Abstract
Background:
All-cause mortality among diverse US Hispanic/Latino groups and factors underlying mortality differences have not been examined prospectively.
Objective:
Describe cumulative all-cause mortality (and factors underlying differences) by Hispanic/Latino background, before and during the COVID-19 pandemic.
Design:
Prospective multi-center cohort study.
Setting:
Hispanic Community Health Study/Study of Latinos.
Participants.
15,568 adults aged 18–74 at baseline (2008–2011), of Cuban, Dominican, Mexican, Puerto Rican, Central American, South American, and other backgrounds from the Bronx, NY, Chicago, IL, Miami, FL, and San Diego, CA.
Measurements:
Sociodemographic, acculturation-related, lifestyle, and clinical factors were assessed at baseline and vital status ascertained through December 2021 (969 deaths; 173,444 person-years of follow-up). Marginally adjusted cumulative all-cause mortality risks (11-year pre-pandemic and 2-year during the pandemic) were examined using progressively adjusted Cox regression.
Results.
Age-sex-adjusted pre-pandemic 11-year cumulative mortality risks were higher in Puerto Rican and Cuban groups (6.3%, 95% confidence interval [CI] 5.2%−7.6% and 5.7%, 5.0%−6.6%), and lowest in the South American group (2.4%, 1.7%−3.5%). Differences were attenuated with adjustment for lifestyle and clinical factors. During the pandemic, age-sex-adjusted 2-year cumulative mortality risks ranged from 2.4% (1.5%−4.0%; South American) to 4.3% (3.0%−6.2%; Central American); CIs overlapped across groups. With adjustment for lifestyle factors, 2-year cumulative mortality risks were highest in Central American and Mexican-background persons and lowest among Puerto Rican and Cuban-background persons.
Limitations:
Lack of data on race and baseline citizenship status; correlation between Hispanic/Latino background and site.
Conclusions.
Differences in pre-pandemic mortality risks across Hispanic/Latino groups were explained by lifestyle and clinical factors. Mortality patterns changed during the pandemic, with higher risks in Central American and Mexican versus Puerto Rican and Cuban-background persons.
INTRODUCTION
Hispanic/Latino persons in the US represent diverse backgrounds and experience differing health-related exposures. Previous research showed that mortality varies by Hispanic/Latino background and by proxy measures of acculturation (i.e., the cultural adaptation due to the meeting of persons or groups from different cultures (1, 2)) such as place of birth and age at immigration to the US, with lower mortality among immigrants compared to US-born persons, and for those who immigrated at older versus younger ages (3–6). However, these studies included only a few Hispanic/Latino groups and lacked comprehensive assessments of health-related factors (7–12). The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) revealed marked variations in rates of cardiovascular disease (CVD) risk factors by background and acculturation; for example, prevalence of multiple adverse risk factors was lowest in persons of South American background and highest in those of Puerto Rican background (13–21).
Moreover, socioeconomic disadvantage and adverse CVD risk profiles are associated with greater mortality in other populations (22–24). Despite lower socioeconomic status (SES) and higher burden of diabetes and obesity, the US Hispanic/Latino population experiences lower all-cause mortality and greater life expectancy than the non-Hispanic white population (25), i.e., the “Hispanic paradox” (26). Conversely, we and others have speculated that aspects of diverse Hispanic cultures may promote resilience and confer a mortality advantage for some Hispanic/Latino groups (7, 27, 28). However, there are no prospective data on all-cause mortality among diverse Hispanic/Latino groups in the US, and on factors that may explain any differences.
This study filled this knowledge gap by describing cumulative all-cause mortality risks among Hispanic/Latino groups in the years before and during the COVID-19 pandemic, using data from the landmark HCHS/SOL, and examining demographic, socioeconomic, acculturation-related, lifestyle, and clinical factors that may explain differences in cumulative mortality risks across groups.
METHODS
Study Design.
The HCHS/SOL is a population-based cohort study of Hispanic/Latino adults designed to investigate prevalence of, and risk/protective factors for chronic conditions and mortality. Details about the methodology are published (29–31). Briefly, between March 2008 and June 2011, 16,415 self-identified Hispanic/Latino persons aged 18–74 years were recruited from 4 US communities (Bronx, New York; Chicago, Illinois; Miami, Florida; San Diego, California) using a multi-stage probability sampling design. Participants were of Cuban, Dominican, Mexican, Puerto Rican, Central American, South American, and other (including backgrounds not included above or those with more than one heritage) groups. The study was approved by institutional review boards at participating institutions; written informed consent was obtained from all participants.
Baseline Examination Methods.
Participants were asked to fast and refrain from smoking for 12 hours and to avoid vigorous physical activity the morning of the visit. Height and body weight were measured; body mass index (BMI) was calculated as weight (kilograms) divided by height squared (meters squared). After a 5-minute rest period, 3 seated blood pressure (BP) measurements were obtained; readings were averaged. Blood samples (fasting and 2-hour post oral glucose load) were collected and analyzed for total serum cholesterol, HDL-cholesterol, plasma glucose, and Hemoglobin A1c (HbA1c) (13). Low-density lipoprotein (LDL) cholesterol was calculated using the Friedewald equation (32).
Interviewer-administered questionnaires were used to ascertain sociodemographic characteristics (education, income), health insurance, acculturation (place of birth [i.e., born in the 50 US states/D.C.], age at immigration, and language preference, i.e., English vs. Spanish), and personal and family medical history. Physical activity was assessed using the Global Physical Activity Questionnaire (33) and categorized per the 2008 Physical Activity Guidelines for Americans (34). Depressive symptoms were assessed with the 10-item Center for Epidemiological Studies Depression Scale (CES-D 10); elevated depressive symptoms were defined as CES-D 10 score≥10 (35). Two 24-hour dietary recalls were administered 6 weeks apart. The Alternate Healthy Eating Index (AHEI-2010), a summary measure of diet quality, was computed (36). The AHEI assesses intake of vegetables other than potatoes, whole fruit, whole grains, sugar-sweetened beverages and fruit juice, nuts and legumes, red/processed meat, trans-fats, long-chain (n-3) fats, polyunsaturated fatty acids, sodium, and alcohol.
Adverse CVD risk factors were defined per national guidelines in use during baseline (2008–2011): hypertension, systolic/diastolic BP ≥140/≥90 mmHg, or taking antihypertensive medication (37); dyslipidemia, LDL-cholesterol ≥160 mg/dL, HDL-cholesterol <40 mg/dL, triglycerides >200 mg/dL, or taking cholesterol-lowering medication (38); current cigarette smoking, currently smoking and having smoked >100 cigarettes over the lifetime; diabetes mellitus, fasting glucose ≥126 mg/dL, 2-hour post-load glucose ≥200 mg/dL, HbA1c ≥6.5%, or diabetes medication use (39); and obesity, BMI ≥30.0 kg/m2 (40).
