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An Anomaly Within the Latino Epidemiological Paradox
The Latino Adolescent Male Mortality Peak
David E. Hayes-Bautista, PhD;
Paul Hsu, BS;
Maria Hayes-Bautista, RN, MPH;
Delmy Iñiguez, MS;
Cynthia L. Chamberlin, MA, CPhil;
Christian Rico, MD;
Rosa Solorio, MD
Arch Pediatr Adolesc Med. 2002;156:480-484.
ABSTRACT
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Objective To describe the anomaly of the Latino adolescent male mortality peak
in relation to the overall Latino epidemiological paradox and in relation
to the need for new conceptual models describing the health of a culturally
diverse population.
Design Population-based study using California's 1989 to 1997 summary death
files for death-related information and the State of California Department
of Finance population estimates for population denominators for corresponding
years.
Participants California's general population for 1989 to 1997, including California's
15- to 19-year-old and 20- to 24-year-old populations. In 1997, those 2 age
groups numbered 4.3 million.
Main Outcome Measures Mortality rates for Latinos and African Americans compared with non-Hispanic
whites expressed as relative risk (RR).
Results Overall, the Latino RR of mortality follows the Latino epidemiological
paradox in that it is lower (RR, <1.00) than that of non-Hispanic whites
for most age groups and both sexes. The anomaly within this paradox is seen
in Latino males aged 15 to 19 years (RR, 1.77; 95% confidence interval, 1.55-2.02)
and 20 to 24 years (RR, 1.79; 95% confidence interval, 1.58-2.02).
Conclusions This period of elevated mortality risk is labeled the Latino adolescent
male mortality peak, and it is an anomaly within the overall Latino epidemiological
paradox.
INTRODUCTION
THERE WERE 4.3 million adolescents, aged 15 to 24 years, in California
in 1997.1 Such a large adolescent population,
larger than the entire populations of 29 states,2
affords the observation of trends that might be overlooked in smaller adolescent
populations. The California adolescent population is not only large, but also
experiencing demographic dynamics that make it a bellwether for the adolescent
population of the United States in the mid-21st century. In 1997, its ethnic
composition was as follows: non-Hispanic white, 44.8%; Latino, 34.2%; Asian/Pacific
Islander, 12.1%; African American, 8.2%; and American Indian, 0.7%. It is
projected that, by 2020, Latinos will comprise 47.0% of the state's adolescent
population.3 With Latinos forming a large and
growing percentage of the state's adolescent population, it is imperative
to understand their health dynamics. This article shows how the Latino adolescent
health dynamic fits into the overall Latino health profile.
Preliminary data from the 2000 census indicate that Latinos outnumber
African Americans in the United States, thereby becoming the largest minority
population in the country. Many models used in social policy (eg, urban underclass)
have been applied to Latinos as if the behavior dynamics of all minority groups
could be explained by a single model. In health care, the Race and Ethnic
Health Disparities model, which repeats this tendency, has been developed
during the past 30 years.
