Velasco-Mondragon et al. Public Health Reviews (2016) 3731 .docx

Velasco-Mondragon et al. Public Health Reviews (2016) 37:31
DOI 10.1186/s40985-016-0043-2
REVIEW Open Access
Hispanic health in the USA: a scoping
review of the literature
Eduardo Velasco-Mondragon1* , Angela Jimenez2, Anna G.
Palladino-Davis3, Dawn Davis4
and Jose A. Escamilla-Cejudo5
* Correspondence:
[email protected]
1College of Osteopathic Medicine,
Touro University California, 1310
Johnson Lane; H-82, Rm. 213,
Vallejo, CA 94592, USA
Full list of author information is
available at the end of the article
Abstract
Hispanics are the largest minority group in the USA. They
contribute to the economy,
cultural diversity, and health of the nation. Assessing their
health status and health needs
is key to inform health policy formulation and program
implementation. To this end, we
conducted a scoping review of the literature and national
statistics on Hispanic health in
the USA using a modified social-ecological framework that
includes social determinants
of health, health disparities, risk factors, and health services, as

they shape the leading
causes of morbidity and mortality. These social, environmental,
and biological forces have
modified the epidemiologic profile of Hispanics in the USA,
with cancer being the
leading cause of mortality, followed by cardiovascular diseases
and unintentional injuries.
Implementation of the Affordable Care Act has resulted in
improved access to health
services for Hispanics, but challenges remain due to limited
cultural sensitivity, health
literacy, and a shortage of Hispanic health care providers.
Acculturation barriers and
underinsured or uninsured status remain as major obstacles to
health care access.
Advantageous health outcomes from the “Hispanic Mortality
Paradox” and the “Latina
Birth Outcomes Paradox” persist, but health gains may be offset
in the future by
increasing rates of obesity and diabetes. Recommendations
focus on the adoption of the
Health in All Policies framework, expanding access to health
care, developing cultural
sensitivity in the health care workforce, and generating and
disseminating research
findings on Hispanic health.
Keywords: Hispanics, Latinos, Scoping study, Social
determinants of health, Health care
inequalities, Health care access
Background
Hispanics are the largest ethnic minority in the USA; in 2014,
Hispanics comprised
17.4% of the US population (55.4 million), and this percentage
is expected to increase

to 28.6% (119 million) by 2060. Hispanics in the USA include
native-born and foreign-
born individuals immigrating from Latin America, the
Caribbean, and Spain [1].
Hispanics are disproportionately affected by poor conditions of
daily life, shaped by struc-
tural and social position factors (such as macroeconomics,
cultural values, income, educa-
tion, occupation, and social support systems, including health
services), known as social
determinants of health (SDH). SDH exert health effects on
individuals through allostatic
load [2], a phenomenon purported to cause chronic stress, which
elicits behavioral risk
factors such as poor diet, sedentary behaviors, and substance
use, as well as biological pro-
cesses such as circadian rhythm disruption, cytokine responses,
and inflammation [3].
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Page 2 of 27
SDH are implicated in health inequalities, which are defined as
health conditions that
typically affect disproportionally certain socioeconomic, ethnic,
and gender population
subgroups [4]. Health inequalities particular to Hispanics are
also those related to their
socioeconomic status, cultural background, employment, and
foreign-born or undocu-
mented status [5, 6]. Hispanics residing in the USA are on
average 15 years younger,
four times more likely to not have finished high school, twice as
likely to live below the
poverty line, and 20 times less likely to speak proficient
English than non-Hispanic

Whites (NHW) [1, 7]. Hispanic women are also a growing
demographic group that en-
dure adverse social and health conditions and lack of access to
health care [8].
Risk factors for non-communicable diseases (NCDs), coupled
with decreased health
care access make Hispanics disproportionately vulnerable to
disease and death.
Hispanics endure major health risks such as obesity, teen
pregnancy, and tobacco use,
among others. Significant differences in risk factors, morbidity,
mortality, and access to
health care can also be observed among Hispanics by country of
origin [4, 9, 10]. The
most recent reports show that the leading causes of disease
among Hispanics are heart
disease, cancer, and high blood pressure, while the leading
causes of death are cancer,
heart disease, and unintentional injuries.
Health care services in the USA are provided mainly through
employer-based health in-
surance, Medicare, and Medicaid. Employer-based insurance is
usually privately pur-

chased. Medicare insures people 65 years and older (or younger
than 65 with disabilities),
and Medicaid is a social welfare program for low-income
population. In 2010, President
Obama signed into law the Patient Protection and Affordable
Care Act (ACA) to expand
health care protection by increasing insurance coverage,
expanding Medicaid, decreasing
health care costs, allowing provider choice and improving the
quality of care [11]. Histor-
ically, Hispanics in the USA have less access to health services
and they utilize fewer pre-
ventive care services than other ethnic groups, with 30%
reporting no health insurance
before the implementation of the ACA in 2014, compared to
11% for NHWs [12].
Several literature reviews on Hispanic and Latino/Latina Health
have been conducted
in the past; most consist of cross-sectional or qualitative studies
focusing separately on
acculturation, health disparities, risk behaviors, specific health
conditions, and access to
health care. Some of them focus on specific age and gender
groups or on country of

origin, migrant workers, and undocumented populations [13–
21], while some others
discuss the Latina Birth Outcomes and Hispanic Mortality
Paradoxes [22, 23].
After a preliminary review of the literature on the topic [7, 11,
24], we identified a
lack of a unified framework to assess Hispanic health in the
USA, as well as the need
to conduct a scoping review of the literature on the main
Hispanic health needs and
health policies and services—including the Latina Birth
Outcomes Paradox and the
Hispanic Mortality Paradox—to help inform policy- and
decision-making for improving
Hispanic health in the USA. Such is the objective of this review
paper.
Conceptual framework
After discussing several conceptual frameworks, and to
accomplish our objective, we devel-
oped a modified conceptual framework based on the social-
ecological model [25] and the
lifespan biopsychosocial model [26]. This comprehensive
framework embodies the complex
interactions—with synergistic and antagonistic effects—
between social, biological, and

