REVIE W Open Access
Hispanic health in the USA: a scoping
review of the literature
Eduardo Velasco-Mondragon
1*
, Angela Jimenez
2
, Anna G. Palladino-Davis
3
, Dawn Davis
4
and Jose A. Escamilla-Cejudo
5
* Correspondence:
eduardo.velasco@tu.edu
1
College of Osteopathic Medicine,
Touro University California, 1310
Johnson Lane; H-82, Rm. 213,
Vallejo, CA 94592, USA
Full list of author information is
available at the end of the article
Abstract
Hispanics are the largest minority group in the USA. They contribute to the economy,
cultural diversity, and health of the nation. Assessing their health status and health needs
is key to inform health policy formulation and program implementation. To this end, we
conducted a scoping review of the literature and national statistics on Hispanic health in
the USA using a modified social-ecological framework that includes social determinants
of health, health disparities, risk factors, and health services, as they shape the leading
causes of morbidity and mortality. These social, environmental, and biological forces have
modified the epidemiologic profile of Hispanics in the USA, with cancer being the
leading cause of mortality, followed by cardiovascular diseases and unintentio nal injuries.
Implementation of the Affordable Care Act has resulted in improved access to health
services for Hispanics, but challenges remain due to limited cultural sensitivity, health
literacy, and a shortage of Hispanic health care providers. Acculturation barriers and
underinsured or uninsured status remainasmajorobstaclestohealthcareaccess.
Advantageous healthoutcomesfromthe“Hispanic Mortality Paradox” and the “Latina
Birth Outcomes Paradox” persist, but health gains may be offset in the future by
increasing rates of obesity and diabetes. Recommendations focus on the adoption of the
Health in All Policies framework, expanding access to health care, developing cultural
sensitivity in the health care workforce, and generating and disseminating research
findings on Hispanic health.
Keywords: Hispanics, Latinos, Scoping study, Social determinants of health, Health care
inequalities, Health care access
Background
Hispanics are the largest ethnic minority in the USA; in 2014, Hispanics comprised
17.4% of the US population (55.4 million), and this percentage is expected to increase
to 28.6% (119 million) by 2060. Hispanics in the USA include native-born and foreign-
born individuals immigrating from Latin America, the Caribbean, and Spain [1].
Hispanics are disproportionately affected by poor conditions of daily life, shaped by struc-
tural and social position factors (such as macroeconomics, cultural values, income, educa-
tion, occupation, and social support systems, including health services), known as social
determinants of health (SDH). SDH exert health effects on individuals through allostatic
load [2], a phenomenon purported to cause chronic stress, which elicits beha vioral risk
factors such as poor diet, sedentary behaviors, and substance use, as well as biological pro-
cesses such as circadian rhythm disruption, cytokine responses, and inflammation [3].
© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International
License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and
indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/
publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Velasco-Mondragon et al. Public Health Reviews (2016) 37:31
DOI 10.1186/s40985-016-0043-2
SDH are implicated in health inequalities, which are defined as health conditions that
typically affect disprop ortionally certain socioeconomic, ethnic, and gender population
subgroups [4]. Health inequalities particular to Hispanics are also those related to their
socioeconomic status, cultural background, employment, and foreign-born or undocu-
mented status [5, 6]. Hispanics residing in the USA are on average 15 years younger,
four times more likely to not have finished high school, twice as likely to live below the
poverty line, and 20 times less likely to speak proficient English than non-Hispanic
Whites (NHW) [1, 7]. Hispanic women are also a growing demographic group that en-
dure adverse social and health conditions and lack of access to health care [8].
Risk factors for non-communicable diseases (NCDs), coupled with decreased health
care access make Hispanics disproportionately vulnerable to disease and death.