Outcome.
The primary outcome was all-cause mortality through December 31, 2021. Participants’ vital status was determined from proxy reports (e.g., by a family member) during annual follow-up telephone calls. Death certificates were requested from next-of-kin and National Death Index (NDI) searches were performed annually for participants who were reported deceased or with unknown status. For the analytic sample, 175 deaths were reported by proxy only, 454 deaths were ascertained by death certificates, and 340 deaths were determined via NDI searches. The observed survival time was the time from baseline to date of death, last contact, or December 31, 2021, whichever happened first.
Exclusion Criteria.
Of the 16,415 participants, 847 were excluded for missing variables of interest. These analyses include data from 15,568 participants (6,212 men, 9,356 women).
Statistical Analyses.
All analyses accounted for the HCHS/SOL complex survey design (clustering and stratification) and sampling weights were used to adjust for the unequal sampling probability and nonresponse. Weighted estimates describe the study population, i.e., noninstitutionalized Hispanic/Latino adults aged 18–74 years residing in the defined geographical areas in the 4 communities. Descriptive baseline characteristics were computed overall, by sex, and by Hispanic/Latino background, and distribution of characteristics for the analytic sample and the full cohort were compared.
To estimate marginal age-adjusted cumulative mortality risk by Hispanic/Latino background, we fit a Cox regression model with main effects for age and Hispanic/Latino background and an interaction term between background and an indicator for whether the follow-up time was during the COVID-19 pandemic, which is a time-dependent covariate. This model allows the effect of background to be different before and during the pandemic. We used March 13, 2020 as the starting date of the COVID-19 pandemic in the US, i.e., the day on which a National Emergency was declared concerning the outbreak. Based on this model, we estimated the survey-weighted log hazard ratios of Hispanic/Latino background using the Cuban group (which had among the highest mortality risk) as the reference. We then calculated the marginally adjusted 11-year cumulative mortality risk before the pandemic, and 2-year cumulative mortality risk during the pandemic, assuming the pandemic started at year 10 of follow up, for each Hispanic/Latino group (overall and by sex) using G-formula (41).
To investigate factors underlying differences in cumulative mortality risk across Hispanic/Latino groups, we conducted Cox regression analyses using progressively adjusted models. The other/mixed heritage group is included in the analyses but results from this group are not presented because of its mixed nature. Model specification was guided by a conceptual framework (Figure 1) based on the Institute of Medicine framework for evaluating unequal treatment (42). We then calculated the marginally adjusted cumulative mortality risk at various time points before and during the pandemic for each Hispanic/Latino group using G-formula (41). We also compared the pre-pandemic marginally adjusted 11-year cumulative mortality risk for each Hispanic/Latino group to that of the Cuban group (reference) to obtain pre-pandemic adjusted mortality risk ratios. Standard errors for cumulative mortality risks and adjusted mortality risk ratios were estimated using bootstrap method based on 100 bootstrap samples and 95%CIs were constructed using the delta method.
Figure 1: Conceptual Model Depicting Factors Underlying Mortality Differences Across Hispanic/Latino Groups.
Analyses were guided by the conceptual model based on the Institute of Medicine framework for evaluating unequal treatment.(42)
Model 1 estimated the difference in cumulative mortality risk among Hispanic/Latino groups after adjusting for age and sex. Progressive models were fit to investigate whether the disparity in cumulative mortality risk across Hispanic/Latino groups persist after accounting for socioeconomic, acculturation, lifestyle, and clinical related factors. Model 2 added SES (income, education), and health insurance. Model 3 added acculturation-related factors (place-of-birth/age-at-immigration, language preference). Model 4 additionally included lifestyle characteristics (diet, physical activity), and Model 5 added clinical factors (major CVD risk factors, family history of CHD, stroke, or cancer, prevalent chronic comorbidities, and elevated depressive symptoms). We interpreted cumulative mortality risk disparity in Model 5 as the residual disparity reflecting unobserved processes (unmeasured confounders) that influence mortality, including structural discrimination, immigration documentation status, and limited access to healthy environments (42).
Analyses were performed using survey procedures in SAS version 9.4 (SAS Institute), SUDAAN release 10.0.0 (RTI), and R (version 4.3.0).
RESULTS
Descriptive Characteristics.
The mean baseline age ranged from 38.6 (Mexican) to 46.5 years (Cuban); 47.7% (Cuban) to 61% (Dominican) were women; 21.6% (Cuban) to 38.1% (Central American) had less than a high school education and 21.9% (Puerto Rican) to 69.1% (Central American) lacked health insurance (Table 1). The proportions of persons who were born in the US 50 states/D.C. ranged from 5.6% (South American) to 48.3% (Puerto Rican) and of those who preferred Spanish vs English ranged from 41.9% (Puerto Rican) to 92.8% (Cuban) (Table 1). Descriptive characteristics by sex, and for the full cohort overall and by Hispanic/Latino group are provided in Tables S1 and S2. The distributions of baseline characteristics for the analytic sample and the full cohort are similar, providing evidence that the analytic sample is representative of the full cohort.
Table 1. Baseline Characteristics of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Study Populationa Overall and by Hispanic/Latino Background.