Page 3 of 27
psychological constructs of health (Fig. 1). It posits that distal
variables pertaining to SDH
(Fig. 1, A)—some of which include the main variables of health
inequalities (Fig. 1, B)—op-
erate as stressors that elicit epigenetic, biological, and
psychological effects on individuals,
resulting in health, disease (Fig. 1, D), and death (Fig. 1, E).
They also interact with proximal
variables such as risk factors (Fig. 1, C) (diet, obesity, physical
inactivity, smoking, alcohol),
in the causal pathways leading to health and disease.
Components of the framework do not have unidirectional cause-
effect temporality but
rather compose causality networks and trajectories that
influence each other over time in
interconnected, multi-directional cycles. For example, social
support systems (education,
labor, sports, food programs, recreation) include health services
that serve as determi-
nants of health which influence health needs and risks;
however, changes in health needs

and risks in turn modulate health services (Fig. 1, F), which—
through prevention, treat-
ment, and rehabilitation services—have an effect on health
needs and risks. These causal
networks exert more nuanced effects across Hispanic population
subgroups by country of
origin, foreign-born status, and migrant and undocumented
status.
The wide-ranging breadth of this framework would be best
approached through a
comprehensive review and detailed analysis that would be too
extensive for this review
paper. Thus, we limit our review and analyses to the main
Hispanic health priorities, as
reported in the literature and based on the authors’ expert
consensus.
Methods
We utilized Arksey and O’Malley’s [27] scoping methodology
to conduct our review.
Scoping studies allow reviewing of both scientific and “gray”
literature to answer broad
Fig. 1 A framework to analyze Hispanic health in the USA

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research questions. They are useful to “map key concepts
underpinning a research area
and the main sources and types of evidence available.” Scoping
studies also serve to
identify research gaps and to summarize and disseminate
research findings to stake-
holders and policymakers who would otherwise have to obtain
information from mul-
tiple sources [28].
We followed the five stages of a scoping study:
1. Identify the research question. Different from systematic
reviews, where research
questions are specific and focused on a particular type of study
design, scoping
studies seek to answer broader questions and collect data from
different types of
information sources. They also allow iterative rather than linear
analytical processes
to fine-tune the research focus in a way that the information is
useful for decision-
making and further research. The research question to pursue in
this scoping review
is, What are the current priority issues, needs and services

germane to the health of
Hispanics in the USA?
2. Identify relevant studies. Guided by our framework, we
searched the literature for
comprehensive Hispanic health review documents in electronic
databases,
government websites and agencies, and civil society
organizations addressing Hispanic
health. The first step was to find out whether there were any
recent comprehensive
reviews addressing our research question. Figure 2 shows a
flowchart of our citation
selection process. In PubMed, we used the Boolean search terms
“Hispanic OR
Hispanics OR Latino OR Latinos OR Latina OR Latinas AND
health,” restricted to
“review” and “10 years,” which yielded 654 citations, too many
to review and too many
tangential to our research question. After a cursory review of
recent titles and
abstracts, we added “in title/abstract” as a filter, which
produced 381 citations. After
eyeballing the references, there were still many tangential to
our study questions. After

a more targeted approach (Fig. 2), we selected 66 citations (as
of September 2016) that
were more specific to our research question (see Additional file
1). A thorough review
of those citations supported our objective to conduct a scoping
study using a unified
framework of Hispanic health to answer our research question.
3. Study selection. A review of the initial reference list
containing 66 citations on
“Hispanic health reviews” showed that only one comprehensive
review had been
published in the previous 10 years [7], although it focused
mostly on health needs
and use of health services, not reflecting our more
comprehensive conceptual
framework and study design. While conducting this scoping
review (alerted by
peer-reviewers), a special issue on Latino Health was published
[23], which seemed
to supplant content in our review; however, the four papers in
that issue refer to
specific Hispanic health topics: cancer, cardiovascular disease,
health promotion,

and health issues in general, with no unifying framework. Upon
completion of our
literature search, a total of 366 references were included in an
EndNote© database.
For this paper, we selected only citations pertinent to each of
the components of
the conceptual framework of Hispanic health presented in Fig.
1, for a total of 179
citations (Fig. 2). All retrieved papers were made available
online to the authors in a
shared Dropbox file for online remote access.
4. Charting the data. A review of the first reference dataset
containing 66 citations
showed—with much overlap—that there were 26 review papers
focusing mainly on
Fig. 2 Literature review flowchart
Page 5 of 27
social determinants of health and health disparities, 20 on
health needs and risk
factors, and 20 on health services (see Additional file 1) versing
on diverse topics.
We were able to retrieve 42 of the initial 66 reviews. All other

references were
added as authors reviewed and retrieved materials from
different information
sources (PubMed, Internet, books), for each component of the
conceptual
framework.
5. Collating, summarizing, and reporting results. We reviewed
and selected papers,
documents, and websites systematically to develop the sections
on social
determinants of health and health disparities, health risks,
morbidity and mortality,
health services, and the Hispanic and Latina paradoxes. Authors
discussed and
agreed upon references to be added for each section. Table 1
was prepared to show
the main organizations addressing Hispanic health.
We did not conduct the optional sixth stage of a scoping study:
“Consultation.”
The following sections present the main components of
Hispanic health, as outlined
in our conceptual framework: social determinants of health and
health inequalities,

