Nelda Mier, Ph.D.
Assistant Professor
School of Rural Public Health
Social and Behavioral Health Department
South Texas Center
The U.S. Census Bureau uses 5 race categories:

American Indian and Alaska Native

Asian

Black or African American

White

Native Hawaiian and Other Pacific
Islander


Race and Hispanic origin are separate and
distinct concepts.
Hispanic" or "Latino" are those who classify
themselves as:




Mexican
Puerto Rican
Cuban
“Other Spanish, Hispanic, or Latino."
U.S. Bureau Census:
 Origin can be considered as the heritage,
nationality group, lineage, or country of
birth of the person or the person’s parents
or ancestors before their arrival in the
United States.
 People who identify their origin as
"Spanish," "Hispanic," or "Latino" may be of
any race.
In 2000, the total population: 281,421,906.
98% of the population reported only one
race, with a majority reporting to be White.
BY 2050….
White
69%
50%
81%
72%
Black
Asian
24%
3%
15%
13% 4%
13%
8% 5%
U.S. Bureau Census
Hispanic or Latino
All other races
White alone, not
Hispanic



More than 1 in 8 people are Hispanic
2 in 5 Hispanics are foreign born
The Hispanic population became the largest
minority group by increasing 67% --22.4
million in 1990 to 37.4 million in 2002,
excluding Puerto Rico and other islands
U.S. Bureau Census 2000
U.S. Bureau Census 2000; Total population: 11 million
% of the Population
that are White alone
(2006)
% of the Population
that are Black alone
(2006)
% of the Population
that are Asian alone
(2006)
% of the Population that
are American Indian and
Alaska Native alone
(2006)
% of the Population that
are Native Hawaiian and
other Pacific Islander
alone (2006)
HOW MUCH DIVERSITY TO YOU SEE
AROUND?

Minorities experience a disproportionate
burden of preventable disease, death, and
disability compared with non-Hispanic
Whites
Williams DR, Collins C. U.S. socioeconomic and racial differences in health. In: LaVeist TA, editor. A
public health reader. Race, ethnicity, and health. San Francisco, CA: Jossey-Bass; 2002. p. 391-431.
Asthma mortality
Rate
(per million; northeast U.S. 1993-1995)
Hispanics/Latinos
whites
34
15.1
HIV/AIDS mortality rate per 100,000 (1999)
Puerto Ricans living on the U.S. mainland
32.7
non-Hispanic whites
2.4
national average
5.4
Adult immunization, 65+ years (2002)
Influenza vaccination
Hispanics/Latinos
46.7%
whites
70.2%
Millard AV, Graham MA, Mier N, Flores I, Carrillo-Zuniga G, & Sánchez ER. Addressing Health Disparities: The Hispanic Perspective. In S. Kosoko-Lasaki, R.L. O'Brien & C.T. Cook
[Eds.]. Promoting Cultural Proficiency in Eliminating Health Disparities. Boston: Jones & Bartlett Publishers. (In Press.)
Cancer of the cervix (2000)
Hispanic incidence higher than that of nonHispanic whites by:
Cancer of the stomach (2000)
Males: Hispanic incidence higher by:
Females: Hispanic incidence higher by:
152%
63%
150%
Overweight among Hispanics 20 to 74 years of age
Males: Hispanic incidence higher than in nonHispanic whites by:
Females: Hispanic incidence higher by:
Obesity, 20 to 74 years of age
Males: Hispanic incidence higher by:
Females: Hispanic incidence higher by:
11%
26%
7%
32%
Millard AV, Graham MA, Mier N, Flores I, Carrillo-Zuniga G, & Sánchez ER. Addressing Health Disparities: The Hispanic Perspective. In S. Kosoko-Lasaki, R.L. O'Brien & C.T. Cook
[Eds.]. Promoting Cultural Proficiency in Eliminating Health Disparities. Boston: Jones & Bartlett Publishers. (In Press.)
CDC, 2005
168%
128%
41%
Diabetes
62%
28%
Stroke
Chronic
liver
disease
HIV
Homicide
Millard AV, Graham MA, Mier N, Flores I, Carrillo-Zuniga G, & Sánchez ER. Addressing Health Disparities: The Hispanic Perspective. In S. Kosoko-Lasaki, R.L. O'Brien & C.T. Cook
[Eds.]. Promoting Cultural Proficiency in Eliminating Health Disparities. Boston: Jones & Bartlett Publishers. (In Press.)
Hispanics
whites
Those under the age of 65 years with
health insurance
66%
87%
Those with a regular source of
ongoing health care
77%
90%
73%
78%
Vaccinations
Children aged 19-35 months who
are fully vaccinated (2002)
Millard AV, Graham MA, Mier N, Flores I, Carrillo-Zuniga G, & Sánchez ER. Addressing Health Disparities: The Hispanic Perspective. In S. Kosoko-Lasaki, R.L. O'Brien & C.T. Cook
[Eds.]. Promoting Cultural Proficiency in Eliminating Health Disparities. Boston: Jones & Bartlett Publishers. (In Press.)
Why is important to
understand cultural diversity
and eliminate health
disparities?


