Overall Health and Healthcare Utilization Among Latino American Women in the United States

JOURNAL OF WOMEN S HEALTH Volume 21, Number 8, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2011.3431 Overall Health and Healthcare Utilization Among Latino American Women in the United States Amy L. Ai, Ph.D., 1 Hoa B. Appel, Ph.D., M.P.H., 2 Bu Huang, Ph.D., 3 and Kathy Lee, M.D. 4 Abstract Purpose: The purpose of this study was to examine the chronic conditions, behavioral-mental health and service utilization of Latino American women in the first epidemiologic survey in the United States. Methods: Using a national sample (n = 1427) from the National Latino and Asian American Study, we assessed and compared the prevalence of overall health and service use in three major subgroups, Cuban, Mexican, and Puerto Rican, and in other Latino American women. Service use included general medical, mental health, and subspecialists. Results: In physical health, Puerto Rican American women reported the highest rate of asthma, whereas Mexican American women reported the highest rate of diabetes. Cuban American women reported the highest rate of hypertension and heart diseases. Body mass index (BMI) indicated that overweight (BMI 25 29.9 kg/m 2 ) and obesity (BMI 30 kg/m 2 ) were prevalent in all three subgroups: two thirds of Mexicans and Puerto Ricans, respectively, and > 50% of Cuban Americans. Of the sample, 11.6% rated their mental health status as fair or poor, and 10.8% reported at least one major depressive disorder (MDD) in the past 12 months. Puerto Rican American women had the highest rates on depression, substance abuse, and seeking mental health service, and Cuban American women saw specialists most frequently. Conclusions: Patterns of overall health issues varied among Latino American subgroup women, yet they have low rates of healthcare use. It is critical to further examine factors associated with the sex-specific health issues and with their health services underuse. Introduction Latinos are the largest ethnic minority population in the United States. It is estimated that by 2050, 24% of the U.S. population will be Latino. 1 Meanwhile, there has been increasing visibility of Latinas in the U.S. labor market, especially in such blue collar jobs as in-home services, hotel work, and farm labor, resulting from increased Latino American immigration over the past decades. 1 However, research on the overall health pattern and service use patterns of Latinos in the United States remains insufficient. Even less is known about these patterns among Latina subgroups nationwide, such as Cubans, Mexicans, and Puerto Rican Latina subgroups. There are considerable variations across these three major subgroups of Latino Americans in the National Latino and Asian American Study (NLAAS) database, the first national population-based study of Latinos living in the United States. 2 4 Such differences include, but are not limited to, their ancestral origins, race and ethnicity, socioeconomic status (SES), geographic locations, and cultural-political experiences in the United States. More sex-specific and ethnicspecific information on their service use, chronic conditions, and behavioral and mental health is needed to establish appropriate preventive care for these rapidly growing subgroups. Below we present known findings on the overall health and healthcare use of Latino Americans as a whole group, including limited data on Latinas, and then highlight the reason for a focus on Latina subgroup analyses. During the past decade, literature has begun to reveal the physical health of Latino Americans. Latinos tend to rate their health as fair or poor. 5 They are more likely than non-hispanic whites to have high blood pressure. 6 Diabetes, which usually co-occurs with obesity, is considered an epidemic among Latinos. 7,8 Research has reported evidence on the behavioralmental health and risks of the Hispanic population in the United States, which have been linked with cultural factors 1 College of Social Work and Department of Psychology, Florida State University, Tallahassee, Florida. 2 Research, Minority Achievers Program, Everett, Washington. 3 Research Institute, Bastyr University, Kenmore, Washington. 4 College of Medicine, Florida State University, Tallahassee, Florida. 878