health risks, morbidity and mortality, health services and the
Latina Birth Outcomes
and Hispanic Mortality Paradoxes. Special subpopulations are
emphasized where infor-
mation was deemed important.
Table 1 Major Hispanic health agencies and initiatives in the
USA
Organizations (n = 13) Initiatives
Office of Minority Health “…addresses disease prevention,
health promotion, risk
reduction, healthier lifestyle choices, use of health care
services and barriers to health care for racial and ethnic
minorities.” http://minorityhealth.hhs.gov/omh/
browse.aspx?lvl=3&lvlid=64
CDC vital signs Hispanics “…includes a Morbidity and
Mortality Weekly Report Early
Release, a graphic fact sheet and website, a media release,
and social media tools. Most of the materials are available
in English and Spanish.” http://www.cdc.gov/vitalsigns/
hispanic-health/
US Office of Disease Prevention and
Health Promotion
“…seeks to engage organizations, professionals,
policymakers, communities, individuals, and families in a
linked, multi-sector effort to improve health literacy” http://
health.gov/communication/initiatives/health-literacy-ac-

tion-plan.asp
Federal Government; US Centers for
Medicare & Medicaid Services
“…health insurance exchange website operated under the
United States federal government under the provisions of
the Patient Protection and Affordable Care Act”
https://www.cuidadodesalud.gov/es/
Study of Latinos “…multi-center epidemiologic study in
Hispanic/Latino
populations to determine the role of acculturation in the
prevalence and development of disease, and to identify
risk factors playing a protective or harmful role in
Hispanics/Latinos.” https://www2.cscc.unc.edu/hchs/view/
biblio/year
Robert Wood Johnson Foundation Center
for Health Policy
“…provides the most in-depth views to date on Latinos’
experiences with the Affordable Care Act (ACA) in the five
years since its passage.” http://www.latinodecisions.com/files/
1214/2707/3700/UNM_RWJF_Center_Toplines_Posted.pdf
League of United Latin American Citizens (LULAC)
“[this]…initiative is a comprehensive approach designed to
reach Latinos across the United States and Puerto Rico to
address health disparities in our communities.”
http://lulac.org/programs/health/
National Hispanic Medical Association (NHMA) “…to empower
Hispanic physicians to lead efforts to
improve the health of Hispanic and other underserved
populations in collaboration with Hispanic state medical

societies, residents, and medical students, and other public
and private sector partners.” http://nhmamd.org/
National Council of La Raza “We partner with Affiliates across
the country to serve
millions of Latinos in the areas of civic engagement, civil
rights and immigration, education, workforce and the
economy, health, and housing.” www.nclr.org
United States - Mexico Border Health Commission “…addresses
border health challenges by advancing
initiatives that improve the health status of border
residents.” http://www.borderhealth.org/
Migrant Clinicians Network “We bring education, technical
assistance, peer support,
and advocacy to the field, creating a chain of connection
and commitment that makes everyone stronger and more
effective as we unite for one cause: health justice for the
mobile poor.” http://www.migrantclinician.org/
National Alliance for Hispanic Health. “We work to insure that
health incorporates the best of
science, culture, and community”
http://www.hispanichealth.org/
Rand Corporation Center for Latin American
Social Policy
“…dedicated to improving the well-being of the Latin
American population and conducts objective, independent
research on topics relevant to Latin Americans living and
working at home and in the United States.”
http://www.rand.org/labor/centers/clasp.html

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http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64
http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64
http://www.cdc.gov/vitalsigns/hispanic-health/
http://www.cdc.gov/vitalsigns/hispanic-health/
http://health.gov/communication/initiatives/health-literacy-
action-plan.asp
action-plan.asp
action-plan.asp
https://www.cuidadodesalud.gov/es/
https://www2.cscc.unc.edu/hchs/view/biblio/year
https://www2.cscc.unc.edu/hchs/view/biblio/year
http://www.latinodecisions.com/files/1214/2707/3700/UNM_R
WJF_Center_Toplines_Posted.pdf
http://www.latinodecisions.com/files/1214/2707/3700/UNM_R
WJF_Center_Toplines_Posted.pdf
http://lulac.org/programs/health/
http://nhmamd.org/
http://www.nclr.org/
http://www.borderhealth.org/
http://www.migrantclinician.org/
http://www.hispanichealth.org/
http://www.rand.org/labor/centers/clasp.html
Page 7 of 27
Social determinants of health and health inequalities
In this section, we present the major SDH of Hispanic health
including demography,
socioeconomic status, environment, occupation, and mobility.

We additionally discuss
the significant contributions of culture, language, poverty, and
gender to Hispanic
health inequalities.
Demography
Hispanics in the USA include people of Mexican (67.9%),
Puerto Rican (10.1%),
Salvadoran (4.0%), Cuban (3.9%), Dominican (3.4%),
Guatemalan (2.6%), and other
Hispanic origins (8.0%) [1]. In 2010, five US states had the
largest Hispanic popula-
tions: California (14 million), Texas (9.5 million), Florida (4.2
million), New York
(3.4 million), and Illinois (1.2 million). The following states
had the highest propor-
tion of Hispanic residents: New Mexico (46.3%), California
(37.6%), Texas (37.6%),
Arizona (29.6%), and Nevada (26.5%) (Fig. 3).
The median age of the US Hispanic population is 27 years, as
compared to the US
population (37 years) and NHWs (42 years) [29, 30]. Life
expectancy at birth is longer
for Hispanics (79.1 years for males, 83.8 for females) than for

NHWs (76.5 years for
males, 81.2 for females) (23), and Hispanics have a lower
lifespan variability than do
NHWs [31]. The growth of the US Hispanic population has
created a significant racial/
ethnic generational gap in the USA; in 2010, 34.9% of
Hispanics were under the age of
18 compared to 20.9% of NHWs [32]. The percentage of
Hispanics aged 65 and older
is expected to grow by 134% between 2012 and 2050 as
compared to 58.4% for the
NHW population [33, 34].
Environment
About 91% of US Hispanics reside in metropolitan areas [35],
and 28.3% of them reside
near major highways with high traffic volume [36]. Living near
a major highway is asso-
ciated with adverse outcomes including acute [37] and chronic
[38, 39] respiratory ill-
nesses, cardiovascular diseases [40, 41], obstetrical
complications [42], and poor
pregnancy outcomes [43]. Cancer risk pollutants emitted
indoors tend to be higher in