For health professionals, there is an ethical
and moral dilemma that must be addressed.
Their ethical standards demand fairness
and compassion.
Healthcare is a resource that is associated to
social justice, opportunity, and quality of
life. Health status is linked to productivity.
Institute of Medicine, 2002


From the perspective of public health,
racial and ethnic disparities threaten
efforts to improve the nation’s health.
Racial and ethnic disparities in healthcare
pose a significant dilemma to a society
that is still dealing with a legacy of racial
discrimination.
Institute of Medicine, 2002
Studies examining disparities
 Studies implementing culturally
sensitive interventions


Race, ethnicity, and cultural are consistently
used interchangeably in health promotion
research, even though they are not
synonymous terms.


Integrated patterns of human behavior that
include: language, thoughts, communications,
actions, customs, beliefs, values and institutions of
racial, ethnic, religious or social groups” (16)
Unique shared values, beliefs, and practices that
are:
- Directly associated with a health-related
behavior
- Indirectly associated with that behavior
- Influencing acceptance and adoption of the
health education message or activity.
(15)
15.Pasick RJ DOC, Otero-Sabogal, R. Similarities and differences Across Cultures: Questions to Inform a Third Generation for Health Promotion Research. Health Education
Quarterly 1996;23(Suppl):S142-S161.
16.Assuring cultural competence in health care: Recommendations for national standards and outcomes-focused research agenda. In: Health USDoHaHSOoM, editor.:
Washington, DC: U.S. Government Printing Office; 2000.

Race, ethnicity, language, nationality, and
even geographic location are most
commonly used as proxies for culture.

African Americans have a perception that
“eating healthy” means giving up part of
their cultural heritage and trying to conform
to the dominant culture
Compared with White women, African
American women are more satisfied with
their weight and, if overweight, are more
likely to feel attractive
.(18)

.(19)
18. James DC. Factors influencing food choices, dietary intake, and nutrition-related attitudes among African
Americans: application of a culturally sensitive model. Ethnicity & health 2004;9(4):349-67.
19. Eyler AA, Matson-Koffman D, Vest JR, Evenson KR, Sanderson B, Thompson JL, et al. Environmental, policy,
and cultural factors related to physical activity in a diverse sample of women: The Women's Cardiovascular
Health Network Project--summary and discussion. Women & health 2002;36(2):123-34.

Another study found that Latina women
believe that sports are for men and that
family and children come before personal
needs (such as being physically active).
Other studies found that Hispanics believe
that diabetes is caused by emotional
trauma
(20)

.(21)
20. Evenson KR, Sarmiento OL, Macon ML, Tawney KW, Ammerman AS. Environmental, policy, and
cultural factors related to physical activity among Latina immigrants. Women & health 2002;36(2):43-57.
21. Arcury TA, Skelly AH, Gesler WM, Dougherty MC. Diabetes meanings among those without diabetes:
explanatory models of immigrant Latinos in rural North Carolina. Soc Sci Med 2004;59(11):2183-93.
Studies examining disparities
 Studies implementing culturally
sensitive interventions

The extent to which ethnic or cultural
characteristics, experiences, norms, values,
behavior patterns, and beliefs of a target
population, and relevant historical,
environmental, and social forces are
incorporated in the design, delivery, and
evaluation of targeted health interventions.
Resnicow K, Braithwaite RL, Dilorio C, Glanz K. Applying theory to culturally diverse and unique
populations. In: Glanz K, Rimer BK, Lewis FM, editors. Health behavior and health education: theory,
research, and practice. 3rd ed. San Francisco, CA: Joseey-Bass; 2002. p. 485-509.