OVERALL HEALTH IN LATINO AMERICAN WOMEN 879 and immigration status. Dual diagnosis of substance abuse and other mental health disorders occurs at an earlier age for U.S.-born Latinos compared with Latino immigrants. 9 Immigrant Latinos have lower rates of substance abuse and dependence compared to their U.S.-born counterparts. 10,11 Further, more recent Mexican and Cuban immigrants reported lower prevalence of depressive disorders compared to Mexican immigrants who arrived in the United States before age 6. 12 U.S.-born Latino Americans are more likely to meet criteria for major depression and most other psychiatric disorders compared to immigrant Latino Americans. 11,13,14 Also, one third of Latinos have been shown to discontinue taking antidepressants, and 18.9% did so without input from their physicians. 15 Evidence suggests that Latinos in the United States are more likely to delay needed care for chronic conditions than other ethnic groups 16,17 and are also more likely to rely on primary care providers and less likely to seek care from a mental health specialist compared to non-hispanic whites. 18 Lower mental health service use has been associated with higher levels of Latino ethnic identity and Spanish language. 11 Latinos were less likely than non-hispanic whites to have entered the healthcare system for any type of care and to have used preventive healthcare. 19 Indeed, there are many barriers to care seeking faced by ethnic minorities, including socioeconomic factors, access to healthcare, insurance, and English proficiency. 20,21 Some previous research on Latino Americans has also addressed Latina-specific information. Higher asthma prevalence was reported in certain Latino American women relative to non-latino women in other ethnic groups in the United States. 22 Latino Americans have disproportionately high rate of diabetes compared to non-hispanic whites and Asian Americans. 23 25 For Latinas aged 45 64, the rate of diabetes is 13.5% compared to 7.8% for non-hispanic white women. 24 Latinas have disproportionately high rates of obesity compared to non-hispanic white women. 7 In particular, American women have the second highest prevalence of obesity, second only to African American women. 26 Information on certain Latina conditions remains fragmented, however, as most studies have focused on comparisons between ethnic groups, with little attention to the subgroup comparisons within Latina Americans. Regarding behavioral health, Latinas appear to have the lowest smoking rate, second only to Asian American women, 27 and Puerto Rican American women have higher substance use than Cuban and Mexican American women. 28 The more sex-specific and ethnic-specific analysis of this topic area found that substance use in U.S.-born and immigrant women is greater for Latinas born in the United States. 29 Lifetime psychiatric disorder was more prevalent among Latino American women, 28 and women reported greater stress compared to men. 30 Female sex and high levels of family conflict were positively correlated with suicide attempts in Latino American women. 31 Latinas with good or excellent English language proficiency were at an increased risk of having experienced at least one psychiatric disorder in the past year. 28 Latina women were also less likely than non-latina women to have a regular source of healthcare. 32 Despite the available preliminary information, there is a dearth of comprehensive analysis about Latina Americans overall health and care-seeking patterns nationwide, even after the availability of the first representative sample from the NLAAS. 2 4 It is worth noting that gender-based cultural characteristics may play an important role in their distinct health patterns and service use. Because of Catholic cultural traditions, Latino culture expects Latinas to focus their attention on the needs of family members rather than on themselves. This other-oriented females family responsibility sometimes may be detrimental to their health. Additionally, most previous research on Latinos and Latinas in the health and medical literature has failed to differentiate results based on subgroup membership. This disparity has hindered the design for culturally appropriate health service to meet the needs of subgroups. Using this national database, results of the gender-specific and ethnic-specific analyses will provide a more comprehensive picture and may have the potential to inform the future infrastructure of and policymaking for healthcare services for Latino Americans. To bridge the gap, this study investigated the chronic conditions and behavioral-mental health-related issues facing