Reducing Health Disparities for Hispanics Through the Development of Culturally Tailored Interventions

Hispanics are the largest and fastest-growing minority group in the United States and bear a disproportionate burden of disease and death compared to non-Hispanics. As the population grows—from a currently estimated 15% of the U.S. population to a projected 30% by 2050 (Bernstein & Edwards, 2008)—so too will disparities in many health areas, particularly without appropriate and effective interventions. Though Hispanics suffer disproportionately from numerous serious health conditions including obesity, diabetes, and liver, stomach, and cervical cancer, this article focuses on a constellation of behaviorally rooted health conditions that disproportionately affect Hispanics in the United States: HIV/AIDS and sexually transmitted infections, substance abuse, family and intimate partner violence (IPV), and co-occurring mental health conditions that impact and are impacted by these other conditions.

HIV/AIDS is the fourth-leading cause of death among Hispanic men and women ages 35–44 (Centers for Disease Control and Prevention [CDC], 2005). Though Hispanics represent 15% of the U.S. population they account for 18% of all new HIV infections; moreover, the rate of new HIV infections among Hispanics is three times that of non-Hispanic Whites (CDC, 2008). Substance abuse is putting our youth at high risk, with Hispanic 8th and 10th graders reporting the highest lifetime, annual, and 30-day use of cigarettes, alcohol, and drugs when compared to non-Hispanic White and African American youngsters (Johnston, O'Malley, Bachman, & Schulenberg, 2006). IPV is a serious concern in the Hispanic community, with Hispanic women experiencing higher rates of homicide compared to the national average (Violence Policy Center, 2001) and the highest recurrence rates of IPV (Caetano, Ramisetty-Mikler, & McGrath, 2005). Though Hispanics have similar rates of mental illness and mental disorders compared to Whites, depression rates have been shown to increase with acculturation level among some groups, and Hispanic adolescents report higher rates of depression and anxiety than non-Hispanics (U.S. Department of Health and Human Services [DHHS], 2008).

Our national health institutions recognize the importance of reducing and ultimately eliminating health disparities. Addressing health disparities is one of two overarching goals of the DHHS “Healthy People 2010” initiative (DHHS, 2000). Moreover, the key role of researchers in this quest is well recognized. Historically there have been numerous barriers to research with minority populations including small numbers of available participants, inadequate funding, unavailability of cross-culturally valid instruments, and controversy that sometimes accompanies research on ethnic minority groups (Sue & Dhindsa, 2006). Further, the Hispanic population is not monolithic; its heterogeneity with regard to country of origin, language preference and proficiency, acculturation, documentation status, immigration experiences, and socioeconomic status complicates research on health disparities and differentially affects disease outcomes.

The National Institutes of Health (NIH) through its National Center on Minority Health and Health Disparities (NCMHD) is investing in research to eliminate health disparities by establishing comprehensive research centers of excellence. The NCMHD released a call for applications in 2006 to make 13 awards at direct costs of up to $950,000 each per year. Though an earlier round of NCMHD centers of excellence focused on community outreach and training in addition to research (NCMHD Project EXPORT), this current round focuses on establishing centers of excellence that are more centrally focused on research for improving minority health and for eliminating health disparities. El Centro: Center of Excellence for Hispanic Health Disparities Research at the University of Miami (1P60 MD002266, N. Peragallo, P.I.), funded in September 2007, is the first and only NCMHD Center of Excellence located at a School of Nursing. The aims of El Centro are to (a) advance the scientific development and evaluation of culturally tailored interventions in HIV/AIDS and sexually transmitted infections, substance abuse, IPV, and co-occurring mental health conditions; (b) develop knowledge on the mechanisms by which culture-related processes lead to or protect from health problems and are linked to differential treatment responses across health conditions; and (c) train the next generation of health disparities scientists.

