Targeting Hispanic populations: future research and prevention strategies.

Minority populations face a wide variety of economic, institutional, and cultural barriers to health care. These barriers and low levels of education and income pose significant challenges for health professionals in developing cancer research and prevention-control strategies. It is suggested that specific segments of Hispanic populations fit the model of an underdeveloped country in the intermediate stage of epidemiological transition. Since noncommunicable diseases have not yet fully emerged in some of these Hispanic population segments, the opportunity exists to apply primordial prevention strategies. Such campaigns would focus on dissuading members of these populations from adopting negative health behaviors while promoting positive lifestyle choices. Optimal programs would increase cancer screening participation and discourage risk behaviors through community-oriented, population-based interventions. Future directions in prevention and control efforts for minority populations should include expanded health insurance coverage, improved access to health care, greater emphasis on minority recruitment in health care fields, focused epidemiologic and clinical research, and identification and replication of effective components within existing prevention-control programs.


Introduction
Contrary to popular belief, the notion of a great American melting pot is fallacious. Underserved populations present diverse experiences, backgrounds, cultures, values, perspectives, and problems. Within populations lie broad variations in education, socioeconomic, and acculturation levels. The implicit individuality of underserved groups extends to health status and promotion, including cancer issues. Evidence for this assertion appears, among other places, in cancer incidence and mortality statistics: African-American men experience a 25% higher risk of all cancers than nonblack men; Hispanics have overall lower death rates from cancer than non-Hispanic whites but higher mortality rates in certain forms of the disease; and among southeast Asian American men, the lung cancer rate is 18% higher than that of the white population, while the liver cancer rate is 12 times higher [SM Schwartz and DB Thomas, unpublished data; (1)].
Examination of cancer research and prevention-control strategies requires that we bear in mind the diverse nature of racial and ethnic populations. Certainly, the need exists to explore factors unique to each underserved group. However, to provide greater focus in this report, we will offer examples that pertain to the growing population of Hispanic Americans.

Barriers to Health Care
Hispanics face significant barriers to seeking and attaining health care, and these barriers often render experiences within the health care system deficient. While particular deficiencies are rooted in an overall lack of cultural awareness throughout the medical community, the larger issue is the socioeconomic disparity that impedes access to health care services for a large segment of the general population.
Hispanics experience a lower rate of health insurance coverage compared to the rest of the country. One-third of the Hispanic population is uninsured, while only 13% of non-Hispanic whites fall into that category. The uninsured numbers are even greater for individual ethnic groups such as Central and South Americans (40% uninsured) and Mexican Americans (36%) (2). Studies show that compared with privately insured Hispanics, uninsured Hispanics are less likely to: a) have a regular source of health care, b) have visited a physician in the past year, c) have received a routine physical examination, and d) rate their health status as excellent or very good (3).
Lack of insurance is a critical factor in Hispanic underuse of health care services but certainly not the only one. Another is the lack of perceived risk of disease. Although this is a tendency within all segments of society, it is more acute in some populations. Hispanics often use emergency rooms for immediate health care needs, primarily because of a tendency to wait until health problems reach a critical stage. This may be the result of ignoring warning signs or not having sufficient knowledge to recognize these signs. Small health problems become large and costly health problems, and one consequence of this is the overloading of public health facilities in urban areas where minority populations are concentrated (4). This overloading results in long lines for patients and extended waiting periods. Compounding the situation, these same emergency rooms often are the sites of routine primary treatment for the economically depressed, many of whom are Hispanic.
Environmental Health Perspectives 287 Additional institutional and cultural barriers impede the path to health care, and even when minority populations do access medical services, it often is accomplished with much sacrifice. The working poor typically lack flexible hours, adequate transportation, and child care. They encounter long, difficult-to-understand enrollment forms and personnel whose attitudes toward minority patients may be negative. They find staff members and health professionals who typically are neither bilingual nor culturally sensitive, and often the minority representation within the health care provider fields is low (5).