Cultural Competence
Multicultural
Culturally appropriate, relevant, congruent,
specific.
Targeting denotes a process of identifying a
population subgroup for the purpose of
insuring exposure to the intervention by
that group. E.g. targeting an ethnic group.

Tailoring implies adapting the intervention
to best fit the needs and characteristics of a
target population.
Cultural tailoring is the development of
interventions, strategies, messages, and
materials to conform with specific cultural
characteristics
(15)

.(15)
Innovate?
Adopt an evidencebased program?


Literature review of
RCTs testing nutrition
and exercise
interventions tailored
for Hispanics
Principles and
components of these
interventions.
Mier N, Ory MG, Medina AA. Anatomy of Culturally Sensitive Interventions Promoting Nutrition and Exercise in Hispanics: A
Critical Examination of Existing Literature Submitted to Health Promotion Practice. In review.

(1) described an intervention that was tailored for
Hispanics; (2) the intervention aimed at
modifying knowledge, beliefs, or behavior related
to nutrition or exercise; (3) the intervention was
tailored for Hispanics of any age group; (4) the
study was based on the randomized controlled
trial research design; (5) the study was published
in a peer review journal, (6) the study was
conducted in the United States; and (7) the study
was published between 1990 and 2006.
71%
29%
Yes
No
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
25%
20%
15%
10%
5%
0%
59%
41%
6%
Yes
No
Measured
effects
53%
47%
Yes
No
Other, 7%
Mexican
American,
29%
Latino,
35%
Hispanic,
29%
Group-settings
24%
Community health workers
24%
Ethnic foods
29%
Back-translation technique
31%
Bilingual materials and delivery
agents
77%
Family-based
29%
47%
29%
35%
Literacy
Social support
Hispanic
values


Not much detail
Settings:




Community agencies
Churches
Schools
Media
Theory-driven, yes. But…
1st Determine a specific health issue for which an
intervention is needed
2nd Identify the theories from a socioecological
perspective and select the most appropriate one for
understanding causal factors and processes of
specific health-behaviors
3rd Determine potential points of interventions
suggested by the selected theory or framework
4th Consider the collective wisdom on what
interventions work with what populations under
what conditions

PRECEED-PROCEED model
http://www.lgreen.net/precede.htm



Influenced by the health belief model,
theory of reasoned action, and PRECEEDPROCEED model
Culture is the core of health promotion and
disease prevention programs
Used to assess cultural eating patterns and
to develop AIDS prevention programs
.(18)
(Airhihenbuwa 1995); 18. James DC. Factors influencing food choices, dietary intake, and nutrition-related
attitudes among African Americans: application of a culturally sensitive model. Ethnicity & health
2004;9(4):349-67.
PEN-3 MODEL
RELATIONSHIPS &
EXPECTATIONS
CULTURAL EMPOWERMENT
Positive
Existential
Negative
Perceptions
Enablers
Nurturers
Person
Extended Family
Neighborhood
CULTURAL
IDENTITY


Acknowledges the role of social and cultural
influences in health behavior
Emphasizes the transactions between
individual and the environment at different
levels: individual, family, community,
environment.
It uses a consumer orientation, audience
analysis and segmentation, and aspects of
exchange theory.
Reaim.org
It emphasizes the idea that communities
themselves can achieve social and
behavioral outcomes and that social forces
influence behaviors.


Formative research plays an important role in
the design and implementation of an
intervention for Hispanics.
Health assessments, focus group discussions,
literature searches, and interviews are tools for
tailoring an intervention by identifying
attitudes, beliefs, language use, and other
opinions of the priority population in relation
to specific health issues or behaviors



The diversity of the Hispanic population
must be acknowledged in intervention
design
Consider immigration and contextual
factors in intervention design
Consider acculturation, but also understand
that it is a complex phenomenon and more
research is needed to better assess its
impact on health outcomes.