El Centro focuses on advancing culturally tailored interventions, that is, those that have been designed or adapted specifically for Hispanics. Though there are empirically supported interventions to address some of the health conditions that are the focus of El Centro, they are generally designed with non-Hispanics in mind. Even when interventions have been tested with mixed samples that include Hispanics, they tend to have insufficient Hispanic subsamples with which to conduct separate outcome analyses. One has to question the cultural utility of such interventions when they have not been designed for or even tested on Hispanics. Culturally tailored interventions are necessary because Hispanics have unique values, beliefs, behaviors, and histories that directly impact health and the efficacy of interventions.

There are promising interventions culturally tailored for Hispanics that incorporate cultural components. Prado and colleagues' (2007) parent-centered intervention, “Familias Unidas,” was found to be efficacious for preventing adolescent substance use and unsafe sex with middle school students in Miami and will soon be tested in 24 Miami-Dade middle schools. Peragallo et al. (2005) demonstrated risk reduction among Hispanic women in a randomized trial of “SEPA” (Salud, Educacion, Prevencion y Autocuidado [Health, Education, Prevention and Self-Care]), a group intervention designed for Hispanic women and tested with Puerto Rican and Mexican women in Chicago and currently being tested in Chile (Cianelli et al., 2006).

El Centro's research portfolio includes two randomized controlled trials. Peragallo's work on SEPA is being continued in a randomized efficacy study with a diverse group of Hispanic women in South Florida. El Centro's other randomized trial tests CIFTA (Culturally Informed Family Therapy for Adolescents; Santisteban, Mena, & Suarez-Morales, 2006), a family-based intervention for Hispanics previously used with older substance-using teens and adapted in the current study to prevent substance use and risky sexual behavior among younger teens at risk due to a mental health condition. Both SEPA and CIFTA interventions have been developed through systematic research programs aimed at ongoing refinement and adaptation of these promising approaches. In addition to the two randomized studies, El Centro funds two pilot studies per year through a program that provides seed grants to facilitate the development of new culturally tailored interventions through basic qualitative and quantitative studies.

Developing culturally tailored interventions requires basic research examining the linkages and common root causes of disorders and culturally related factors. For Hispanics, four culture-related processes highly relevant for health interventions and outcomes include acculturation, family functioning, familism, and culturally related stress. The immigration process can have a profound impact on health due to disruptions to the social network and family separations (Falicov, 2007; Mitrani, Santisteban, & Muir, 2004). We need to gain a better understanding of how such culture-related factors contribute to risk for and protection from disease and problematic health behaviors and how these cultural factors influence responses to interventions. A better understanding of the impact of these factors can help us refine interventions and make them more effective as well as design interventions that can address multiple disorders that have common root causes.

Health disparities research is fraught with the complexity of enrolling, retaining, and assessing vulnerable participants whose worldview and life situations might not be amenable to traditional research methods. The challenges multiply when investigating sensitive and stigmatized conditions such as HIV/AIDS, sexually transmitted infections, substance abuse, and family violence. Therefore, health disparities researchers need the support of a research infrastructure that can facilitate quality, efficiency, and productivity. El Centro's research and administrative cores provide resources to researchers such as a library of common measures, translation services, assistance with preparing protocols for Institutional Review Boards, data management and quality assurance services, and staff training on informed consent.

Finally, the future of health disparities science requires investment in interdisciplinary and culturally informed research training and mentorship of health science professionals. El Centro's pilot studies program aims not only at facilitating the development of new interventions but also at mentoring junior scientists in treatment development, study management, and grantsmanship. Doctoral students from a variety of disciplines receive hands-on training and opportunities for collaborating on scholarly products and applying for dissertation grants. We need culturally competent researchers who are knowledgeable about the many adaptations needed in studies involving Hispanics such as how to conduct recruitment, retention, and data collection procedures. We need for the next generation of health disparities scientists to be people who “get it”—who understand and who are committed to improving the health of Hispanics and developing culturally tailored interventions—and who are culturally competent to work with multiple constituencies in the community including consumers of interventions and social and health service providers.