Hispanic households [44].
Fig. 3 Percentage of Hispanic population in 2010. Source: [178]
Page 8 of 27
Despite significant improvements in water availability and
quality in the USA, some
Hispanic communities still face water quality associated health
threats including
elevated levels of arsenic [45] and nitrates [46].
In 2013, 21.5% of US Hispanics were estimated to live near
Superfund1 sites [47].
Compared to NHWs, Hispanics are more likely to reside in
areas with increased indus-
trial pollution [48]. Residence near hazardous waste sites has
been positively related to
an increase in hospitalization from diabetes [49].
Occupation
The employment rate among Hispanics (66.4%) is similar to that
of NHWs (64%).
Hispanic workers perform a disproportionate amount of
unskilled, high-risk jobs (59%) as
compared to NHWs (38.1%) in construction, domestic
maintenance and repair services,

nondurable manufacturing, and personal and household services
[50]. Hispanics face an
increased risk of mortality from some occupational hazards. As
compared to NHW, the
relative risk (RR) of a heat-related death among Hispanic
agricultural workers was 3.4
(95% CI 2.0, 5.8) and among construction workers 1.7 (95% CI
1.1, 2.6); the risk of death
from occupational carbon monoxide exposure was 1.4 (p < 0.05)
[51, 52].
Mobility
In recent years, the US Hispanic population has disseminated
towards Central and
Eastern States, with nine of them experiencing increments over
100% (SC, AL, TN, KY,
AR, NC, MD, MS, and SD) in search of work and better living
conditions (Fig. 4).
Culture and language
Hispanics in the USA have a particular social and cultural
identity that characterizes
them as an ethnic group. These, together with language, are the
main manifestations of
their culture. First-generation Hispanics (meaning they

themselves were foreign-born)
differ from second-generation Hispanics (US-born sons or
daughters of at least one
foreign-born parent) in language use, acculturation, diet, and
other characteristics
which exert differential health effects. For example, second-
and third-generation
Hispanics have an increased frequency of overweight and
obesity when compared to
Fig. 4 Percentage of Hispanic population growth 2000–2010.
Source: [178, 179]
Page 9 of 27
first-generation Hispanics [53]. Familism is also an important
cultural value among
Hispanics [54] and is a source of emotional and financial
support that may exert health
risk-mitigating effects [17, 55].
In 2014, 68.4% of Hispanics reported they speak English at
home or that they speak
English “very well” as compared to 59.0% in 1980 [56]. Though
English proficiency and
educational level among Hispanics have increased, educational
attainment is still low

mainly among foreign-born Hispanics [57]. Between 2000 and
2013, the high school
dropout rate decreased from 32 to 14%; still, it was nearly three
times higher than that
of NHWs (5%). Two- and four-year college enrollment
increased 201% for Hispanics
(versus 14% for NHWs), but in 2013 only 15% of Hispanics had
at least a bachelor’s
degree as compared to 40% of NHWs (34). Hispanics are
underrepresented in Science,
Technology, Engineering, and Mathematics (STEM) careers
[58], and there is a
growing shortage of Hispanic health care professionals [59].
Poverty and household income
In 2014, the median household income of Hispanics (USD
$39,600) was 52% lower than
that of NHWs (USD $60,300) [60]. Between 2000 and 2010, the
poverty rate among
Hispanics in the USA increased 5.1% as compared to that of
NHWs (2.5%) [61]. By 2014,
23.6% of Hispanics were living below the poverty level, starkly
differing from that of the
national population (14.8%) and NHWs (10.1%). Additionally,

the income-to-poverty
ratio, a measure of depth of poverty, showed that 9.6% of
Hispanics had income below
one half of their poverty threshold (deep poverty) as compared
to 4.6% of NHWs [60].
Poverty is high among the youngest and oldest Hispanics. In
2010, 6.1 million Hispanic
children were living in poverty, the majority of which (4.1
million) were children of immi-
grant parents. Among adults 65 years and older, Hispanics have
the highest poverty rate
(20%) when compared to national estimates of poverty (10%)
[62].
Poverty and health care
Health care services both influence health and are influenced by
health needs. In the
USA, health insurance is a key determinant of access to health
care services. Hispanics
have lower rates of health insurance enrollment than NHWs
[63], a figure that is higher
for recent immigrants [64]. In 2014, 26.5% of Hispanics were
uninsured as compared to
10.4% of non-Hispanics under age 65. The gap was higher for
persons aged 65 and

over: 4.4% among Hispanics, compared with 0.5% among
NHWs. When poverty levels
were considered, gaps were higher. Among the Hispanic poor
under age 65, 37.1%
lacked insurance as compared to 19.7% of poor NHWs and
19.5% of poor African-
Americans. Among persons aged 65 and over, 7.1% lacked
health insurance as
compared to 0.5% of near poor NHWs and 2.2% of poor
African-Americans [65].
Gender
Health inequalities are heightened among US women, mostly
related to social de-
terminants such as unfair paid labor, schooling, and violence.
Longitudinal analyses
of changes in racial and gender inequality during the last four
decades (1970 to
2010) have found important differences in median income by
race/ethnicity among
those aged 25 to 64 years. For example, in 1970 NHW women’s
earned income
was 20% higher than that for Hispanic women; it was 50%
higher in 2009. Lower

Page 10 of 27
educational attainment among Hispanic women has worsened
over time, from 11%
in 1969 to 22% in 2009 [66]. Lower educational attainment has
been shown to pro-
tect against morbidity, mortality, and depression, although
recent research has
shown that, among US-born Mexican-American women, higher
educational attain-
ment was associated with diabetes [67].
Hispanic women tend to be more vulnerable to abuse and
mistreatment; Hispanic
women may suffer lower self-esteem and higher intimate partner
violence (IPV), with
differential rates by country of origin [64]. Those who recently
immigrated to the
US—who work in bars or cantinas—were found to be at higher
risks of experiencing
intimate partner violence, including increased sexual risk
behaviors from their primary
or non-primary sexual partners [68].
Migrant seasonal farm workers (MSFW)

The US Hispanic population includes a large number of migrant
and temporary
workers who are foreign-born. Self-selection of migrant workers
may explain some of
the apparent health advantages in the US Hispanic population.
This is also known as
the healthy migrant effect [69].
MSFWs are one of the most marginalized populations in the
USA. A high proportion
of them (68%) were born in Mexico [70], 78% are males, 59%
are married, and their
average age is 36 years.
Given the nature of agricultural work, MSFWs face particular
occupational health
hazards such as pesticide exposure [71, 72], heat exposure [73],
musculoskeletal injuries
[74], respiratory illnesses [75], skin disorders [76], eye injuries
[77], food insecurity [78],
and depression [79]. Assessment of these and other health risks
and outcomes is
hampered by MSFWs’ highly mobile lifestyle, limited English
proficiency, varying levels
of citizenship status, and cultural barriers.

