racial/ethnic category or did not attempt to distinguish

16 between the different ethnicities and merely grouped them all together. This pan-ethnic labeling of many different groups cannot be continued because the groups within the

Hispanic category are very different. Not only are there differences between each the different regions, Central and South American and the Caribbean, but each particular country is different as well. Also, Hispanics do not refer to each other as Hispanic.

Instead, they refer to one another based on their country of origin so the group itself recognizes that each group is different.

This practice of combining the groups may be a good indicator of averages but there are also negative consequences. This may inadvertently hide the disadvantages of a particular group by averaging them together. This was less of an issue when searching for physical health, but it still did present as a problem. Also, since Puerto Ricans health is so poor, by combining them into one group we may actually lower the average of the group because of their diminished health profile and we may not be giving an accurate representation of how well the Hispanic Paradox can be applied. If we are to better understand the Puerto Rican mental and physical health, we must separate them from other Hispanic groups when performing research. This will eventually lead to better results and possible solutions.

Throughout my research I found that Puerto Ricans had a unique experience to acculturation. There were times when they did not follow the typical pattern for acculturation and I believe that this is one area that should be focused on more. Puerto

Ricans are a very unique group of people and so it would be not unheard of for them to

17 have a different reaction for acculturation. For example, when it comes to depression, acculturation has an opposite effect on them where it actually hurts them instead of helping them. Studying this in greater detail will surely give us a better understanding of this experience and how it affects them and their health.

The mental health for those that lived on the island seemed to fair better in comparison to those that lived in the U.S. But some of the articles that I researched did not make a distinction between whether or not the data for Puerto Ricans were from those that were on the island or in the U.S. This could possibly lead to data that does not fully represent those Puerto Ricans that live in the U.S. due to the possible variations between the two populations. In this situation, there is a need for further research into exactly what causes the variations between Puerto Ricans that are born in the U.S. and those that are born on the island itself. These variations could occur from a numerous set of factors and possibly any of the ones that were mentioned earlier. The difference in SES is but one factor that could have an effect and cause a difference between the two groups.

One particular topic that I could not seem to find much data on was the factor of religion in Puerto Rican’s lives. The amount of time that they spend and how religious they are could have an effect on their mental and physical health. Religion has been shown to have an important role in a person’s life and especially their mental and physical health. If a study were done to compare the levels of religiosity between

Hispanic groups, then this could perhaps shed light on a possible factor in their diminished health profile. Also, while it would be important as well to compare the

18 differences between Hispanic groups, it would also be crucial to compare them within the different regions that Puerto Ricans reside within the United States and between the mainland and island Puerto Ricans. Since religion is a crucial part of Puerto Rican’s lives, studying their religiosity and what role it plays exactly in their lives could shed light on their overall health profile and perhaps give us a greater understanding.

When I first began to look through research, one of my original factors that I meant to analyze were the psychological factors that could influence Puerto Ricans overall health profile. During this process though, there was limited information on psychological research and what did exist mainly focused on the Hispanic group as a whole and did not distinguish between various groups. There were some studies that focused on factors like self-esteem and sense of control, but they were focused on

Hispanics overall and did not distinguish between different groups of people. Future research aimed specifically at Puerto Ricans could shed valuable light on this subject and what psychological factors affect them and their overall health.

CONCLUSION

The Hispanic group is the largest growing minority in the United States currently.

They are a heterogeneous group of people that consists of many different ethnicities and races. As they become more populous in the U.S., I believe that their role in society will become ever more important and we will need to know more about them. We cannot continue to combine them into a single category anymore, or else we risk attributing the

19 wrong results and conclusions to people which they do not belong. We also risk not understanding the dynamics of each subgroup within the Hispanic category. Data of course may be limited in such a way that this is what occurs, but if this is the case then we should attempt to collect data more efficiently. I believe that all of this can be applied to any Hispanic group, but especially for Puerto Ricans. By studying Puerto Ricans, we can gain a better and more refined understanding of the Hispanic Paradox. This is because we will know where the Hispanic Paradox can be applied and who it affects exactly.

They are a very under researched group in comparison to other ethnicities and any additional information could help us understand more. Since they are so disadvantaged, I argue that it is necessary to study them closely and look at what it is exactly that causes their mental and physical health to be worse than the other Hispanic groups. By doing this, we would potentially be able to gain a better understanding of the Hispanic Paradox and possibly foster solutions for the issues that are currently being faced by Puerto Ricans here in the U.S. I hope that by analyzing the possible areas for new research and changing data collection methods that it will eventually lead to improvements in the mental and physical health and mortality of Puerto Ricans.

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