| Overall | Central American | Cuban | Dominican | Mexican | Puerto Rican | South American | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Characteristic | N | Est (95% CI) | N | Est (95% CI) | N | Est (95% CI) | N | Est (95% CI) | N | Est (95% CI) | N | Est (95% CI) | N | Est (95% CI) |
| Mean Age (Years) | 15,568 | 41.1 (40.6, 41.6) | 1,662 | 39.7 (38.8, 40.7) | 2,265 | 46.5 (45.5, 47.6) | 1,334 | 40.0 (38.6, 41.4) | 6,301 | 38.6 (37.9, 39.3) | 2,503 | 43.2 (42.2, 44.2) | 1,022 | 42.4 (40.9, 44.0) |
| Sex | ||||||||||||||
| Women | 9,356 | 52.4 (51.2, 53.5) | 999 | 52.3 (49.1, 55.8) | 1,206 | 47.7 (45.7, 49.8) | 879 | 61.0 (57.2, 65.0) | 3,936 | 53.7 (51.8, 55.7) | 1,458 | 49.8 (47.2, 52.7) | 609 | 54.6 (50.9, 58.6) |
| Men | 6,212 | 47.6 (46.5, 48.8) | 663 | 47.7 (44.5, 51.1) | 1,059 | 52.3 (50.3, 54.4) | 455 | 39.0 (35.3, 43.1) | 2,365 | 46.3 (44.4, 48.3) | 1,045 | 50.2 (47.5, 53.0) | 413 | 45.4 (41.7, 49.4) |
| Field Center (%) | ||||||||||||||
| Bronx | 3,658 | 27.0 (24.3, 29.9) | 207 | 18.7 (14.5, 24.1) | 40 | 1.3 (0.8, 2.2) | 1,246 | 94.1 (91.6, 96.6) | 184 | 7.5 (5.6, 10.0) | 1,641 | 70.3 (66.4, 74.5) | 157 | 21.6 (17.1, 27.1) |
| Chicago | 4,014 | 16.2 (14.4, 18.4) | 408 | 14.4 (11.2, 18.4) | 24 | 0.8 (0.3, 2.0) | 26 | 0.9 (0.5, 1.5) | 2,350 | 26.2 (22.7, 30.2) | 746 | 22.2 (18.9, 26.2) | 365 | 21.4 (16.7, 27.3) |
| Miami | 3,921 | 29.9 (25.9, 34.5) | 986 | 62.9 (56.3, 70.2) | 2,192 | 97.4 (96.3, 98.6) | 60 | 4.6 (2.8, 7.7) | 38 | 1.2 (0.7, 1.9) | 77 | 4.6 (3.3, 6.5) | 457 | 52.4 (45.8, 60.1) |
| San Diego | 3,975 | 26.9 (23.6, 30.6) | 61 | 4.1 (2.7, 6.2) | 9 | 0.4 (0.1, 1.5) | 2 | 0.4 (0.1, 1.6) | 3,729 | 65.2 (61.0, 69.7) | 39 | 2.8 (1.6, 4.9) | 43 | 4.6 (2.4, 8.8) |
| Annual Family Income (%) | ||||||||||||||
| <$20000 | 6,829 | 41.8 (40.1, 43.7) | 811 | 47.3 (43.5, 51.4) | 1,104 | 45.9 (43.1, 48.9) | 683 | 49.6 (45.2, 54.5) | 2,444 | 37.0 (34.0, 40.2) | 1,178 | 45.0 (41.6, 48.7) | 435 | 39.3 (35.4, 43.6) |
| $20000–50000 | 5,896 | 37.3 (36.0, 38.7) | 576 | 34.2 (30.8, 38.0) | 705 | 31.1 (28.3, 34.1) | 455 | 33.6 (29.9, 37.7) | 2,769 | 42.9 (40.8, 45.1) | 774 | 32.6 (29.4, 36.1) | 426 | 41.7 (37.9, 45.8) |
| >$50000 | 1,542 | 11.9 (10.4, 13.6) | 98 | 7.1 (5.4, 9.4) | 140 | 7.7 (6.0, 9.9) | 80 | 7.3 (5.3, 10.0) | 717 | 15.0 (12.4, 18.1) | 337 | 13.6 (11.5, 16.1) | 98 | 11.2 (8.8, 14.2) |
| Not Reported | 1,301 | 8.9 (8.2, 9.7) | 177 | 11.4 (9.6, 13.5) | 316 | 15.3 (13.4, 17.5) | 116 | 9.6 (7.7, 11.9) | 371 | 5.1 (4.4, 6.0) | 214 | 8.8 (7.4, 10.4) | 63 | 7.9 (5.9, 10.6) |
| Education Level (%) | ||||||||||||||
| Less Than High School | 5,874 | 32.0 (30.6, 33.5) | 686 | 38.1 (35.0, 41.4) | 514 | 21.6 (19.5, 23.8) | 557 | 36.9 (33.4, 40.7) | 2,774 | 36.0 (33.4, 38.7) | 972 | 36.4 (33.3, 39.7) | 253 | 21.7 (18.2, 25.8) |
| High School Graduate | 4,002 | 28.4 (27.3, 29.5) | 385 | 26.4 (23.7, 29.4) | 666 | 30.0 (27.4, 32.9) | 273 | 23.3 (19.8, 27.5) | 1,642 | 30.0 (28.0, 32.0) | 675 | 27.9 (25.4, 30.5) | 262 | 28.0 (24.5, 31.9) |
| More than High School | 5,692 | 39.6 (38.0, 41.3) | 591 | 35.5 (32.4, 38.9) | 1,085 | 48.4 (45.6, 51.3) | 504 | 39.8 (36.3, 43.6) | 1,885 | 34.1 (31.0, 37.4) | 856 | 35.8 (32.7, 39.1) | 507 | 50.4 (46.2, 54.9) |
| Health Insurance (%Yes) | 7,861 | 50.1 (48.3, 52.0) | 530 | 30.9 (27.1, 35.2) | 883 | 41.7 (38.6, 45.1) | 999 | 71.4 (67.5, 75.5) | 2,778 | 42.2 (39.5, 45.2) | 2,030 | 78.1 (75.5, 80.9) | 379 | 41.4 (37.2, 46.1) |
| Diet Score (AHEI) b | 15,568 | 47.6 (47.2, 47.9) | 1,662 | 47.1 (46.7, 47.6) | 2,265 | 43.9 (43.7, 44.2) | 1,334 | 48.6 (48.1, 49.1) | 6,301 | 52.0 (51.7, 52.4) | 2,503 | 41.8 (41.5, 42.1) | 1,022 | 46.0 (45.4, 46.7) |
| Physical Activityc (%Yes) | 9,920 | 66.8 (65.5, 68.1) | 1,107 | 69.8 (66.8, 72.8) | 1,187 | 54.8 (52.3, 57.4) | 851 | 66.7 (62.9, 70.8) | 4,165 | 70.8 (69.0, 72.6) | 1,580 | 67.9 (65.0, 70.8) | 687 | 69.9 (66.6, 73.4) |
| Place of Birth/ Age at immigration (%) | ||||||||||||||
| US born (50 States/ D.C.) | 2,678 | 22.5 (21.0, 24.1) | 75 | 7.0 (5.1, 9.6) | 113 | 7.0 (5.4, 9.1) | 119 | 15.9 (12.3, 20.5) | 1,041 | 23.8 (21.8, 25.9) | 1,028 | 48.3 (45.2, 51.6) | 42 | 5.6 (4.0, 7.9) |
| Immigrated at < 18 Years | 2,612 | 19.1 (18.1, 20.1) | 207 | 18.3 (15.7, 21.3) | 226 | 11.4 (10.0, 13.1) | 212 | 21.1 (18.4, 24.1) | 1,115 | 20.9 (19.2, 22.9) | 694 | 25.4 (22.8, 28.1) | 110 | 16.2 (12.8, 20.5) |