The Office of Minority Health, supporting the federal Race and Minority
Health Initiative, cites "compelling evidence that race and ethnicity correlate
with persistent, and often increasing, health disparities among US populations,"4 and the Office of Research on Minority Health goes
on to specify that "African Americans, American Indians/Alaska Native, Asian
and Pacific Islander, and Hispanic citizens suffer poorer health and higher
rates of premature death than the majority population."5
In its 1997 position paper,6 the American College
of Physicians provided a summary of the relationship between minority status
and risk factors, such as poverty, unemployment, and minority group membership
in deteriorating inner cities, concluding, "Urban health problems arise from
the complex interaction of socioeconomic factors, behavior, environment, and
disease that is related to race and ethnicity." In general, low income, low
education, and low access to care are causes of poorer minority health.7
Although Latino populations often exhibit these classic risk factors,
Latino health profiles have presented a paradox to researchers: despite high-risk
factors for poor health—low income, low education, low access to care,
and increased likelihood of being overweight—Latino health outcomes
generally are similar to, or better than, those for whites.8-9
This observation is supported by evidence from such key health indicators
as infant mortality,10-12
life expectancy,9, 13-15
mortality from cardiovascular diseases and major types of cancer, and measures
of functional health.8-9 Overall,
this phenomenon is observed in California, where, in 1997, the age-adjusted
mortality rate from all causes for non-Hispanic whites was 439.2, whereas
the rate for Latinos was 327.4, about 25.5% lower. It seems paradoxical that
a minority population with such high-risk factors manages to show such good
health profiles; thus, this has been labeled the Latino
epidemiological paradox (LEP).16-17
Although it has been customary to think of the Race and Ethnic Health
Disparities model as applicable to all minority groups, the LEP suggests that
this may not be appropriate in every case. Now that Latinos are the nation's
largest minority group, it would be prudent to develop new models that can
better explain the health profiles of populations that are not non-Hispanic
white, covering both the Latino paradox and the African American disparities.
These models have yet to be developed, but the field of adolescent health
offers some insight.
In general, adolescence is a period of increased mortality. National
statistics show that adolescents aged 15 to 19 years have higher mortality
rates than younger children.18 As Latinos are
becoming the largest portion of the adolescent population in California, their
patterns rapidly are becoming the norm for adolescent behavior in general.
We wanted to determine if Latino adolescent mortality followed the LEP model
or presented some other profile. This article considers Latino adolescent
mortality (15-19 years and 20-24 years) as part of Latino mortality during
a lifespan (birth to  85 years). We found that Latina (female) adolescents
in these age groups exhibit the general tendency of the LEP, showing no elevated
mortality risk during the late adolescent (15-19 years) and early adult (20-24
years) periods. Because female adolescents conform to the LEP, no further
analysis of their mortality rates is presented herein. By contrast, males
show a definite countertrend: in the late adolescent and early adult periods,
their mortality is nearly twice as high as that of non-Hispanic whites, returning
later in life to the levels expected by the LEP. Although mortality rates
for the general Latino population conform to the LEP pattern, male adolescents
are an interesting anomaly in the paradox.
METHODS
The primary data sources for this analysis were California's 1997 summary
death files19 for death-related information
and the State of California Department of Finance population estimates1 for population denominators. Both sets of files include
age, sex, and ethnicity identifiers, with Latinos identified separately from
non-Hispanic whites, African Americans, and Asian/Pacific Islanders. The deaths
and population estimates were aggregated into 5-year age groups (0-4 years,
5-9 years, 10-14 years, and so on) to compute age-specific death rates for
males and females separately.
Because the Latino population in California is so large, there were
sufficient events in the adolescent 5-year age groupings to allow estimation
of significance. During 1997, in the male 15- to 19-year age group, there
were 387 non-Hispanic white deaths, 518 Latino deaths, and 140 African American
deaths. In the male 20- to 24-year age group, there were 456, 635, and 235
deaths, respectively. The relative risk (RR) for Latinos and African Americans
for each age group was computed for 1997 deaths, using non-Hispanic whites
as the comparison base, and 95% confidence intervals (CIs) were calculated.20
There were too few deaths in most of these specific age groups to analyze
specific causes of death for 1997 alone with reasonable estimates of significance.
To examine specific causes of death for each race/ethnic and age group, data
were aggregated from the summary death files for the 9-year period of 1989
through 1997 to calculate an annualized rate for a particular cause of death,
using the midpoint 1993 population figures for the denominator (because race/ethnic-
and age-specific denominators were not available for 1989, 1991, or 1992),
then the RR and 95% CI was generated. To track long-term trends for specific
causes of death by race/ethnicity, the age groups 10 through 14 years, 15
through 19 years, and 20 through 24 years were combined for each year. Although
this aggregation loses the age specificity, it allows a 9-year window to observe
trends during that period.