Latinas in the United States. In addition, we examined 12-month use of mental health-related services and general healthcare-seeking patterns among Latina subgroups using a national database. Materials and Methods Data source and the sample The NLAAS collected data from May 2002 to December 2003. The NLAAS was designed in coordination with the Collaborative Psychiatric Epidemiology Studies (CPES), which includes NLAAS, the National Survey of American Life, and the National Comorbidity Survey Replication. The CPES compares the association of immigration factors with the use of mental health services across three major racial and ethnic categories (African Americans, Asian Americans, and Latino Americans). Using the interval estimates from other CPES studies, the NLAAS uses bayesian methods to produce weighted estimates. The NLAAS data included social demographics, mental health screening and diagnosis, and health service use and evaluations, among other data. These were all self-reported. The questionnaire was available in English, Spanish, and several Asian languages. In particular, the NLAAS identified the three major Latino ethnic groups (Cubans, Mexicans, and Puerto Ricans) and amalgamated other Latinos (e.g., Costa Ricans, Ecuadorans, Guatemalans, and Hondurans) into a single category labeled other. The sampling procedure for the NLAAS was documented previously, and weights were developed to correct for sampling bias for the total sample. 2,3 The three stages of sampling have been documented 2,3 and include three principal methods. The first was core sampling, in which primary sampling units (defined as metropolitan statistical areas or county units) and secondary sampling units (formed from contiguous groupings of Census blocks) were selected with probability proportionate to size. Housing units and household members were sampled from the primary and secondary units. The second method was high-density supplemental sampling to oversample Census block groups with > 5% density of target ancestry groups. The third method was second respondent sampling to recruit participants from households in which one eligible member had already been

880 AI ET AL. interviewed. Individuals of Latino ancestry who did not belong to the target groups under which these geographical areas were classified were still eligible to participate. All NLAAS participants were interviewed by trained bilingual interviewers. The total sample size of the NLAAS was 4649, including 2554 Latino Americans and 2095 Asian Americans. Our study sample comprised 1427 Latino American women aged 18 years residing in the United States, including 301 Cubans, 470 Mexicans, 282 Puerto Ricans, and 374 other Latinas. The 1127 Latino American men were excluded from this study. Measures and variables Chronic conditions. The participants were asked if they had had any health problems at any time in their lives. The list of problems included arthritis, back problems, frequent headaches, chronic pain, allergies, stroke, heart disease, high blood pressure, asthma, chronic lung disease, diabetes, ulcer, epilepsy, and cancer. Body mass index and drug and substance abuse. We calculated body mass index (BMI) to classify participants into a weight category consistent with World Health Organization (WHO) standards: underweight (BMI < 18.5), normal (18.5 24.9), overweight (25 29.9), obese (BMI 30). Height and weight were self-reported. Smoking and other drug abuse also were self-reported. The substance abuse items we examined were self-reported, and all involved recreational drugs (other drug use), such as marijuana and cocaine. Mental health issues. Detailed mental health measurements based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) 33 were included in the questionnaire, administered by the interviewer, and also self-rated. We examined the 12-month prevalence of depression and the selfrating among subgroup Latino American women in this analysis. The World Mental Health Survey Initiative version of the WMH-CIDI 34 was used to assess the 12-month prevalence of major depression using criteria from the DSM-IV. Self-rated mental health was measured with one question (How would you rate your overall mental health?) on a 5-point Likert scale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent.) Service-seeking frequency. The participants were asked about mental health service use and visits both to physicians and to mental health professionals. Statistical analysis Descriptive