Undocumented immigrant workers
Unauthorized immigration is an important demographic
phenomenon in the USA;
undocumented immigrant workers play an important role in the
US economy.
Although declining, by 2012 the number of unauthorized
immigrants was estimated at
11.2 million, the majority of whom (53%) were Mexican-born
[80]. Undocumented
migrant workers are employed in substandard, high-risk jobs
with risky occupational
exposures and very limited or no health insurance [81].
Risk factors
This section presents some of the main risk factors underlying
the most important
chronic diseases affecting Hispanics in the USA, namely
obesity, tobacco smoking, and
alcohol intake.
Obesity
The obesity epidemic underlies multiple health issues among
Hispanics; it is a common
denominator in the development of metabolic syndrome, non-

alcoholic fatty liver
disease (NAFLD), diabetes, and cardiovascular disease (CVD).
In addition, obesity
increases the risk for several forms of malignancies [53]. The
Hispanic population in
the USA is disproportionately affected by obesity, with 42.5%
[82] of adults currently
Page 11 of 27
classified as obese. This reflects a significant increase in
prevalence since 1999, when
approximately 20% of Hispanic adults were classified as obese
[83]. Additionally,
Hispanics have the highest rates of obesity among American
youth (ages 2–19 years) at
21.9%, compared with 14.7% in NHWs [82], and Hispanic
children aged 2–5 years have
a fivefold higher prevalence of obesity compared to their NHW
counterparts [82, 84].
Previous data showed that Hispanic children born outside of the
USA were less likely
to be obese than those born in the USA to immigrant parents
[85]. More recent data

demonstrate that foreign-born children of Hispanic immigrants
are more likely to be
overweight than children of more settled Hispanic immigrants
and children of US
natives [86].
The prevalence of obesity is heterogeneous among Hispanic
subgroups, though
across all subgroups females are more likely to be obese than
males. Obesity rates vary
from 26.8% of South American males to 51.4% of Puerto Rican
females [87]. Puerto
Rican Hispanics have a higher-risk profile for diabetes, cancer,
and CVD [87]. Signifi-
cant differences in the prevalence of obesity have also been
noted between US-born
Hispanics (47.1%) and foreign-born Hispanics (36.3%) [7].
Higher degrees of accultur-
ation correspond with greater body weight in all migrant groups
to the USA [88],
though this effect is particularly pronounced in Mexican-born
individuals [89, 90].
Obesity increases the risk for multiple associated health
conditions. Obesity indirectly
increases the risk of CVD and stroke by increasing the risk of

hypertension [88] and
diabetes [91]. The prevalence of diabetes and hypertension has
been demonstrated to
rise steadily in Hispanics of all ages with an increasingly
elevated body mass index
(BMI) [92]. Obesity also contributes to metabolic syndrome,
which is characterized by
insulin resistance. In turn, insulin resistance is a major risk
factor for the development
of diabetes as well as NAFLD [93], a condition that
disproportionately affects Hispanics
and can increase the risk of liver malignancies. Finally, the
metabolic syndrome directly
promotes the development of atherosclerotic CVD [94].
The high incidence of obesity in US Hispanics is a
multifactorial problem. Food and
beverage marketing for Hispanics in the USA promotes the
consumption of low-
nutrient, calorie-dense foods and beverages, especially among
children [20]. Low-
income Hispanic mothers have been found to engage in highly
permissive, indulgent
feeding patterns that relate directly to child obesity [95]. Food
insecurity (when mem-

bers of a household experience reduced quality, variety, or
desirability of food products)
has been significantly associated with obesity in low-income
Mexican-American women
living in California [96]. Other risk factors such as glucose
intolerance and gestational
diabetes affect Hispanic women and their descendants, as they
will be more likely to
develop diabetes themselves [97]. Moreover, health care
inequalities contribute to obes-
ity as well. For example, only 23% of Hispanics reported that
their physician had
discussed diet and exercise with them in the previous year; this
percentage was lower
(17%) among foreign-born Hispanics [91]. Behavioral factors
have a much greater
impact on premature death than does health care, making this
lack of preventative
counseling significant [98].
Tobacco
The tobacco industry targets Hispanics by utilizing custom
advertising and by finan-
cially contributing to Hispanic community activities [99, 100].