| Immigrated at >= 18 Years | 10,278 | 58.4 (56.6, 60.3) | 1,380 | 74.7 (71.4, 78.2) | 1,926 | 81.6 (79.2, 84.0) | 1,003 | 63.1 (58.5, 67.9) | 4,145 | 55.3 (53.2, 57.5) | 781 | 26.4 (23.5, 29.7) | 870 | 78.2 (74.1, 82.5) |
| Language Preference | ||||||||||||||
| Spanish | 12,525 | 75.4 (73.7, 77.2) | 1,544 | 88.6 (85.8, 91.5) | 2,134 | 92.8 (91.2, 94.5) | 1,133 | 77.0 (72.1, 82.1) | 5,295 | 77.9 (75.8, 80.1) | 1,234 | 41.9 (38.3, 45.7) | 942 | 89.2 (86.4, 92.1) |
| English | 3,043 | 24.6 (22.8, 26.4) | 118 | 11.4 (8.9, 14.6) | 131 | 7.2 (5.7, 9.0) | 201 | 23.0 (18.6, 28.6) | 1,006 | 22.1 (20.0, 24.3) | 1,269 | 58.1 (54.6, 61.9) | 80 | 10.8 (8.3, 14.0) |
| CVD Risk Factorsd (%) | ||||||||||||||
| Hypertension | 4,221 | 21.9 (20.8, 23.1) | 428 | 20.1 (17.8, 22.7) | 811 | 32.9 (30.5, 35.6) | 434 | 23.9 (21.1, 27.2) | 1,303 | 14.7 (13.1, 16.4) | 942 | 28.6 (26.0, 31.4) | 205 | 17.5 (14.6, 20.9) |
| Dyslipidemia | 7,389 | 44.3 (43.1, 45.5) | 808 | 46.5 (43.4, 49.9) | 1,165 | 50.5 (48.0, 53.2) | 566 | 37.3 (33.7, 41.3) | 2,914 | 42.1 (40.2, 44.1) | 1279 | 47.6 (44.7, 50.7) | 464 | 42.5 (38.3, 47.1) |
| Current Smoker | 2,966 | 21.1 (20.0, 22.3) | 226 | 14.7 (12.5, 17.3) | 654 | 26.3 (23.9, 29.0) | 139 | 12.0 (9.2, 15.6) | 938 | 17.7 (16.0, 19.5) | 762 | 33.0 (30.4, 35.9) | 134 | 13.1 (10.4, 16.5) |
| Diabetes | 3,028 | 14.8 (13.9, 15.6) | 287 | 13.3 (11.4, 15.6) | 395 | 15.8 (13.9, 18.0) | 249 | 14.7 (12.5, 17.2) | 1,263 | 14.3 (13.1, 15.7) | 644 | 17.8 (16.0, 19.9) | 127 | 9.4 (7.4, 11.9) |
| Obesity | 6,594 | 39.6 (38.3, 41.0) | 692 | 37.6 (34.8, 40.5) | 869 | 38.0 (35.5, 40.6) | 554 | 41.4 (37.7, 45.6) | 2,694 | 38.6 (36.2, 41.2) | 1,215 | 46.5 (43.5, 49.7) | 351 | 30.4 (26.8, 34.5) |
| Family History (%) | ||||||||||||||
| Family History of CHD | 4,479 | 24.6 (23.4, 25.7) | 376 | 17.5 (15.2, 20.0) | 728 | 27.8 (26.0, 29.8) | 396 | 24.3 (21.8, 27.2) | 1,585 | 21.0 (18.9, 23.4) | 1,005 | 34.3 (31.3, 37.6) | 263 | 23.3 (20.2, 26.8) |
| Family History of Stroke | 2,371 | 12.8 (12.0, 13.6) | 244 | 11.5 (9.9, 13.3) | 351 | 13.9 (12.3, 15.8) | 200 | 13.3 (10.9, 16.2) | 774 | 9.3 (8.4, 10.4) | 569 | 19.6 (17.2, 22.4) | 149 | 13.4 (10.8, 16.6) |
| Family History of Cancer | 3,805 | 21.7 (20.7, 22.7) | 356 | 18.3 (16.1, 20.8) | 697 | 27.2 (25.1, 29.5) | 253 | 16.0 (13.7, 18.7) | 1,407 | 19.4 (17.9, 21.0) | 721 | 24.9 (22.5, 27.6) | 256 | 22.9 (19.6, 26.6) |
| Prevalent Disease (%) | ||||||||||||||
| Self-Reported CHD including MI, CABG, Stent, or Balloon Angioplasty | 503 | 2.7 (2.4, 3.1) | 33 | 1.2 (0.8, 1.7) | 88 | 3.8 (2.9, 4.9) | 51 | 2.6 (1.9, 3.6) | 141 | 1.6 (1.1, 2.3) | 155 | 4.8 (3.8, 5.9) | 21 | 2.2 (1.3, 3.5) |
| Self-Report of ever having COPD/ Emphysema or CB | 1,035 | 6.1 (5.6, 6.7) | 55 | 2.6 (1.8, 3.8) | 191 | 7.1 (6.0, 8.5) | 62 | 5.2 (3.0, 9.1) | 314 | 4.5 (3.9, 5.3) | 323 | 11.2 (9.4, 13.4) | 39 | 4.2 (2.9, 6.1) |
| Self-Reported Stroke | 229 | 1.3 (1.1, 1.6) | 24 | 1.1 (0.7, 1.9) | 38 | 1.7 (1.2, 2.4) | 22 | 1.9 (1.2, 3.0) | 64 | 0.9 (0.6, 1.3) | 65 | 2.0 (1.5, 2.7) | 10 | 0.8 (0.4, 1.8) |
| Renal Disease | 2,048 | 12.1 (11.3, 12.9) | 229 | 12.8 (11.0, 14.9) | 455 | 19.2 (17.3, 21.2) | 202 | 14.0 (11.8, 16.5) | 642 | 8.5 (7.6, 9.6) | 349 | 11.3 (9.8, 13.1) | 119 | 10.8 (8.8, 13.4) |
| Self-Reported Cancer -- Any | 613 | 3.7 (3.2, 4.2) | 57 | 2.4 (1.8, 3.3) | 124 | 5.8 (4.5, 7.4) | 36 | 2.5 (1.6, 3.9) | 211 | 2.6 (2.0, 3.5) | 134 | 5.2 (3.7, 7.4) | 35 | 3.0 (2.0, 4.5) |
| Elevated Depressive Symptomsc (%) | ||||||||||||||
| CESD10<10 | 11,014 | 73.1 (72.0, 74.3) | 1,195 | 75.5 (73.0, 78.2) | 1,547 | 71.7 (69.4, 74.1) | 946 | 72.4 (69.5, 75.5) | 4,769 | 77.8 (75.9, 79.8) | 1,469 | 62.2 (59.5, 65.1) | 754 | 75.5 (72.1, 79.1) |
| CESD10≥10 | 4,554 | 26.9 (25.7, 28.1) | 467 | 24.5 (22.0, 27.2) | 718 | 28.3 (26.0, 30.8) | 388 | 27.6 (24.8, 30.8) | 1,532 | 22.2 (20.3, 24.2) | 1,034 | 37.8 (35.1, 40.7) | 268 | 24.5 (21.2, 28.2) |
Abbreviations: AHEI: Alternate Healthy Eating Index; CABG: coronary artery bypass graft; CB: chronic bronchitis; CHD: coronary heart disease; COPD: chronic obstructive pulmonary disease; CVD: cardiovascular disease; CESD-10: Center of Epidemiologic Studies Depression Scale, 10-item version; Est.: Estimate; GED: General Educational Development; MI: myocardial infarction
All values are weighted for study design and non-response except for N where the unweighted N is presented.