analyses were performed for all variables of interest. The actual number of cases was reported for the three ethnic subgroups, as well as for the whole group and other groups. Their representative percentage in the population was computed and reported using weights to correct potential sampling bias. Chi-square tests were used to compare differences in categorical variables among the selected Cubans, Mexicans, Puerto Ricans, and other Latino American women. The weights were created for the data presented in the results, based on demographic, social, and economic variables to correct for sampling bias, including an age variable. All analyses were performed using SPSS version 18 (IBM Corporation, Somers, NY). Statistical significance was determined at an alpha level of 0.05 for all tests. Results Demographics The age range for Latino Americans in NLAAS was from 18 to 97, with a median age of 38 and a mean age of 41. Education levels ranged from 4th grade to 17 years, with a median of 12 years. Income was measured using the 2001 Census household income/needs ratio. The average English proficiency (three items: read English, speak English, and write English) ranged from 1 to 4, (mean = 2.44), with 4 being the most proficient. In the whole sample, categories of years in the United States ranged from 1 to 5 (mean = 3.72), with 1 = U.S.-born, 2 = 0 5 years, 3 = 6 10 years, 4 = 11 20 years, and 5 21 years. The subgroup details are shown in Table 1. Physical health and chronic conditions Table 2 shows headaches, allergies, arthritis, neck and back pain, and high blood pressure were reported most frequently among all chronic conditions for all Latino Americans. Chronic lung disease, stroke, epilepsy, and heart disease were reported least frequently. There are differences and similarities among the major subgroups in both the number of itemized diseases and chronic conditions. Across the four subgroups, Puerto Rican American women reported highest rates of headaches (34.8%), allergies (32%), asthma (23.5%), other chronic pain (9.1%), heart attack (7.5%), cancer (3.1%), and stroke (2.0%). Mexican Americans had the highest rates of back and neck pain (22.3%) and diabetes (13.2%), whereas their rate of arthritis was nearly as high as that of Puerto Ricans. Cuban American women had the highest rate of hypertension (23.0%) and heart disease (2.2%), and their rate of heart attack was close to that of Puerto Ricans. Comparatively, at least 53% of all three subgroups reported having at least two chronic conditions, with headaches being the highest. Table 2 also indicates BMI as computed for the whole group of Latino Americans as follows: 1.6% underweight, 36.6% normal, 33.4% overweight, and 28.4% obese. The clear similarities among ethnic subgroups were as follows. For all three subgroups, at least 31% reported being overweight (BMI 25 29.9, using WHO standard); the Cuban American sample had the lowest rate of obesity (18.8%) compared with Puerto Rican and Mexican obesity (BMI 30). Mexican American women also had the highest BMIs for being overweight and obese (33.6% and 32.9%, respectively), closely followed by Puerto Ricans. Behavioral-mental health and substance abuse Table 3 shows substance abuse by ethnic subgroup: 13.1% were current smokers, 14.1% were former smokers, 20.9% had ever used marijuana, 8.4% had ever used cocaine, 7.0% abused prescription medication, and 3.1% used other drugs. Significant group differences were found only in two categories. Compared with much lower rates of Cuban and Mexican American women, Puerto Rican American women reported the highest rates of current smokers and ex-smokers and the use of marijuana (Table 3). The differences in rates of

OVERALL HEALTH IN LATINO AMERICAN WOMEN 881 Table 1. Demographic and Acculturation Information Reported by Latino American Women, by Ethnic Subgroup, National Latino and Asian American Study, 2002 2003 Total Cuban Mexican Puerto Rican Other Hispanic Characteristic n = 1427 % n = 301 % n = 470 % n = 282 % n = 374 % P Age (mean) 41.1 50.2 37.1 40.7 39.2 0.000 Years of education (mean) 11.3 12.0 10.3 11.6 11.7 0.000 Employment 0.003 No 48.1% 48.2% 47.2% 54.0% 41.2% Yes 51.9% 51.8% 52.8% 46.0% 58.8% Income level (mean) 3.1 3.7 2.5 3.4 3.3 0.000 Acculturation stress (mean) 0.18 0.22 0.19 0.09 0.21 0.000 Birthplace 0.000 United States 36.5% 12.3% 45.3% 58.2% 28.6% Other 63.5% 87.7% 54.7% 41.8% 71.4% English skills 2.4 2.1 2.4 2.9 2.4 0.000 Discrimination (mean) 1.67 1.38 