RESULTS
The pattern of Latino male mortality is seen in Figure 1. Before the age of 15 years, the number of deaths among
Latino boys is slightly lower than among non-Hispanic whites, but this finding
was not statistically significant. In the 15- to 19-year age group, however,
the RR for Latinos is nearly twice as high as that for non-Hispanic whites
(RR, 1.77; 95% CI, 1.55-2.02). This is the front side of the Latino adolescent
male mortality peak (LAMMP). The mortality peak continues into the next age
group (20-24 years) in which Latino RR remains nearly twice as high (RR, 1.79;
95% CI, 1.58-2.02). At ages 25 to 29 years, the RR plunges, so that Latino
mortality rates are virtually identical to non-Hispanic white rates (RR, 1.12;
95% CI, 1.00-1.26). By this age, the LAMMP has passed. In the age groups 30
to 34 years and 35 to 39 years, the RR for Latino men is slightly lower than
for non-Hispanic white men, but this finding is not statistically significant.
From the age of 40 years to 90 years or older, the RR for Latino men is significantly
lower than for non-Hispanic white men. In contrast, in all age groups until
90 years or older, the RR for African Americans is significantly higher than
for non-Hispanic whites.
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Figure 1. Relative risk of Latino and African
American mortality to white mortality by age group, 1997. Bars indicate 95%
confidence intervals.
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African American male mortality seems to follow the Race and Ethnic
Health Disparities model. Latino male mortality generally follows a different
model, the LEP pattern, but with an important anomaly within the paradox:
the LAMMP. Further analysis of the LAMMP for the years 1989 through 1997 revealed
that the major causes of deaths were homicides and motor vehicle crashes (MVCs),
as given in Table 1. The LAMMP
was not observed in suicide rates.
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Comparison of Annualized Mortality Rates for Male Latinos and Whites
in California, 1989-1997 (per 100 000) Population*
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Latinos consistently had higher rates for homicide than non-Hispanic
whites (in ages 10-14 years, RR, 3.95; 95% CI, 3.04-5.13; in ages 15-19 years,
RR, 7.71; 95% CI, 6.96-8.54; in ages 20-24 years, RR, 5.34; 95% CI, 4.90-5.82;
and in ages 25-29 years, RR, 3.58; 95% CI, 3.28-3.89). The rates for deaths
due to MVCs were closer to non-Hispanic white rates, with the Latino rate
actually slightly lower in the 10- to 14-year age group (RR, 0.80; 95% CI,
0.66-0.96) and slightly higher in the rest (in ages 15-19 years, RR, 1.06;
95% CI, 0.98-1.15; in ages 20-24 years, RR, 1.20; 95% CI, 1.13-1.28; and in
ages 25-29 years, RR, 1.20; 95% CI, 1.11-1.29). Latinos had significantly
lower suicide rates than non-Hispanic whites for all age groups.
There have been secular trends in mortality for homicide and MVCs that
need to be used as context for the 1997 figures. The rate of male homicides
seems to have peaked in the mid-1990s, with a gradual decrease since then
(Figure 2). This was most noted
in African American males, with a rise from 1989 to 1993, then a marked decrease,
so that in 1997 African American male rates were much lower than at the beginning
of the decade. Latino rates rose slowly from 1989 to 1992, reached a plateau
until 1995, then decreased, approaching the 1989 level. Rates for both African
American and Latino adolescents are far greater than those for non-Hispanic
whites; at one point (1995), Latinos were more than 9 times as likely to die
from homicide, and at another (1993), African Americans were 18 times as likely
to die as non-Hispanic whites.
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Figure 2. Male adolescent (age 15-24 years)
mortality rates for homicide by ethnicity and year.
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For MVCs, there has been a general decline over time for all races/ethnicities
(Figure 3). The sharpest decrease
occurred before 1992, with some leveling off and then a less striking decline
afterward. Latino rates were the highest overall, about 30% higher than white
rates in some years. More recently, African American deaths due to MVCs have
dipped below those of whites.
