Do healthy behaviors decline with greater acculturation?: Implications for the Latino mortality paradox

Abstract

Relative to non-Latino whites, Latinos in the United States have a lower socioeconomic status (SES) profile, but a lower all-cause mortality rate. Because lower SES is associated with poorer overall health, a great deal of controversy surrounds the Latino mortality paradox. We employed a secondary data analysis of the 1991 National Health Interview Survey to test the health behavior and acculturation hypotheses, which have been proposed to explain this paradox. These hypotheses posit that: (1) Latinos have more favorable health behaviors and risk factor profiles than non-Latino whites, and (2) Health behaviors and risk factors become more unfavorable with greater acculturation. Specific health behaviors and risk factors studied were: smoking, alcohol use, leisure-time exercise activity, and body mass index (BMI). Consistent with the health behaviors hypothesis, Latinos relative to non-Latino whites were less likely to smoke and drink alcohol, controlling for sociodemographic factors. Latinos, however, were less likely to engage in any exercise activity, and were more likely to have a high BMI compared with non-Latino whites, after controlling for age and SES. Results provided partial support for the acculturation hypothesis. After adjusting for age and SES, higher acculturation was associated with three unhealthy behaviors (a greater likelihood of high alcohol intake, current smoking, a high BMI), but improvement in a fourth (greater likelihood of recent exercise). Gender-specific analyses indicated that the observed differences between Latinos and non-Latino whites, as well as the effects of acculturation on health behaviors, varied across men and women. Results suggest that the health behaviors and acculturation hypotheses may help to at least partially explain the Latino mortality paradox. The mechanisms accounting for the relationship between acculturation and risky behaviors have yet to be identified.

Introduction

An inverse relationship between socioeconomic status (SES) and poor health is well-documented, both in terms of morbidity and mortality (Adler et al., 1994). High rates of morbidity and mortality among Latinos in the United States, who are disproportionately represented among the poor (Falcón, Aguirre-Molina, & Molina, 2001), would be expected on these grounds alone. It is surprising, therefore, Latinos have a lower all-cause mortality rate and higher life expectancy than do non-Latino whites (Hummer, Rogers, Amir, Forbes, & Frisbie, 2000; Lin, Rogot, Johnson, Sorlie, & Arias, 2003; Singh & Siahpush, 2002; Sorlie, Backlund, Johnson, & Rogot, 1993). Because Latinos have higher rates of poverty, less education, and are less likely to have health insurance than non-Latino whites (Falcón et al., 2001), the lower Latino mortality rate presents an epidemiologic paradox (Markides & Coreil, 1986).

A great deal of controversy surrounds the Latino mortality paradox (Franzini, Ribble, & Keddi, 2001; Patel, Eschbach, Ray, & Markides, 2004; Hunt et al., 2003), and a number of explanations for it have been proposed. The healthy migrant hypothesis suggests that the paradox results from selection into the United States of healthy Latino migrants. Another migratory hypothesis, the salmon bias, proposes that many Latinos return to and eventually die in their country of birth, resulting in an artificially low US Latino mortality rate (Pablos-Méndez, 1994). A recent study that did not support either the salmon or healthy migrant hypotheses concluded that other factors, such as health behaviors, must account for the epidemiologic paradox (Abraído-Lanza, Dohrenwend, Ng-Mak, & Turner, 1999).

The purpose of the present study was to test the health behaviors and acculturation hypotheses. The health behavior hypothesis proposes that Latinos have more favorable health behaviors and risk factor profiles than do non-Latino whites, which result in their relative health advantage (Scribner, 1994; Markides & Coreil, 1986). For instance, Latinos are less likely to drink alcohol and smoke than are non-Latino whites (Pérez-Stable, Marin, & Marin, 1994; Singh & Siahpush, 2002).

These favorable health behaviors may be related to Latino cultural values and practices (e.g., dietary practices; proscriptions against smoking, drinking). These positive health behaviors, however, decline with acculturation (Clark & Hofsess, 1998; Vega & Amaro, 1994; Scribner, 1994). Acculturation refers to the process by which immigrants adopt the attitudes, values, customs, beliefs and behaviors of a new culture (Abraído-Lanza, White, & Vásquez, 2004). Alcohol consumption, smoking, and a number of other risky health behaviors increase with acculturation, as do rates of overall cancer, infant mortality, and other illnesses (see Clark & Hofsess, 1998; Vega & Amaro, 1994). Acculturation, however, is associated with some healthy behaviors, such as leisure-time physical activity (Crespo, Smit, Carter-Pokras, & Andersen, 2001). Few studies, however, examine the association between acculturation and health-promoting behaviors such as exercise.

There is also evidence that, among Latinos, the effect of acculturation on certain health behaviors, such as smoking, varies by sex, perhaps reflecting the prevailing gender norms in the United States (e.g., Pérez-Stable et al., 2001). Furthermore, more favorable risk profiles among Latinos than non-Latino whites are not found consistently. Some studies find that Latinos are more likely than non-Latino whites to be overweight (Singh & Siahpush, 2002), but in studies that stratify by sex, the difference occurs only among women (Shea et al., 1991; Winkleby, Fortmann, & Rockhill, 1993). Whereas some studies report that Latinos are less likely than whites to exercise on a regular basis (Crespo, Andersen, Carter-Pokras, & Ainsworth, 2000; Shea et al., 1991; Pérez-Stable et al., 1994), others find no differences between the groups (Winkleby et al., 1993).

Thus, there is mixed evidence for the health behavior and acculturation hypotheses. These issues, therefore, require further study. We tested the hypothesis that Latinos engage in more favorable health behaviors than do non-Latino whites, and examined whether these behaviors decline with greater acculturation. The specific health behaviors and risk factors examined were: current smoking status, alcohol use, exercise activity, and body mass index (BMI). We selected these specific indices given that more than half of the premature deaths in the United States result from these risk behaviors, particularly smoking (USDHHS, 1998), obesity (US Department of Health and Human Services, 2001), alcohol use (Gilbert & Cervantes, 1996), and physical inactivity (Dubbert, 2002).

The health behavior hypothesis predicts that Latinos have better health behavior profiles than do non-Latino whites. Because these health behaviors are believed to be associated with Latino cultural norms, the acculturation hypothesis predicts that health behaviors become riskier with greater acculturation. Thus, the present study addressed a series of questions derived from these hypotheses. First, do Latinos differ from non-Latino whites on risk (i.e., smoking and alcohol use) and protective (i.e., maintaining a healthy body weight and engaging in any exercise) behaviors? Second, do these differences remain after controlling for sociodemographic variables (SES and age)? Third, among Latinos, is acculturation associated with increased risk and decreased protective health behaviors, controlling for SES and age? Finally, do the effects of ethnicity and acculturation on risk and protective behaviors vary by gender?