In 2013, 20.9% of
Page 12 of 27
Hispanic adults in the USA had used tobacco products within
the last month, as com-
pared to 28.5% of the non-Hispanic population. The incidence
of tobacco use is highest
in Puerto Ricans, with 34.7% of males and 31.7% of females
reporting tobacco use. In
contrast, the incidence of smoking is lowest in Dominican males
(11.1%) and Central
American females (8.7%) [87].
In the USA, second-generation Hispanics have a
disproportionately high rate of to-
bacco use, which increases their risk for CVD, diabetes, and
cancer [101].
Many prevalent cancers in Hispanics (lung, breast, colorectal,
and liver) share pre-
ventable risk factors, including, tobacco consumption, sedentary
lifestyle, alcohol abuse,
obesity, and an unhealthy diet. Additionally, other cancers
(gastric, liver, and cervical)
are associated with previous preventable or treatable infections,

such as Helicobacter
pylori, hepatitis B/C virus (HBV/HCV), and human
papillomavirus. In the future,
cancer mortality rates may decrease by avoiding risk factors
that are the outcomes of
acculturation, culturally insensitive public health approaches,
and limited health care
access [102].
Alcohol
Consumption of alcohol constitutes a risk factor for cancer,
diabetes, CVD, and meta-
bolic syndrome [103]. In the USA, Hispanics are less likely to
binge-drink (defined as
having a blood alcohol concentration greater or equal to 0.08
g/dL after 2 h of intake)
when compared with NHWs [103]. However, alcohol
consumption among Hispanics
who already drink is higher than among NHWs. In 2010, the
rate of alcohol depend-
ence by country of origin was as follows: Puerto Rico 5.5%,
Mexico 4.7%, South/Central
America 3.1%, and Cuba 2.4% [90]. Binge drinking contributes
to the development of

fatty liver disease [104, 105].
Morbidity and mortality
Social, environmental, and biological forces have modified the
epidemiologic profile
of Hispanics in the USA, with cancer being the leading cause of
mortality, followed
by cardiovascular diseases, liver disease, and unintentional
injuries. CVD and
diabetes share a host of common risk factors. Most specifically,
these take the form
of the metabolic syndrome, which is diagnosed when an
individual meets any three
of the following five criteria: elevated waist circumference
(central obesity), elevated
triglycerides, reduced high-density lipoprotein-C, elevated
blood pressure, or ele-
vated fasting glucose [94].
Cardiovascular disease
CVD is the second leading cause of death for Hispanics residing
in the USA [67].
Significant risk factors for CVD include hyperlipidemia,
tobacco use, diabetes, obesity,
and hypertension [87]. Despite having an increased prevalence
of several of the risk

factors for CVD, Hispanics have a 25% lower death rate from
cardiac disease than
NHWs [7] and a 20% lower age-adjusted prevalence of
congestive heart disease than
NHWs [106]. This seemingly paradoxical finding may be
explained by the relatively
low median age of Hispanics residing in the USA, or it may
represent an extension of
the Hispanic Mortality Paradox, as supported by recent
publications [7, 106, 107].
Page 13 of 27
Diabetes
In 2012, it was estimated that 29 million Americans had
diabetes [97]. The incidence of
diabetes increased until 2010 and then decelerated between
2011 and 2014. As shown
in Fig. 5, the Hispanic population is disproportionately affected
by diabetes [97]. The
incidence of diabetes in Hispanics has been increasing when
compared to NHWs [108].
The prevalence of diabetes varies among Hispanic subgroups: in
2012, the age-adjusted

rate of diagnosed diabetes was 14.8% for Puerto Ricans, 13.9%
for Mexicans, 9.3% for
Cubans, and 8.5% for Central and South Americans (Fig. 6)
[97].
Hispanics with diabetes in the USA are affected by related
comorbidities such as
CVD, diabetic retinopathy, chronic renal disease, and diabetic
neuropathy. These
diseases generate additional medical expenses that especially
affect uninsured Hispanics
[97]. In the USA, the total diabetes expenditure for the year
2012 was 245 billion US
dollars: 176 billion expended in direct medical costs
(comorbidities, medications, med-
ical supplies, hospitalization) and 69 billion in indirect costs
(loss of employment, per-
manent disability, low healthy life expectancy) [97]. The
medical expenses of
Americans with diabetes were 2.3 times higher than the medical
expenses of their
healthy counterparts [97].
In the USA, diabetes mortality disproportionately affects
Hispanics. In 2010, diabetes

was one of the top ten causes of mortality in the country with
69,071 deaths [97]. The
death rates from diabetes were significantly different for
Hispanics (26.3 per 100,000)
when compared to NHWs (18.6 per 100,000) in 2013. Among
Hispanic males, diabetes
death rates were higher (30.4 per 100,000) when compared to
NHW males (23.1 per
100,000). For Hispanic women, diabetes death rates were also
higher (23.0 per 100,000)
when compared to NHW women (14.9 per 100,000) [108, 109].
Cancer
While Hispanics have a 30% lower mortality and 20% lower
morbidity due to cancer
than NHWs, cancer is now the leading cause of death among
Hispanics. In 2015,
125,900 incident cases of cancer were estimated to have
occurred among Hispanics,
with a case-fatality rate of 30% (37,900 deaths) [110, 111].
Consistent with decreasing
Fig. 5 Percentage of diagnosed diabetes by ethnicity in people
aged 20 years or older for the period
2010–2012. *Age-adjusted based on the 2000 US standard
population. Source: [97]

Fig. 6 Percentage of diagnosed diabetes by Hispanic subgroups
2010–2012. *Age-adjusted based on the
2000 US standard population. Source: [97]
Page 14 of 27
trends in cancer mortality among NHWs, cancer mortality has
also decreased among
Hispanic men (1.5% per year) and women (1.0%).
Cancer of the prostate is the most common cancer in Hispanic
men (22%), followed
by colorectal (11%) and lung (9%) cancer. Among women,
breast cancer is the most
frequent (29%), followed by thyroid (9%), colorectal (8%), and
uterine (8%) cancer.
Among men, the main cause of cancer death is lung (17%)
cancer, followed by liver
(12%) and colorectal (11%) cancer [112]. Among women, the
most frequent cause of
cancer death is breast (16%) cancer, followed by lung (13%)
and colorectal (9%) cancer.
Breast cancer death rates are about 30% lower in Hispanic
women than NHW women.
The incidence of gastric cancer is increasing in young Hispanic
men [113, 114].