Dietary intake was ascertained by two 24-hour dietary recalls administered 6 weeks apart. The Alternate Healthy Eating Index (AHEI-2010), a summary measure of diet quality based on foods/nutrients predictive of chronic disease risk, was computed. The AHEI assesses intake of 11 dietary components, i.e., vegetables other than potatoes, whole fruit, whole grains, sugar-sweetened beverages and fruit juice, nuts and legumes, red/processed meat, trans-fats, long-chain (n-3) fats (eicosapentaenoic acid and docosahexaenoic acid), polyunsaturated fatty acids, sodium, and alcohol intake. The NCI method was used to estimate the usual intake for each component. Individual components were scored from 0 (worst) to 10 (best) and were summed to compute the overall AHEI score.
Self-reported physical activity was assessed using the Global Physical Activity Questionnaire (GPAQ) (33). Information was obtained on weekly frequency and average daily duration of transportation-related activity (i.e., walking or bicycling for travel, considered as moderate-intensity activity), and moderate- and vigorous-intensity work-related and leisure-time physical activity. Physical activity levels were categorized as whether or not the participant met high or medium activity levels per the 2008 Physical Activity Guidelines for Americans, i.e., at least 150 minutes/week of moderate-intensity, or 75 minutes/week of vigorous-intensity aerobic physical activity, or an equivalent combination of both.
Hypertension was defined as systolic BP ≥140 mmHg, diastolic BP ≥90 mmHg, or taking antihypertensive medication. Dyslipidemia was defined as LDL cholesterol >=160 mg/dL or HDL cholesterol <40 mg/dL or triglycerides >=200 mg/dL or taking cholesterol lowering medication. Current cigarette smoking was defined as currently smoking and having smoked >100 cigarettes over the lifetime. Diabetes mellitus was defined as fasting glucose ≥126 mg/dL, 2-hour oral glucose tolerance test (OGTT) ≥200 mg/dL, HbA1c ≥6.5%, or self-reported diabetes medication use. Obesity was defined as body mass index ≥30.0 kg/m2.
Depressive symptoms were assessed with the 10-item Center for Epidemiological Studies Depression Scale (CES-D 10) and elevated depressive symptoms were defined as CES-D 10 score≥10.
Marginal Age-Adjusted Cumulative All-Cause Mortality Risks.
By December 31, 2021, the sample had 173,444 person-years of follow-up with 969 deaths.
Before the pandemic, the overall age-adjusted 11-year cumulative all-cause mortality risk was highest for individuals of Puerto Rican and Cuban background (6.3%, 95% CI, 5.2%−7.5% and 5.9%, 95% CI, 5.1%−6.8%) and lowest for those of South American background (2.3%, 95% CI, 1.6%−3.4%). The CIs for the Puerto Rican and Cuban groups did not overlap with those for the South American, Mexican, and Central American groups (Table 2). In sex-stratified analyses, pre-pandemic age-adjusted 11-year cumulative all-cause mortality risks ranged from 3.0% (South American) to 8.9% (Puerto Rican) among men, and from 1.9% (South American) to 4.6% (Cuban) among women (Table 2). Figure S1 provides the corresponding age-standardized mortality rates.
Table 2. Marginal Age-Adjusted Cumulative Mortality Riska by Hispanic/Latino Background – Overall and by Sex.
| Central American | Cuban | Dominican | Mexican | Puerto Rican | South American | |
|---|---|---|---|---|---|---|
| Before the Pandemic: 11-Year Cumulative Mortality Risk | ||||||
| Overall | ||||||
| Person-Yearsa | 18671.31 | 24412.68 | 15015.66 | 70854.84 | 27626.74 | 11495.78 |
| Deathsa | 86 | 211 | 75 | 288 | 246 | 40 |
| Mortality Risk | 3.9% | 5.9% | 3.6% | 3.6% | 6.3% | 2.3% |
| 95% CI | (3.0%, 5.0%) | (5.1%, 6.8%) | (2.5%, 5.2%) | (3.0%, 4.4%) | (5.2%, 7.5%) | (1.6%, 3.4%) |
| Women | ||||||
| Person-Yearsa | 11456.24 | 13273.74 | 9950.07 | 44552.38 | 16352.82 | 6890.78 |
| Deathsa | 34 | 87 | 39 | 145 | 109 | 21 |
| Mortality Risk | 1.7% | 4.6% | 2.3% | 2.7% | 3.9% | 1.9% |
| 95% CI | (1.0%, 3.0%) | (3.8%, 5.4%) | (1.5%, 3.7%) | (2.1%, 3.5%) | (3.0%, 5.1%) | (1.0%, 3.6%) |
| Men | ||||||
| Person-Years | 7215.08 | 11138.94 | 5065.58 | 26302.46 | 11273.93 | 4604.99 |
| Deaths | 52 | 124 | 36 | 143 | 137 | 19 |
| Mortality Risk | 6.6% | 7.0% | 5.4% | 4.8% | 8.9% | 3.0% |
| 95% CI | (4.8%, 9.1%) | (5.9%, 8.4%) | (3.4%, 8.5%) | (3.6%, 6.3%) | (7.0%, 11.4%) | (1.7%, 5.1%) |
| During the Pandemic: 2-Year Cumulative Mortality Risk | ||||||
| Overall | ||||||
| Mortality Risk | 2.0% | 1.4% | 1.6% | 1.5% | 1.4% | 1.1% |
| 95% CI | (1.3%, 2.9%) | (1.1%, 1.8%) | (1.1%, 2.5%) | (1.2%, 1.9%) | (1.0%, 2.0%) | (0.6%, 1.9%) |
| Women | ||||||
| Mortality Risk | 1.4% | 1.3% | 1.3% | 1.4% | 0.8% | 1.0% |
| 95% CI | (0.8%, 2.5%) | (0.9%, 1.8%) | (0.7%, 2.3%) | (1.0%, 1.9%) | (0.4%, 1.4%) | (0.4%, 2.3%) |
| Men | ||||||
| Mortality Risk | 2.6% | 1.6% | 2.1% | 1.7% | 2.2% | 1.2% |
| 95% CI | (1.7%, 4.0%) | (1.2%, 2.1%) | (1.1%, 3.7%) | (1.2%, 2.4%) | (1.6%, 3.0%) | (0.5%, 2.9%) |
Abbreviations: CI: confidence intervals
All values are weighted for study design and non-response except for person-years and number of deaths for which unweighted numbers are presented.