1.73 1.90 1.66 0.000 Years in United States 0.000 < 5 10.4% 17.6% 10.4% 2.1% 11.0% 5 10 8.5% 9.3% 9.1% 2.5% 11.8% 11 20 16.3% 9.6% 17.9% 8.5% 25.7% 21 28.3% 51.1% 17.2% 28.7% 22.9% Born in United States 36.5% 12.3% 45.3% 58.2% 28.6% p values reported here are from chi-square crosstabs for % or analysis of variance (ANOVA) for means among different ethnic groups. Table 2. Number and Weighted Percentages of Chronic Conditions Reported by Latino American Women, by Ethnic Subgroup, National Latino and Asian American Study, 2002 2003 Latino American subgroups Total Cuban Mexican Puerto Rican Other a Condition n = 1427 % n = 301 % n = 470 % n = 282 % n = 374 % p b Allergies/hay fever 365 26.1 59 22.5 123 25.7 88 32.1 95 25.5 0.014 Arthritis 325 21.0 95 17.1 90 21.5 68 21.6 72 20.6 0.000 Asthma 186 10.9 44 19.5 34 7.3 62 23.5 46 12.4 0.000 Back/neck pain 309 21.3 79 20.3 99 22.3 66 21.7 65 19.7 0.038 Cancer 39 2.3 11 2.2 11 2.2 10 3.1 5 2.3 0.395 Chronic lung disease 11 0.4 5 1.5 1 0.2 4 1.4 1 0.2 0.050 Diabetes 139 11.0 27 4.6 48 13.2 40 12.8 24 7.1 0.009 Epilepsy 16 1.1 3 1.2 5 1.1 5 1.3 3 1.2 0.683 Headaches 436 29.1 96 31.4 122 27.1 100 34.8 118 30.6 0.037 Heart attack 85 4.5 32 7.1 12 3.3 22 7.5 19 5.3 0.000 Heart disease 24 1.5 10 2.2 2 0.6 5 1.5 7 3.0 0.024 High blood pressure 297 18.3 104 23.0 71 17.7 60 21.2 62 17.7 0.000 Other chronic pain 101 6.8 18 7.4 24 5.3 29 9.1 30 9.1 0.040 Stroke 18 0.9 2 0.6 2 0.5 7 2.0 7 1.5 0.046 Ulcer 86 6.3 14 2.3 33 3.9 18 5.3 21 6.0 0.578 BMI, WHO standard c 0.008 Underweight 19 1.6 4 2.3 5 1.2 4 2.5 6 1.8 Normal 519 36.6 115 45.9 147 32.3 97 35.8 160 43.3 Overweight 468 33.4 113 32.9 148 33.6 87 31.0 120 34.0 Obese 362 28.4 62 18.8 134 32.9 89 30.7 77 20.9 These are raw numbers. The percentages are the weighted %. The weights are created based on demographic, social and economic variables to correct for sampling bias. Weighting was previously reported by Alegría et al. 2 and Heeringa et al. 3 a Other = Costa Ricans, Ecuadorans, Guatemalans, and Hondurans. b p reported here are from chi-square crosstabs used to compare difference in percentages of self-reported chronic conditions between Latina subgroups. p < 0.05 is statistically significant and indicates that comparisons of the subgroup difference are significant at 0.05. c Body mass index (BMI), World health organization (WHO) standard: underweight (BMI < 18.5), normal (BMI 18.5 24.99), overweight (BMI 25 29.99), obese (BMI 30).

882 AI ET AL. Table 3. Substance Abuse in Latino American Women by Ethnic Subgroup, National Latino and Asian American Study, 2002 2003 Latino American subgroups Total Cuban Mexican Puerto Rican Other a Risk factor n = 1427 % n = 301 % n = 470 % n = 282 % n = 374 % p b Smoking 0.000 Current smoker 213 13.1 37 14.7 48 10.1 76 27.8 52 13.7 Ex-smoker 221 14.1 52 13.7 58 12.8 57 19.5 54 14.8 Never smoked 993 72.7 212 71.6 364 77.1 149 52.6 268 71.6 Abused marijuana 294 20.9 44 22.0 87 17.2 83 29.8 80 25.0 0.000 Abused cocaine 115 8.4 19 8.9 40 7.7 27 9.7 29 9.3 0.516 Abused prescription drugs 102 7.0 19 8.4 26 5.3 24 8.8 33 9.7 0.209 Abused other drugs 44 3.1 7 3.9 15 2.8 9 3.1 13 3.5 0.849 The percentages are the weighted %. The weights are created based on demographic, social, and economic variables to correct for sampling bias. Weighting was previously reported by Alegría et al. 2 and Heeringa et al. 3 a Other = Costa Ricans, Ecuadorans, Guatemalans, and Hondurans. b These are raw numbers. p reported here are from chi-square crosstabs used to compare difference in percentages of self-reported BMI and substance use between Latina subgroups. p < 0.05 is statistically significant and indicates that comparisons of the subgroup difference are significant at 0.05. cocaine use, prescription drug abuse, and other drugs did not reach statistically significant levels. There was no significant difference in the self-reported ratings of mental health among the different ethnic groups (Table 4). Within the past 12 months, 10.8% reported a DSM- IV major depressive disorder. In subgroup analyses, more Cuban American women rated their mental health as excellent/ very good than did Puerto Rican and Mexican women; however, Cuban Americans also reported the highest rate of poor mental health. Health service seeking Among Latino Americans, 23.6% had ever sought help from mental health service providers during the life span, with Puerto Rican American women claiming a much higher rate than other groups (Table 5). The three major