Cancer morbidity and mortality rates differ by country of origin
and ethnicity. For
example, Puerto Ricans and Cubans have similar incidence rates
as NHWs but lower
rates than Mexicans. Death rates among Puerto Ricans are 12%
lower than for NHW
men but 20% higher than those of Mexican men. Compared to
NHWs, Hispanics are
more likely to be diagnosed with infection-related cancers such
as gastric, hepatic, and
cervical but are less likely to be diagnosed with prostate, breast,
lung, and colorectal
cancer. US-born male Hispanics are twice as likely to develop
hepatocellular carcinoma
than foreign-born Hispanics [115]. The reasons for these
morbidity and mortality
differences have been attributed to first-generation status,
healthy immigrant effects,
country of origin, younger age structure, late-stage diagnoses,
and lower survival rates
likely due to lower access to preventive and diagnostic health
services [112, 116].
Liver disease
Liver disease is the 11th most common cause of death in

Americans, but the sixth most
common cause of death in Hispanic individuals residing in the
USA. For both
Hispanics and NHWs, deaths attributed to chronic liver disease
are equally divided
between alcohol and other causes [7]. Hispanic individuals in
the USA have a 48%
higher death rate from liver disease and cirrhosis than NHWs.
Common causes of liver
disease affecting Hispanics in the USA include non-alcoholic
fatty liver disease
(NAFLD), alcoholic liver disease (ALD), and chronic infections
with viral hepatitis.
Page 15 of 27
NAFLD encompasses a variety of liver conditions that are
histologically similar to al-
coholic liver disease and can culminate in cirrhosis and liver
failure [93]. Obesity and
insulin resistance, two components of the metabolic syndrome,
are risk factors for
NAFLD and have been found to be correlated with hepatic fat
accumulation in

Hispanics [117]. NAFLD is associated with CVD in all affected
populations, and cardio-
vascular complications are the most common cause of death in
persons with NAFLD
[118, 119]. The worldwide prevalence of NAFLD is estimated at
20%. The prevalence
of NAFLD in Hispanics living in the USA is at least 29% [120,
121], where the risk is
heterogeneous. For instance, Hispanics of Mexican origin
maintain a significantly
higher risk of NAFLD (33%) than do individuals of Dominican
(16%) or Puerto Rican
(18%) origin [12].
The risk for Mexican-Americans remains high even after
controlling for age, sex, BMI,
waist circumference, hypertension, and insulin resistance. The
reasons for the Hispanic
preponderance of NAFLD have yet to be fully elucidated;
polymorphisms in the patatin-
like phospholipase domain-containing 3 gene, which is
exceptionally common in Hispanic
populations, may help to explain the susceptibility to NAFLD
[93, 122, 123].
There is a paucity of literature regarding ALD among US

Hispanics. Overall, His-
panics have lower rates of alcohol consumption than do NHWs.
Mexican and Puerto
Rican subgroups have the highest documented alcohol
consumption [124]. There are
disparities in care which affect Hispanics, including decreased
access to professional
substance abuse programs [121]. Hispanic patients with ALD
often present with more
severe disease at earlier ages than do NHW and Black patients
[125].
The contribution of viral hepatitis to liver disease in the
Hispanic population is simi-
lar to that of the general NHW population. The Hispanic
Community Health Study/
Study of Latinos (HCHS/SOL) reported that the overall
incidence of active HBV infec-
tion was 0.29% [126]. However, these results were
heterogeneous, with the highest inci-
dence of active infection noted in those born in the Dominican
Republic (0.95%) and
the USA (0.57%). The HCHS/SOL cohort also demonstrated
heterogeneity in HCV in-
fection among Hispanics living in the USA [126].

The HCV prevalence among Hispanics 18–74 years of age
residing in the USA was
reported as 1.5% in the National Health and Nutrition
Examination Survey 2007–2010
[4, 127] and 2.0% in the HCHS/SOL population [128]. The HCV
seropositivity rates
varied from 0.4% among males of South American descent to
11.6% of males of Puerto
Rican descent. On average, females had lower rates of HCV
than males in all Hispanic
subgroups. The rates of HCV also varied by age and current city
of residence [126]. All
of the previously mentioned causes of liver disease increase the
risk of liver cancer. US
Hispanics are also at higher risk of developing [3] and dying
from cancer of the liver
and bile ducts [7, 129].
Unintentional injuries
Mortality from unintentional injuries in 2010 ranked third for
the Hispanic population,
accounting for 7.3% of deaths after malignant neoplasms
(21.5%) and heart disease
(20.8%), while deaths from unintentional injuries accounted for

4.8 and 4.2% among
NHWs and non-Hispanic blacks, respectively [9].
The three leading causes of unintentional injuries were motor
vehicle collisions, acci-
dental poisoning, and falls. When combined, these three
represented 49.2 and 50.2% of
Page 16 of 27
all deaths from intentional and unintentional causes in 2000 and
2009, respectively
[130]. Furthermore, Hispanics and Blacks had lower motor
vehicle traffic crash ad-
justed mortality rates than did Whites. These are in line with
previous findings examin-
ing ethnic differences showing declines in unintentional injury
deaths among Hispanics
as compared to NHWs for the periods 1992–2002 [131] and
1999–2005 [132]. Lastly,
increased pedestrian-related deaths in the Hispanic elderly
population contribute to
mortality from unintentional injuries in this vulnerable
population [133].
The Latina Birth Outcomes and the Hispanic Mortality
Paradoxes

Despite their socioeconomic disadvantages and burden of
disease, all-cause mortality
among Hispanics is 24% lower than for NHWs and mortality is
also lower for nine out
of 15 leading causes of death [7]. Hispanics in the USA have a
longer life expectancy at
birth and experience some better health outcomes than similar
socioeconomic groups,
a phenomenon described roughly 30 years ago as the “Hispanic
Mortality Paradox.”
Seeming to persist to this date, the Hispanic Mortality Paradox
is mostly attributed to a
“healthy migrant effect” [134–137] involving cultural mores
and health behaviors of
first-generation Hispanics in the USA. Additionally, Hispanic
women in the USA have
birth outcomes similar to those of women with a higher
socioeconomic status and ac-
cess to health services in the USA, a phenomenon known as the
“Latina Birth Out-
comes Paradox” [138, 139], apparently due to acculturation-
related behaviors such as
diet, smoking, and social support [18], although this paradox
remains controversial