During the pandemic, marginal age-adjusted 2-year cumulative mortality risks ranged from 1.1% (South American) to 2.0% (Central American) and CIs overlapped across all groups (Table 2).
Marginal Multivariable-Adjusted Cumulative All-Cause Mortality Risks.
Eleven-year cumulative mortality risks before the pandemic.
Persons of Puerto Rican and Cuban backgrounds had the highest age-sex-adjusted 11-year cumulative mortality risk (6.3% [95% CI, 5.2%−7.6%] and 5.7% [95% CI, 5.0%−6.6%], respectively), and those of South American background had the lowest (2.4% [95% CI, 1.7%−3.5%]); CIs for the South American and Mexican group did not overlap with those for the Puerto Rican and Cuban groups (Table 3, Model 1). Findings remained similar with additional adjustment for SES (Model 2), but differences between the Puerto Rican and Mexican groups were attenuated with addition of acculturation-related factors (Model 3). Additional adjustment for lifestyle factors (Model 4) increased the cumulative mortality risks for the Mexican group but also further attenuated the differences across most groups, and with inclusion of clinical factors (Model 5) no differences remained (CIs overlapped across all groups). Corresponding pre-pandemic 11-year cumulative mortality risk ratios are depicted in Figure 2.
Table 3. Marginal Adjusted Cumulative Mortality Riska by Hispanic/Latino Background based on the Progressively Adjusted Modelsb.
| Summary | Central American | Cuban | Dominican | Mexican | Puerto Rican | South American |
|---|---|---|---|---|---|---|
| Person-Yearsa | 18671.31 | 24412.68 | 15015.66 | 70854.84 | 27626.74 | 11495.78 |
| Deathsa | 86 | 211 | 75 | 288 | 246 | 40 |
| Before the Pandemic: 11-Year Cumulative Mortality Risk | ||||||
| Model 1 (Age and Sex) | ||||||
| Mortality Risk | 4.0% | 5.7% | 3.7% | 3.7% | 6.3% | 2.4% |
| 95% CI | (3.1%, 5.1%) | (5.0%, 6.6%) | (2.6%, 5.3%) | (3.0%, 4.5%) | (5.2%, 7.6%) | (1.7%, 3.5%) |
| Model 2 (Age, Sex, and SES) | ||||||
| Mortality Risk | 4.0% | 5.7% | 3.4% | 3.8% | 6.0% | 2.6% |
| 95% CI | (3.1%, 5.2%) | (4.9%, 6.7%) | (2.4%, 4.9%) | (3.1%, 4.7%) | (4.9%, 7.3%) | (1.8%, 3.8%) |
| Model 3 (Age, Sex, SES, and Acculturation-Related Factors) | ||||||
| Mortality Risk | 4.3% | 6.1% | 3.7% | 3.8% | 5.3% | 2.8% |
| 95% CI | (3.4%, 5.6%) | (5.2%, 7.1%) | (2.6%, 5.2%) | (3.1%, 4.7%) | (4.3%, 6.5%) | (1.9%, 4.1%) |
| Model 4 (Age, Sex, SES, Acculturation-Related, and Lifestyle Factors) | ||||||
| Mortality Risk | 4.6% | 5.0% | 4.4% | 5.4% | 4.3% | 2.8% |
| 95% CI | (3.6%, 6.0%) | (4.2%, 5.8%) | (3.1%, 6.4%) | (4.2%, 6.9%) | (3.3%, 5.5%) | (1.9%, 4.1%) |
| Model 5 (Age, Sex, SES, Acculturation-Related, Lifestyle, and Clinical Factors) | ||||||
| Mortality Risk | 4.9% | 4.6% | 4.3% | 5.6% | 4.3% | 3.4% |
| 95% CI | (3.8%, 6.3%) | (3.9%, 5.4%) | (3.0%, 6.2%) | (4.4%, 7.1%) | (3.4%, 5.5%) | (2.4%, 5.0%) |
| During the Pandemic: 2-Year Cumulative Mortality Risk | ||||||
| Model 1 (Age and Sex) | ||||||
| Mortality Risk | 2.0% | 1.4% | 1.7% | 1.5% | 1.5% | 1.1% |
| 95% CI | (1.4%, 3.0%) | (1.1%, 1.7%) | (1.1%, 2.6%) | (1.2%, 1.9%) | (1.1%, 2.0%) | (0.6%, 2.0%) |
| Model 2 Age, Sex, and SES) | ||||||
| Mortality Risk | 2.0% | 1.4% | 1.6% | 1.6% | 1.4% | 1.2% |
| 95% CI | (1.4%, 3.0%) | (1.1%, 1.8%) | (1.0%, 2.4%) | (1.2%, 2.0%) | (1.0%, 1.9%) | (0.7%, 2.1%) |
| Model 3 (Age-Sex, SES, and Acculturation-Related Factors) | ||||||
| Mortality Risk | 2.1% | 1.5% | 1.7% | 1.6% | 1.2% | 1.3% |
| 95% CI | (1.5%, 3.1%) | (1.2%, 1.8%) | (1.1%, 2.5%) | (1.2%, 2.0%) | (0.9%, 1.7%) | (0.7%, 2.2%) |
| Model 4 (Age, Sex, SES, Acculturation-Related, and Lifestyle Factors) | ||||||
| Mortality Risk | 2.1% | 1.2% | 1.9% | 2.0% | 1.0% | 1.2% |
| 95% CI | (1.5%, 3.1%) | (1.0%, 1.5%) | (1.3%, 2.7%) | (1.6%, 2.6%) | (0.7%, 1.5%) | (0.7%, 2.1%) |
| Model 5 (Age, Sex, SES, Acculturation-Related, Lifestyle, and Clinical Factors) | ||||||
| Mortality Risk | 2.1% | 1.1% | 1.8% | 2.0% | 1.0% | 1.4% |
| 95% CI | (1.5%, 3.0%) | (0.9%, 1.4%) | (1.3%, 2.6%) | (1.6%, 2.5%) | (0.7%, 1.5%) | (0.9%, 2.4%) |
Abbreviations: CI: confidence intervals; SES: socioeconomic status
All values are weighted for study design and non-response except for person-years and number of deaths for which unweighted numbers are presented.