subgroups, however, had different itemized service use patterns. Medical subspecialists received significantly more visits from Cuban and Puerto Rican Americans in the last 12 months than from Mexican or other Latino Americans. Different rates of seeking care from other categories did not reach a statistically significant level. Discussion This study may be among the first of its kind to present the differences among major ethnic subgroups of Latino American women with respect to chronic conditions, behavioral and mental health, and service use, using data from the first nationally representative survey of Latinos in the United States. Our study findings showed that all groups encountered physical and behavioral health issues, but the three major subgroups differed with respect to both overall health and Table 4. Behavioral-Mental Health in Latino American Women by Ethnic Subgroup, National Latino and Asian American Study, 2002 2003 Latino American subgroups Total Cuban Mexican Puerto Rican Other a n = 1427 % n = 301 % n = 470 % n = 282 % n = 374 % p b Self-rating of mental health, c mean (SD) 12-months DSM-IV diagnosis major depression 3.68 (1.05) 3.63 (1.15) 3.65 (1.01) 3.65 (1.08) 3.80 (0.97) 0.085 171 10.8 35 9.2 54 10.4 40 13.1 42 11.1 0.650 The percentages are the weighted %. The weights are created based on demographic, social and economic variables to correct for sampling bias. The WHO Composite International Diagnostic Interview (WMH-CIDI) was used to assess 12-month presence of depression using criteria from DSM-IV. a Other = Costa Ricans, Ecuadorans, Guatemalans, and Hondurans. b p reported here are from chi-square crosstabs used to compare difference between different Latina group s self-report of mental health rating and depressive episode in the past 12 months. p < 0.05 is statistically significant and indicates that comparisons of the subgroup difference are significant at 0.05. c Mental health self-rating categories: excellent = 5, very good = 4, good = 3, fair = 2, poor = 1. SD, standard deviation.

OVERALL HEALTH IN LATINO AMERICAN WOMEN 883 Table 5. Latino American Women s Mental Health Service Seeking by Ethnic Subgroup, National Latino and Asian American Study, 2002 2003 Latino American subgroups Total Cuban Mexican Puerto Rican Other b Type and frequency of mental health service seeking a n = 1427 % n = 301 % n = 470 % n = 282 % n = 374 % p c Lifetime ever seek mental health service 372 23.6 87 26.8 103 21.9 89 32.1 93 23.4 0.017 Last 12 months General practitioner 94 5.9 23 7.0 26 5.7 24 7.9 21 5.3 0.300 Last 12 months Specialist 81 3.3 29 8.4 11 2.2 26 7.8 15 3.0 0.000 Last 12 months Other health provider 90 6.2 13 4.2 29 6.2 25 9.2 23 5.6 0.160 The percentages are the weighted %. The weights are created based on demographic, social, and economic variables to correct for sampling bias. a Lifetime ever seek includes all types of providers: general practitioner: family/general practice medical doctor; specialist: psychiatrist, psychologist; other health providers: D.O., R.N., OT/PT, MSW, counselor, other mental health provider, religious or spiritual healer. b Other = Costa Ricans, Ecuadorans, Guatemalans, and Hondurans. c p reported here are from chi-square crosstabs used to compare difference in percentage of self-reported help-seeking behaviors among Latino subgroups. p < 0.05 is statistically significant and indicates that comparisons of the subgroup difference is significant at 0.05. service use. In line with our earlier analyses, there are also sexspecific patterns in Latino Americans. We have found, regarding physical health, that Puerto Rican American men had the highest rates for 8 of 15 physical ailments, including cardiovascular diseases (CVD) (hypertension, heart diseases, and heart attacks). 35 The ranking in the men s data followed the order: Puerto Rican, Cuban, and Mexican Americans. 35 The current study indicates that the data for women differ from the data for men. Despite differences in racial heritage, SES, and geographic locations, Cuban and Puerto Rican American women share similar rates of CVD; both are higher than those of Mexican American women. 35 The American Heart Association (AHA) reported that black Americans (nearly one third) have much higher rates of hypertension than non-hispanic white Americans (nearly one fourth). 