Hispanics endure major health risks such as obesity, teen pregnancy, and to bacco use,
among others. Significant differences in risk factors, morbidity, mortality, and access to
health care can also be observed among Hispanics by country of origin [4, 9, 10]. The
most recent reports show that the leading causes of disease among Hispanics are heart
disease, cancer, and high blood pressure, while the leading causes of death are cancer,
heart disease, an d unintentional injuries.
Health care services in the USA are provided mainly through employer-based health in-
surance, Medicare, and Medicaid. Employer-based insurance is usually privately pur-
chased. Medicare insures people 65 years and older (or younger than 65 with disabilities),
and Medicaid is a social welfare program for low-income population. In 2010, President
Obama signed into law the Patient Protection and Affordable Care Act (ACA) to expand
health care protection by increasing insurance coverage, expanding Medicaid, decreasing
health care costs, allowing provider choice and improving the quality of care [11]. Histor-
ically, Hispanics in the USA have less access to health services and they utilize fewer pre-
ventive care services than other ethnic groups, with 30% reporting no health insurance
before the implementation of the ACA in 2014, compared to 11% for NHWs [12].
Several literature reviews on Hispanic and Latino/Latina Health have been conducted
in the past; most consist of cross-sectional or qualitative studies focusing separately on
acculturation, health disparities, risk behaviors, specific health conditions, and access to
health care. Some of them focus on specific age and gender groups or on country of
origin, migrant workers, and undocumented populations [13–21], while some others
discuss the Latina Birth Outcomes and Hispanic Mortality Paradoxes [22, 23].
After a preliminary review of the literature on the topic [7, 11, 24], we identified a
lack of a unified framework to assess Hispanic health in the USA, as well as the need
to conduct a scoping review of the literature on the main Hispanic health needs and
health policies and services—including the Latina Birth Outcomes Paradox and the
Hispanic Mortality Paradox—to help inform policy- and decision-making for improving
Hispanic health in the USA. Such is the objective of this review paper.
Conceptual framework
After discussing several conceptual frameworks, and to accomplish our objective, we devel-
oped a modified conceptual framework based on the social-ecological model [25] and the
lifespan biopsychosocial model [26]. This comprehensive framework embodies the complex
interactions—with synergistic and antagonistic effects—between social, biological, and
Velasco-Mondragon et al. Public Health Reviews (2016) 37:31 Page 2 of 27
psychological constructs of health (Fig. 1). It posits that distal variables pertaining to SDH
(Fig.1,A)—some of which include the main variables of health inequalities (Fig. 1, B)—op-
erate as stressors that elicit epigenetic, biological, and psychological effects on individuals,
resulting in health, disease (Fig. 1, D), and death (Fig. 1, E). They also interact with proximal
variables such as risk factors (Fig. 1, C) (diet, obesity, physical inactivity, smoking, alcohol),
in the causal pathways leading to health and disease.
Components of the framework do not have unidirectional cause-effect temporality but
rather compose causality networks and trajectories that influence each other over time in
interconnected, multi-directional cycles. For example, social support systems (education,
labor, sports, food programs, recreation) include health services that serve as determi-
nants of health which influence health needs and risks; however, changes in health needs
and risks in turn modulate health services (Fig. 1, F), which—through prevention, treat-
ment, and rehabilitation services—have an effect on health needs and risks. These causal
networks exert more nuanced effects across Hispanic population subgroups by country of
origin, foreign-born status, and migrant and undocumented status.
The wide-ranging breadth of this framework would be best approached through a
comprehensive re view and detailed analysis that would be too extensive for this review
paper. Thus, we limit our review and analyses to the main Hispanic health priorities, as
reported in the literature and based on the authors’ expert consensus.
Methods
We utilized Arksey and O’Malley’s [27] scoping methodology to conduct our review.
Scoping studies allow reviewing of both scientific and “gray” literature to answer broad
Fig. 1 A framework to analyze Hispanic health in the USA
Velasco-Mondragon et al. Public Health Reviews (2016) 37:31 Page 3 of 27
research questions. They are useful to “map key concepts underpinning a research area
and the main sources and types of evidence available.” Scoping studies also serve to
identify research gaps and to summarize and disseminate research findings to stake-
holders and poli cymakers who would otherwise have to obtain information from mul-
tiple sources [28].