Level of immersion in the new culture or how
far people have deviated from their cultural
origins in adopting features of the new or
dominant culture
Conflicting evidence about the influence of
acculturation on health behaviors (see table).
Lara M, Gamoa C, Kahramanian MI, Morales LS, Hayes Bautista DE. (2005). Annu Rev Public Health, 26, 367-97.
Millard AV, Graham MA, Mier N, Flores I, Carrillo-Zuniga G, & Sánchez ER. Addressing Health Disparities: The Hispanic Perspective. In S. Kosoko-Lasaki, R.L. O'Brien & C.T. Cook
[Eds.]. Promoting Cultural Proficiency in Eliminating Health Disparities. Boston: Jones & Bartlett Publishers. (In Press.)

Salient culturally sensitive intervention
components are





Bilingual and bicultural facilitators and
materials
Family-based activities
Literacy-appropriate materials
Social support.
Having a clear understanding of Hispanic
cultural values is also required.


Evidence-based programs must use a
program structure and curriculum that have
been proven through prior research to be
beneficial for participants.
Incorporate measurable goals so that
program managers can further evaluate and
document their benefits in different settings
and populations.
Mary Altpeter, Ph.D., “Healthy Aging Briefing Series: The Basics of Evidence-Based Health Promotion
Programming,” July 20, 2006.




Pilot study
A walking program for low-income women
of Mexican origin living in areas known as
“colonias” in the Texas-Mexico border
region.
Stages of Change Model
Community-based Participatory Research
1.2 million
people (U.S. Census 2006)
Hidalgo and
Cameron: 2 of
the 10 poorest
counties in the
US
89.5% of the
population:
Hispanic
(US Census Bureau,
2006)
(Fronczek 2005)
SOURCE: The Rio Grande Valley Partnership/Chamber of
22%
2001- 2006
8%
13%
Valley El Paso Texas
6%
2006
US
(US Census Bureau,
2006)
EDUCATION LEVEL (< HS)
% people 25 years and over
39%
21%
Valley
Texas
16%
US
(US Census Bureau,
2006)
Speak a language other than English
at home
(% population > 5 yrs)
79%
34%
20%
Valley
Texas
US
(US Census Bureau,
2006)


Unincorporated, impoverished
settlements located along the U.S.-Mexico
international boundary (Ward, 1999)
Texas: 1,524 colonias (N=400,000) (Ward, 1999);
60% of these colonias are located in
Hidalgo County
.
(Federal Reserve Bank of Dallas (FRBD), 1995; Housing Assistant
Council, 2000; Ward, 1999)



Average household income > $834 month
70% of residents have less than high
school education
High unemployment rates (20% - 60%,
compared to 7% at the state level) and a
lack of medical services .
50% of colonia residents are immigrants,
mostly from Mexico
(FRBD)

(Dutton, Weldon, Shannon, Bowcock, Tackett-Gibson,
Blakely et al., 2000).
IDENTIFIED
PHYSICAL
ACTIVITY
NEEDS
ADMINISTERED
A SURVEY
COLONIA
RESIDENTS
ASKED FOR A
PROGRAM
Location
Dates
Residents
and
promotoras
Recruitment
Times
Developed
the Vamos a
Caminar
handbook
-Included topics of
diabetes and
exercise
- Addressed dogs
problem
- Social activities
- Certificate
- Children’s issue
Be Active for
Life
Handbook
Researchers
and
promotoras
revised
contents
WALKING PROGRAM
-Nonexpensive
- Feasible
activities





The duration of the program was 12 weeks
Program based on PA recommendations and
encouraged participants to incorporate
walking activities into their lifestyle.
The groups met separately every week for 1hour
The promotoras worked with participants
using a problem-solving, self-management
approach to discuss physical activity behavior
change strategies.
Addressed challenges



Ninety-three percent of participants
attended 88% of the sessions
According to the program fidelity
assessment we conducted, the promotoras
delivered every lesson of the program as
planned
Acceptance of the program was assessed
through feedback sessions with
participants.




Theory driven and use of the communitybased participatory research
Feasibility issues: cost, setting, training,
language.
Acculturation?
Evaluation issues