The list of barriers continues. Given the demographic profile of underserved populations with high proportions of members who have not completed high school (6), live below the poverty level (6), and lack health insurance (2,3), combined with the host of existing institutional and cultural barriers, a very negative picture emerges regarding the challenges health care professionals face in developing health promotion and disease prevention programs targeting Hispanics.
These barriers to adequate health care are even more pronounced among those segments of the Hispanic population that fall in the migrant worker and undocumented immigrant categories. Many of these Hispanics are relatively recent immigrants who have been forced to leave their homelands by economic, political, and other circumstances. It is believed that such migration and the subsequent culture shock are stressful experiences that can lead to healththreatening conditions such as anxiety and depression as well as accompanying feelings of irritability, helplessness, and despair (7).
Such health stresses may increase the risk for organic disease and somatic and functional illness (8). These problems have traditionally been ignored, but clearly they must be recognized and addressed.
Though this picture may appear bleak, there are bright spots, or positive signs, as well. For example, Hispanics exhibit certain behavioral tendencies that support a health promotion model. Studies show that Hispanics have a lower smoking rate than other segments of the general population, which is primarily a result of lower, although increasing, tobacco consumption among Hispanic women (9)(10)(11). Research among Mexican-American women also reported lower rates of alcoholism than among non-Hispanic whites (12). In addition, positive health patterns were found in the typical  (17). rtillas and rice. These positive In the South Texas study, Mexican--haviors should be researched more American females appeared to increasingly ily and reinforced.
adopt negative health behaviors such as outh Texas study found that in smoking. An increase in economic and ation with economic and educa-educational opportunities for this popula-Ivances and acculturation, Mexi-tion may also serve to increase these negative erican women also tended to adopt behaviors. Since limiting personal improvehealth practices (13). For example, ment opportunities is not an option, the and drinking rates were evidence questions arise: How can this underserved s that more closely approached the population reach the advanced stages of epiates among non-Hispanic white demiological transition without experiencing (13). Adoption of mainstream the higher levels of noncommunicable diss appears to increase risks for cancer ease associated with the intermediate stage? er diseases common to the larger Is it possible to adopt the positive health (14). Examination of the South practices that accompany increased affluence Lta by age, education, and language while rejecting the negative behaviors? ved that the behaviors associated The answers lie in an approach called e and cost, such as participation in primordial prevention, an effort to prevent re screening services, did not change populations from adopting lifestyles that Llturation (15). generate future increases in noncommunimiolgica Tran n cable disease incidence (16,17). Since nonrniorogical Traenstion communicable diseases have not yet fully ilmordial Prevenltion emerged among the Mexican-American ngly, the South Texas study partic-population, the opportunity exists to accelossess characteristics that may fit erate movement through the intermediate lel of underdeveloped countries stage of epidemiological transition to a the middle stage of epidemiological point at which higher socioeconomic status tn ( Figure 1) (13,15). The model begins to correlate with decreased levels of o account various stages that coun-obesity, smoking, and alcohol abuse through as economic development (13,17,18). Prevention strategies should be .nd new patterns of mortality are actively applied that would combine edu-1 (16). At the earliest point, prication and health promotion campaigns to alth problems include infectious discourage young women from risk behavand infant mortality. After this, iors while encouraging proper nutrition, s and injuries become major con-exercise, and preventive care. Ideal primorto mortality. In the intermediate dial prevention programs would be offered onomic progress typically results in in a culturally appropriate context, with ase in deaths associated with non-the integrated participation of individuals, licable diseases such as those related institutions, and community organizations cco, alcohol, and obesity. In its (13,18). Since it is more difficult to change d stage, epidemiological transition addictive behaviors than to prevent them, decrease in the incidence of these we should identify those segments of as the more affluent society adopts the Hispanic population in which the r lifestyles. Although the United primordial prevention opportunity can be 5S reached this later stage, sectors of optimally applied (13 The mission of the NHLIC: En Accion is to bring together national and regional experts in medicine and public health with local and grassroots community leaders to engage Hispanic populations in a comprehensive cancer prevention and control effort. It is believed that an increase in cancer screening services and a reduction in cancer risk factors can be achieved among these Hispanic populations through the multicomponent, population-based intervention that this program employs. Currently there is a lack of timely cancer data on all Hispanic groups. It has been more than a decade since the Hispanic Health and Nutrition Examination Survey (HHANES) was conducted, and that project represented a limited spectrum of Hispanic populations. The NHLIC: En Accion represents one of the first efforts to develop a comprehensive assessment of all cancer risk factors among men and women from the various Hispanic populations. One of the program's initial endeavors has been a baseline telephone survey of more than 9000 Hispanics, which, in combination with data collected from other sources through archival methods, will contribute valuable information to future program planning, policy, and advocacy efforts.