Model 1 estimated the difference in mortality risk among Hispanic/Latino groups after adjusting for age and sex. Progressive models were fit to investigate whether the disparity in mortality risk across Hispanic/Latino groups persist after accounting for socioeconomic, acculturation, lifestyle, and clinical related factors. Model 2 added socioeconomic status (income, education, and health insurance). Model 3 added acculturation related factors (place of birth /age at immigration, language preference). Model 4 was additionally adjusted for lifestyle characteristics (diet, physical activity), and Model 5 added clinical factors (major CVD risk factors, family history of CHD, stroke, or cancer, prevalent chronic comorbidities, and elevated depressive symptoms).
Figure 2: Pre-Pandemic Marginal Adjusted 11-Year Cumulative Mortality Risk Ratios based on the Progressively Adjusted Models.a,b.
a All values are weighted for study design and non-response.
b Progressive models were fit to investigate whether the disparity in cumulative mortality risk across Hispanic/Latino groups persist after accounting for socioeconomic, acculturation, lifestyle, and clinical related factors.
Model 1 estimated the difference in mortality risk among Hispanic/Latino groups after adjusting for age and sex.
Model 2 added socioeconomic status (income, education, and health insurance).
Model 3 added acculturation related factors (place of birth/age at immigration, language preference).
Model 4 added lifestyle characteristics (diet, physical activity).
Model 5 added clinical factors (major CVD risk factors, family history of CHD, stroke, or cancer, prevalent chronic comorbidities, and elevated depressive symptoms).
Two-year cumulative mortality risks during the pandemic.
The age-sex-adjusted 2-year cumulative mortality risk ranged from 1.1% [95% CI, 0.6%−2.0%] in South American-background persons to 2.0% [95% CI, 1.4%−3.0%] in those of Central American backgrounds and CIs overlapped across all groups. The 2-year cumulative mortality risk estimates remained similar with progressive adjustment for SES and acculturation (Models 2 and 3). However, with addition of lifestyle factors (Model 4), cumulative mortality risk slightly increased for the Mexican group and decreased for the Puerto Rican and Cuban groups. In the fully adjusted model (additionally including clinical factors) 2-year cumulative mortality risks differed slightly across groups and was lower for persons of Puerto Rican and Cuban backgrounds.
Figure S2 (left panel) presents the age-sex-adjusted cumulative mortality risks over time. Before the pandemic, the relative order of cumulative mortality risk across the background groups stayed the same over time. During the pandemic, the 2-year cumulative mortality risks increased sharply and became similar across all groups. In the fully adjusted models (Figure S2 right panel), the relative order of the cumulative mortality risks across groups stayed the same over time before the pandemic, but mortality risk was higher for persons of Central American and Mexican compared to those of both Puerto Rican and Cuban backgrounds during the pandemic. Estimated coefficients for the Hispanic/Latino background and the interaction term between background and the indicator for whether the follow-up time was during the COVID-19 pandemic in the Cox regression model together with their corresponding 95% confidence intervals are presented in Table S3.
DISCUSSION
In the HCHS/SOL population, Puerto Rican and Cuban-background persons had the highest age-sex-adjusted 11-year pre-pandemic cumulative mortality risks; this was largely explained by lifestyle and clinical factors. Persons of South American background consistently had relatively lower mortality before the pandemic compared to other groups. Mortality risks increased at a greater rate during (versus before) the pandemic for most groups. During the pandemic, age-sex adjusted 2-year cumulative mortality risks ranged narrowly from about 1% (South American) to 2% (Central American). Estimates remained similar with adjustment for socioeconomic and acculturation, but with addition of lifestyle and clinical factors, mortality risks for the Mexican group became similar to those for the Central American group, the ordering of risk estimates across groups was altered (albeit within that narrow range), and differences in mortality risk among groups became evident. In fully adjusted analyses, the Puerto Rican and Cuban groups had lower mortality compared to others.
Earlier investigations have compared Hispanic/Latino group-specific mortality with non-Hispanic white mortality by combining national survey data and mortality records (7–9, 11). These studies suggested heterogeneity in all-cause mortality rates across Hispanic/Latino groups, with some reporting higher mortality for Puerto Rican persons (8, 10) and others showing no significant differences across groups (7). Comparisons across Hispanic/Latino groups in these previous reports are limited by reliance only on national sources of mortality data which may suffer from differential under-ascertainment of mortality due to varying levels of reverse migration across groups (43).
The HCHS/SOL is the first longitudinal study to examine differences in mortality across diverse Hispanic/Latino groups from a large, well-characterized cohort including in the early years of the pandemic (with annual participant contacts and multiple methods for ascertaining mortality) and to prospectively examine factors that may underlie such mortality variations observed. In this analysis, the pre-pandemic 11-year cumulative age-sex-adjusted mortality risks were higher in the Puerto Rican and Cuban groups and lower in the South American group. However, variations in lifestyles and clinical factors largely explained the observed pre-pandemic differences in mortality.
The US Hispanic/Latino population has varying exposures to structural factors (e.g., discrimination, economic disadvantage, limited access to health care, and exposure to unhealthy environments, driven to some extent by circumstances surrounding their immigration and acculturation to US society) that have profound influences on health. For example, in the HCHS/SOL population, persons of Mexican background were less likely than others to have attained more than a high school education, and rates of health insurance coverage were lowest in those of Central American background.
The current analyses cannot directly address the Hispanic paradox (since this requires comparison with the non-Hispanic white population). However, the differences in pre-pandemic mortality risk across Hispanic/Latino groups, and the increasing mortality risk estimates for the Mexican group combined with attenuation of group differences when accounting for lifestyle and chronic disease risk factors, imply that the Hispanic paradox if any, could be operating in some groups but not others. Of note, the differences in age-sex adjusted 11-year cumulative mortality risk largely persisted with adjustment for acculturation, suggesting that these findings were not influenced by a healthy immigrant effect. Previous HCHS/SOL reports have demonstrated wide variations by background in prevalence of individual CVD risk factors and burden of multiple adverse risk factors (13). For example, prevalence of multiple adverse risk factors was highest in persons of Puerto Rican background followed by those of Cuban background (13). However, the current findings also point to a more complex picture, with similar pre-pandemic 11-year cumulative mortality risks noted for the Cuban and Puerto Rican groups despite the differences in prevalence of CVD risk factors. Thus, continued longitudinal research is imperative to elucidate risk/protective factors that may operate differentially across groups and contribute to heterogeneity in mortality by background.