We followed the five stages of a scoping stud y:
1. Identify the research question. Different from systematic reviews, where research
questions are specific and focused on a particular type of study design, scoping
studies seek to answer broader questions and colle ct data from different types of
information sources. They also allow iterat ive rather than linear analytical processes
to fine-tune the research focus in a way that the information is useful for decision-
making and further research. The research question to pursue in this scoping review
is, What are the current priority issues, needs and services germane to the health of
Hispanics in the USA?
2. Identify relevant studies. Guided by our framework, we searched the literature for
comprehensive Hispanic health review documents in electronic databases,
government websites and agencies, and civil society organizations addressing Hispanic
health. The first step was to find out whether there were any recent comprehensive
reviews addressing our research question. Figure
2 shows a flowchart of our citation
selection process. In PubMed, we used the Boolean search terms “Hispanic OR
Hispanics OR Latino OR Latinos OR Latina OR Latinas AND health,” restricted to
“review” and “10 years,” which yielded 654 citations, too many to review and too many
tangential to our research question. After a cursory review of recent titles and
abstracts, we added “in title/abstract” as a filter, which produced 381 citations. After
eyeballing the references, there were still many tangential to our study questions. After
a more targeted approach (Fig.
2), we selected 66 citations (as of September 2016) that
were more specific to our research question (see Additional file
1). A thorough review
of those citations supported our objective to conduct a scoping study using a unified
framework of Hispanic health to answer our research question.
3. Study selection. A review of the initial reference list containing 66 citations on
“Hispanic health reviews” showed that only one comprehensive review had been
published in the previous 10 years [
7], although it focused mostly on health needs
and use of health services, not reflecting our more comprehensive conceptual
framework and study design. While conducting this scoping review (alerted by
peer-reviewers), a special issue on Latino Health was published [
23], which seemed
to supplant content in our review; however, the four papers in that issue refer to
specific Hispanic health topics: cancer, cardiovascular disease, health promotion,
and health issues in general, with no unifying framework. Upon completion of our
literature search, a total of 366 references were included in an EndNote© database.
For this paper, we selected only citations pertinent to each of the components of
the conceptual framework of Hispanic health presented in Fig.
1, for a total of 179
citations (Fig.
2). All retrieved papers were made available onlin e to the authors in a
shared Dropbox file for online remote access.
4. Charting the data. A review of the first reference dataset containing 66 citations
showed—with much overlap—that there were 26 review papers focusing mainly on
Velasco-Mondragon et al. Public Health Reviews (2016) 37:31 Page 4 of 27
social determinants of health and health disparities, 20 on health needs and risk
factors, and 20 on health services (see Additional file
1) versing on diverse topics.
We were able to retrieve 42 of the initial 66 revi ews. All other references were
added as authors reviewed and retrieved materials from different information
sources (PubMed, Internet, books), for each component of the conceptua l
framework.
5. Collating, summarizing, and reporting results. We reviewed and selected papers,
documents, and websites systematically to develop the sections on social
determinants of health and health disparities, health risks, morbidity and mortality,
health services, and the Hispanic and Latina paradoxes. Authors discussed and
agreed upon references to be added for each section. Table
1 was prepared to show
the main organizations addressing Hispanic health.
We did not conduct the optional sixth stage of a scoping study: “Consultation.”
The following sections present the main components of Hispanic health, as outlined
in our conceptual framework: social determin ants of health and health inequalities,
health risks , morbidity and mortality, health services and the Latina Birth Outcomes
and Hispanic Mortality Paradoxes. Special subpopulations are emphasized where infor-
mation was deemed important.
Fig. 2 Literature review flowchart
Velasco-Mondragon et al. Public Health Reviews (2016) 37:31 Page 5 of 27