36 However, rates of hypertension in the NLAAS Latina Americans do not follow the race-related rates in the AHA data. Cuban women tend to share the racial heritage with non-latino white women, whereas Puerto Rican women are more similar to black women. Rates of hypertension in Cuban women are slightly higher than those in Puerto Rican women in this study. The sex-specific differential patterns of chronic conditions among Latino Americans suggest the influence of factors related to living environment, SES, and lifestyles on their physical health, apart from the impact of their racial heritage. How cultural and environmental factors may interact with each other in these sex-specific patterns deserves further investigation. Our data also indicate other health disparities in the two primarily nonwhite Hispanic subgroups. The findings show that Mexican and Puerto Rican American women had higher rates of diabetes and allergies compared to Cuban American women, which is consistent with the literature. Puerto Rican American women reported the highest rates of asthma and headache among all subgroups. 7,11 In relation to the risk of both CVD and diabetes, our findings indicate significant overweight and obesity issues across all subgroups. These weight issues involve over two thirds of Mexican Americans, nearly two thirds of Puerto Rican Americans, and over half of Cuban Americans. Mexican American and Puerto Rican American women have much higher rates of obesity than Cuban American women, although rates of being overweight in each subgroup appear to be compatible. This pattern was different from the pattern of Latino men s data in that Mexican American and Cuban American men have considerably higher rates of being overweight than do Puerto Rican American men. 35 Puerto Rican American women reported the highest rates for smoking and marijuana use among all subgroups, but not in other substance abuse categories, reinforcing findings in the literature. 28 However, Puerto Rican American men had the highest rates for all substance abuse except prescription drugs. 35 Thus, risks in behavioral health indicators vary more for Latino American women than for Latino American men, that is, the men s pattern showed consistent top rates of almost all risks in Puerto Rican American Latinos. 35 Previous research suggests a lower prevalence of major depressive disorders among racial/ethnic groups, such as Latinos, compared to European Americans. 11,37 Our analyses found that 1 in 10 Latino American women received a diagnosis of major depression over the past 12 months. However, Puerto Rican American, Mexican American, and Cuban American women all reported considerably higher rates of a diagnosis (13.1%, 10.4%, and 9.2%, respectively) than Latino men (9.7%, 6.5%, and 6.3%, respectively), 35 consistent with the sex gap in the literature. 23,24 Cuban American women s selfrates of mental health as poor are triple those of Puerto Rican American and Mexican American women, which is similar to the rank in the men s subgroup analyses, 35 although rates in the fair category are similar in this women s study. Mexican American men s rates as fair are much higher than rates for their Cuban American and Puerto Rican American counterparts in the men s study. 35 The highest rate of lifetime ever seeking mental health service in Puerto Rican Americans is compatible with higher rates of serious mental illness, mental disorder symptoms, and higher rates of use in the literature. 38 The elevated rates in

884 AI ET AL. Puerto Rican American women may be explained by the overrepresentation of Puerto Rican households headed by single women in the United States. 39 Ortega et al. 4 noted that Puerto Ricans have the highest prevalence of meeting criteria for any comorbid psychiatric illness. Our study, however, suggests that Cuban American women, closely followed by Puerto Rican American women, seek help from medical subspecialist services much more frequently than Mexican American women. This may be a consequence of Cubans highest rates in the poor category of self-reported mental health or their better access to mental health services. On the other hand, the lowest level of professional service seeking among Mexican American women may also reflect the low availability of services in their rural communities or the stigma related to mental health problems. 