It is hoped that the NHLIC: En Accion not only will have an impact on the lives of many Hispanics, but also will examine the nature of community-based disease prevention and control research and identify ways that health promotion messages should be delivered to culturally diverse communities. This project may stand as a model for future programs, as it has embraced elements that investigators historically have determined to be effective approaches to target research and technology transfer to underserved populations.

Future Directions
What are some other future directions for cancer prevention and control among minority populations? It is of utmost importance that all Americans have adequate access to health care. It is a national tragedy that more than 37 million citizens, many of whom are among our minority populations, are listed among the medically indigent. We need to extend health insurance to the working poor and others who cannot afford or do not qualify for subsidized coverage.
As our underserved populations continue to grow, industries are increasingly directing marketing efforts toward this segment of consumer America. One negative consequence of these efforts is that sales and consumption of unhealthy products such as tobacco and alcohol will almost assuredly increase among these populations. Effective programs are needed to counter these marketing campaigns and to provide underserved consumers with the information and skills to protect themselves. Greater emphasis should be placed on recruiting and training health care providers from various racial and ethnic populations and increasing cultural sensitivity among the current professionals in all health fields. The responsibilities for overcoming pervasive and long-standing barriers to health care must be shared by the medical and research communities as well as by educators and members of the lay community. Only when the educational efforts of health care providers are accomplished can real progress in breaking down these barriers be realized. An example of the present minority underrepresentation in health fields is that although Hispanics comprise more than 9% of the U.S. population, less than 5% of physicians in this country are Hispanic. The proportion of Hispanics in dentistry and nursing is even lowerbetween 2.5 and 3.5% (19). There is a strong need to provide a more equitable distribution of health professionals in areas that are traditionally underserved such as inner-city and rural sites.
Research priorities that focus attention on health problems and health promotion specific to underserved populations are of paramount importance. As with health care providers, we need to involve more minority researchers and to improve cross-cultural competence of nonminority scientists in research. Efforts should be made to fill major gaps that exist in the collection, analysis, and dissemination of data related to the health of Hispanics and other ethnic and racial groups. Epidemiologic research can contribute to our knowledge about prevalent cancer problems among these populations and enable us to better understand why incidence rates for other types of cancer are low. More clinical studies will help physicians assess treatment effectiveness and improve quality of care. Also, we need to gain greater insight into the influence of cultural considerations as they pertain to underserved populations participation in cancer control efforts, and the problem of underrepresentation of racial and ethnic populations in clinical trials should be addressed.
Much has been learned about environmental influences in cancer incidence and mortality. We must intensify efforts to bridge the gap between science and the public, to increase awareness and invalidate misconceptions, and to disseminate information about risk factors and the importance of personal behavior in cancer prevention. Efforts should focus on finding optimal approaches in educating the underserved public about positive and negative health behaviors. Greater precision is needed to identify particular segments of underserved populations that are at highest risk for developing cancer and to enable individuals to make informed lifestyle choices.
In developing and executing new cancer prevention and control strategies, we would be wise to learn from past experience. The few underserved population intervention programs offered to date support the need for more community models, and typically involve media and community outreach in reaching target populations. Future endeavors should evaluate the strengths and weaknesses of existing programs, identify those elements that achieve desired results, and replicate strategies proven to be effective and successful.