The COVID-19 pandemic exacerbated structural inequities in society (44), and intensified economic hardships faced by Hispanic/Latino persons (45). The current study included mortality follow-up during the early pandemic period and demonstrated greater increases in 2-year cumulative mortality risks during the pandemic compared to previous years. While cumulative mortality risk did not differ across groups in the 11 years prior to the pandemic in the fully adjusted analyses, our findings (based on 2 years of follow-up) suggest that mortality risks varied during the pandemic after accounting for lifestyle and clinical factors, i.e., risks were somewhat higher for persons of Central American and Mexican compared to those of Puerto Rican and Cuban backgrounds. This may reflect the influence of unobserved processes such as structural discrimination and access to health-promoting resources.
Key strengths of HCHS/SOL include comprehensive baseline assessments, annual follow-up, and multiple approaches for ascertaining mortality, including proxy informants (especially for participants no longer in the US), death certificates, and NDI records. With availability of proxy informants and censoring at last contact, mortality ascertainment and results in HCHS/SOL are less likely to be biased by reverse migration (salmon bias). Moreover, findings are not biased by misclassification of ethnicity on death certificates since participants had self-identified as being Hispanic/Latino. The rigorous HCHS/SOL complex survey sampling design is superior to the convenience samples typically used in epidemiologic cohort studies, allowing inferences to the target population. Study sites were selected to include regions with high concentrations of the major Hispanic/Latino groups and include 4 of the 11 US cities with the largest Hispanic/Latino populations. However, limitations exist. Due to the sampling design, the study cohort is not a representative sample of the Hispanic/Latino population across all US cities or from rural areas. Moreover, the small number of deaths in some groups to date and the selection of sites to facilitate inclusion of the major US Hispanic/Latino groups result in high correlation between site and background, which preclude examination of geographic differences in mortality within Hispanic/Latino groups. In addition, HCHS/SOL lacks complete data on racial background (about 40% did not respond to this question). Thus, race could not be examined as a marker for racial discrimination. Lastly, immigration documentation status was not assessed at baseline. These could be potential sources of unmeasured confounding. The continued follow-up of HCHS/SOL will generate sufficient power to allow in-depth investigations of risk/resilience factors underlying the variations in mortality among diverse Hispanic/Latino men and women including by study site, and of associations of changes in risk factors over time with mortality.
In summary, these findings from HCHS/SOL demonstrate sizeable variations in mortality risks by Hispanic/Latino background of origin, extend our understanding of the heterogeneity of this population, shed light on differences in cumulative mortality risk across groups before and during the pandemic, and suggest complex variations in mortality risks beyond the pattern expected based on the risk factor burden. Importantly, our findings suggest a change in order of mortality by Hispanic/Latino background during the pandemic. Lifestyle characteristics and chronic disease risk factors/conditions explained the differences in 11-year cumulative mortality risk before the pandemic and appeared to play a role in the alteration in mortality patterns during the pandemic.
Supplementary Material
Figure S1: Age-Standardized 11-Year All-Cause Mortality Rate by Sex and Hispanic/Latino Background in the HCHS/SOL Study Population
Figure S2. Marginal Adjusted Mortality Risk Curves by Hispanic/Latino Background based on Model 1 (Age and Sex) and Model 5 (Age, Sex, SES, Acculturation-Related, Lifestyle, and Clinical Factors)
Table S1: Baseline Characteristics of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Study Population by Sex
Table S2: Baseline Characteristics of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Study Population Overall and by Hispanic/Latino Background based on the Full Cohort.
Table S3: Coefficient Estimates for the Progressive Models with the Interaction terms between the Hispanic/Latino Background Groups and the Indicator for During (vs. Before) the Pandemic
ACKNOWLEDGEMENTS
The authors thank the staff and participants of HCHS/SOL for their important contributions. A complete list of staff and investigators has been provided by Sorlie P., et al. in Ann Epidemiol. 2010 Aug;20:642-649 and is also available on the study website http://www.cscc.unc.edu/hchs/.
Primary Funding Source:
National Institutes of Health.
Funding/Support:
The Hispanic Community Health Study/Study of Latinos is a collaborative study supported by contracts from the National Heart, Lung, and Blood Institute (NHLBI) to the University of North Carolina (HHSN268201300001I/ N01-HC-65233), University of Miami (HHSN268201300004I/ N01-HC-65234), Albert Einstein College of Medicine (HHSN268201300002I/ N01-HC-65235), University of Illinois at Chicago - HHSN268201300003I/ N01-HC-65236 Northwestern University), and San Diego State University (HHSN268201300005I/ N01-HC-65237). The following Institutes/Centers/Offices have contributed to the HCHS/SOL through a transfer of funds to the NHLBI: National Institute on Minority Health and Health Disparities, National Institute on Deafness and Other Communication Disorders, National Institute of Dental and Craniofacial Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Neurological Disorders and Stroke, NIH Institution-Office of Dietary Supplements.
Role of the Sponsor:
The funding agency had a role in the design and conduct of the HCHS/SOL; in the collection, analysis, and interpretation of the HCHS/SOL data; and in the review and approval of this manuscript.
Footnotes
Reproducible Research Statement:
Protocol: Available on the HCHS/SOL website (http://www.cscc.unc.edu/hchs/).
Statistical Code: Available to interested readers by contacting Dr. Cai at cai@bios.unc.edu.
Data: Available through collaboration with existing HCHS/SOL investigators. Limited access data for visits 1 and 2 are also publicly available on the National Heart, Lung, and Blood Institute Biologic Specimen and Data Repository Information Coordinating Center repository per the National Heart, Lung, and Blood Institute Policy for Distribution of Data.
Disclaimer: The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institute on Minority Health and Health Disparities; the National Institutes of Health; or the U.S. Department of Health and Human Services.
Conflict of Interest Disclosures: No authors had any conflicts of interests to disclose.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Figure S1: Age-Standardized 11-Year All-Cause Mortality Rate by Sex and Hispanic/Latino Background in the HCHS/SOL Study Population
Figure S2. Marginal Adjusted Mortality Risk Curves by Hispanic/Latino Background based on Model 1 (Age and Sex) and Model 5 (Age, Sex, SES, Acculturation-Related, Lifestyle, and Clinical Factors)
Table S1: Baseline Characteristics of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Study Population by Sex
Table S2: Baseline Characteristics of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Study Population Overall and by Hispanic/Latino Background based on the Full Cohort.
Table S3: Coefficient Estimates for the Progressive Models with the Interaction terms between the Hispanic/Latino Background Groups and the Indicator for During (vs. Before) the Pandemic