40 Either hypothesis warrants future research. Limitations and implications Our study has certain limitations, including potential recall bias in the survey, the cross-sectional data, and undetected cultural bias in responding to sensitive questions. Other Latino ethnic subgroups from Costa Rica, Ecuador, Guatemala, and Honduras were not represented and were included in the other Latinos category despite the variety of languages, ethnicities, cultures, and practices among them. The NLAAS was based on psychiatric disorders defined by the DSM-IV, which allowed us to compare mental disorders within the same measure. Rates of mental disorders may have been underestimated, however, as different ethnic groups might express their mental health problems in distinctive ways not identified in the DSM-IV. Further, the self-reported NLAAS data are certainly not as objective and as adequate as physicians assessment. Because of likely report errors and recall flaws, the findings should be considered as preliminary. Study participants could have underreported certain physical and behavioral health conditions. Even self-reported physicians assessments may be biased in some situations. Therefore, it would be more accurate to obtain objective data, such as measuring actual body weight. Certainly, self-reported health conditions present a major limitation of the existing dataset. The NLAAS data are now nearly 10 years old. Alegría et al. 2 found a cross-wave differences in more recent and previous Latino immigrants. Compared to their conditions during 2002 2003, some changes may have occurred relative to the mental health of the new generation of Latino immigrants and their service use. In particular, there are major differences in the Cuban population. For example, Cubans who immigrated to the United States in the 1960s were better educated and more affluent, whereas more recent immigrants tend to be poorer and less well educated. Thus, findings among Cuban Americans can vary depending on their time of immigration. This fact limits the generalizability of this study to healthcare use by the new generations and to the design of specific healthcare services. Still, this complication indicates that the subgroup analysis for Latino American women is long overdue. Even though the NLAAS data are not quite timely, more investigation and more multivariate analyses should be done in our next effort. Despite the limitations, the information provided in our study is valuable because of the increasing need for sex-specific minority health and mental health information. Most importantly, the differential patterns in Latino American women and men revealed in this and previous studies implies that sex per se may have a predominant influence on certain Latinas chronic conditions. Such patterns also point to the potential significance of sociocultural/environmental influences over racial heritage in the overall health and care-seeking patterns of Latinas. Our findings suggest that future studies should explore the role of both protective and risk factors, such as lifestyles, cultural stigma, health insurance, accessibility, and discrimination, in sex-specific Latino American subgroups. The information from this study may have implications for future preventive care policy and health services on overall health issues encountered by this vulnerable population, given the apparent diversity among these subgroups. Clinically, health providers may pay special attention to developing weight control programs for all Latina subgroups. More ethnic group-oriented assessment and treatment may help such subgroups as Puerto Rican American women to cope with asthma and headaches and Mexican American women to help reduce their risk of diabetes. The prevention of the former may have more to do with stress reduction or housing conditions in poor inner city environments, whereas prevention of the latter may have to do with lifestyle and diet modifications. The high risk for CVDs and poor mental health rating among both Puerto Rican American and Cuban American women should be noted by their care providers. Finally, the need to educate physicians and other health professionals on the sex-specific and ethnic-specific data about this ever growing population cannot be overstated because of the increasing role of Latinas in the U.S. workforce and our communities. Acknowledgment The study has been supported by a grant from the Pittsburgh Center for Race and Social Problems. The opinions expressed in this article are those of the authors and do not necessarily reflect the views of this organization. Disclosure Statement The authors have no conflicts of interest to report. References 1. Bergman M. 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