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Figure 3. Male adolescent (age 15-24 years)
mortality rates for motor vehicle crashes by ethnicity and year.
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For suicides, the general pattern over time is less clear (Figure 4). Although there has been a slight
decline in suicides over the years for non-Hispanic white adolescents, these
adolescents are consistently at highest risk overall. Latino suicides seem
to be increasing somewhat. African American rates have fluctuated from rising
above the white rate to decreasing below the Latino rate, with such variation
possibly a result of extremely small numbers of cases (eg, 32 in 1996).
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Figure 4. Male adolescent (age 15-24 years)
mortality rates for suicide by ethnicity and year.
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The limitations of the data are those inherent in using any large, public
administrative data set. A recent National Center for Health Statistics report,21 providing a summary of current knowledge on the quality
and reliability of death rates by race and Latino origin in the official mortality
statistics of the United States, concluded that for the non-Hispanic white
and African American populations, published death rates were overstated in
official publications by an estimated 1.0% and 5.0%, respectively, principally
because of undercounts of these population groups in the census. Death rates
for Latinos were underestimated by approximately 2.0%. In addition, although
there has been nearly 20 years' experience with Latino ethnic coding, there
still is the possibility of miscoding. The population estimates also are subject
to error, although by using official State of California Department of Finance
estimates, this analysis will share the same error as any other analysis using
these population estimates. The strength of using these data is that they
are comprehensive, covering the entire universe, and hence not subject to
the selection bias inherent in small area studies.
COMMENT
Clearly, further study of the LAMMP phenomenon is needed to understand
the causes of this striking anomaly in the LEP. Certain risk factors for adolescent
mortality already have been identified for the general population, including
structural components such as ease of access to firearms, alcohol use, and
education levels of both adolescents and their parents, and psychosocial ones
such as exposure to violence or substance abuse.22-30
Counterbalancing these are certain general protective factors, such as parental
presence, positive role models, and involvement in prosocial activities.30-32 The role of both
sets of factors, risk and protective, in specifically adolescent male Latino
culture requires study and analysis. Furthermore, the LEP in general has been
attributed to "cultural protective factors,"33-35
but these have yet to be defined. Research aimed at identifying and analyzing
these factors not only would add to the further understanding of this Latino
norm, but also might provide a basis of comparison for identifying how and
why adolescent Latino males in California depart from it, only to return to
the norm in early adulthood. The patterns of other Latino adolescent populations
(eg, Puerto Rican, Cuban) in other states (eg, New York, Texas, Florida) need
to be calculated and compared for similarities and differences.
| What This Study Adds
Even though Latino populations often exhibit high-risk factors for mortality
(eg, low income, low education, low access to care), they also usually exhibit
the LEP (eg, lower age-adjusted mortality). In the general US population,
adolescence is seen as a period of increased mortality. This study analyzes,
for the first time to our knowledge, the phenomenon of Latino adolescent mortality
within the context of the overall LEP. By analyzing the sexes separately,
it is seen that the LEP holds for Latina (female) adolescents. In contrast,
Latino male adolescents show anomalously higher mortality among the age groups
of 15 to 19 years and 20 to 24 years, returning to the LEP pattern after age
25 years. Specific suggestions for further research are provided.
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AUTHOR INFORMATION
Accepted for publication January 17, 2002.
Corresponding author and reprints: David E. Hayes-Bautista, PhD,
Center for the Study of Latino Health and Culture, 924 Westwood Blvd, Suite
730, Los Angeles, CA 90024 (e-mail: dhayesb{at}ucla.edu).
From the Center for the Study of Latino Health and Culture, Division
of General Internal Medicine and Health Services Research, Departments of
Medicine (Dr Hayes-Bautista, Messrs Hsu and Iñiguez, and Mss Hayes-Bautista
and Chamberlin), and Family Medicine (Dr Solorio), UCLA School of Medicine
(Dr Rico), University of California, Los Angeles.
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