[140, 141].
Infant mortality and the Latina Birth Outcomes Paradox
The infant mortality rate is an accurate reflection of a nation’s
health that proves
that social determinants of health are shaped by the economics,
social policies, and
politics surrounding the circumstances in which people are
born, grow up, live,
work, and age [142].
The US Centers for Disease Control and Prevention (CDC)
estimates the infant mor-
tality rate in the USA at 5.96 per 1000 live births, which is only
a 10% reduction since
the year 2000. Specifically, for Hispanics the infant mortality
rate is 5.1 per 1000 live
births [143]. Hispanics in the USA have the highest birth rate
among racial/ethnic
groups [144]. Despite being a vulnerable population due to their
socioeconomic status
and inadequate health care, babies born to Hispanic women,
particularly to foreign-
born mothers, experience lower rates of low birth weight and
mortality compared to

national averages, a phenomenon known as the Latina Birth
Outcomes Paradox
[145–147]. Various explanations have been proposed for this
paradox. One is that
perceived cultural and protective factors may be a result of
social support from ex-
tended family members, community health workers, and lay
midwives [148]. Some
protective factors that have been identified “include a strong
cultural support for
maternity, healthy traditional dietary practices, and the norm of
selfless devotion to
the maternal role” [149]. However, given the health coverage
disadvantage in this
population, the potential for their undocumented/inadequate
legal status presents
challenges to the foreign-born Hispanic pregnant population.
While the importance
of adequate prenatal care is recognized, as seen in the Latina
Paradox, it shows
that there is more to prenatal care in this population.

of 27
The CDC states that “the risk of…infant mortality and
pregnancy-related complica-
tions can be reduced by increasing access to quality…care
[because pregnancy provides]
an opportunity to identify existing health risks in women and to
prevent future health
problems for women and their children” [150].
An unanswered question is whether the ACA and enhanced
Medicaid perinatal care
programs are having an effect on birth outcomes [151]. Initial
data are promising that
the ACA does indeed have the capacity to improve perinatal
outcomes even further
once fully implemented, though these data are not yet available
[151]. Prematurity, the
number one reason for infant mortality, declined in the states
that have implemented
Medicaid expansion [152].
Nonetheless, the main reasons for Hispanic women not being
able to access care are
(1) not being “poor enough” to qualify for Medicaid without any
structured perinatal
care on which to rely on; (2) unable to afford coverage offered

by the ACA; and (3)
born outside the USA and may not qualify for Medicaid
coverage depending on their
legal status and the state they live in, as there are differences in
eligibility and perinatal
coverage among states [153]. It thus begs the question as to how
Hispanic women
within the gap will be able to afford and obtain quality perinatal
care.
The Hispanic Mortality Paradox
The Hispanic Mortality Paradox refers to lower mortality rates
and better health out-
comes among foreign-born, newly arrived, and thus less
acculturated Hispanics as com-
pared to native-born Hispanics or to NHWs. Reasons for this
paradox may be that
migrants and first-generation Hispanics may represent a self-
selected healthier popula-
tion. Also, undocumented or un-acculturated Hispanics may
leave the country if un-
healthy or their negative health outcomes may be underreported
due to lack of access
to health services. Lower rates of smoking seem to be at the
heart of the Hispanic Mor-

tality Paradox; however, the obesity and diabetes epidemics,
together with higher levels
of inflammatory biomarkers and increasing social and
environmental stressors, may off-
set the health advantages of Hispanics in the future [106, 107,
135, 136].
Health services
The social response to health needs is implemented through
health policy and pro-
grams, generically called “health services.” Typical health
service indicators include ac-
cess, coverage, utilization, costs and expenditures, and quality
and performance. In the
case of Hispanics, health literacy and cultural competence play
important roles.
The implementation of the ACA has increased access to health
care for Hispanics; a
recent survey showed that 87% of US-born Hispanics have
health insurance, compared
to 78% of those born outside the USA [154]. The ACA has
expanded coverage by 5.3%
since it was established, granting access to Medicaid and state
and federal health insur-

ance. The uninsured rate has decreased by 11.9% among
Hispanics compared to a 6.1%
decrease among NHWs [155]. However, barriers to access
persist: about half of
Hispanics who are uninsured have household incomes under
133% of the poverty line
(about USD $15,500 a year), which makes them eligible for
Medicaid [10, 156]. As of
December 10, 2015, 25 states had expanded Medicaid while 20
had not and another six
are using alternative expansion waivers.2 By the end of 2014,
about a quarter of
Hispanics remained uninsured in states that expanded Medicaid
eligibility as compared
Page 18 of 27
to about a half of Hispanics in states that have not, and still
higher percentages remain
uninsured in states like Texas and Florida, which have the
second and third largest
Hispanic populations.
An analysis of four national health surveys reported higher rates
(41.5%) of uninsured

Hispanics ages 18–64 years (45.3% men, 37.4% women)
compared with 15.1% of
NHWs of the same age. Moreover, foreign-born Hispanics 18–
64 years were over twice
as likely to be uninsured than US-born individuals (54.7 vs.
25.9%, respectively). About
15.5% of Hispanics reported delayed or lack of medical care
because of cost concerns
compared to just 13.6% of NHWs and 12.5% did not obtain
needed prescription drugs
because of cost compared to just 9.5% of NHWs [7].
Hispanics use fewer health screenings, have less follow-up care,
and face more eco-
nomic and cultural barriers to health care. Hispanics are 28%
less likely to be screened
for colorectal cancer than are NHWs. Hispanic women have less
access to breast can-
cer and cervical cancer screening [157, 158].
Hispanics are more likely than NHWs to receive mental health
care through emer-
gency departments rather than self-referral or outpatient
services [159]. They are also
more likely than other ethnic groups to discontinue diabetes
medications after losing

health care coverage [160].
The number of Hispanic health care professionals does not
mirror the total percent-
age of Hispanics in the USA (17.4%). Hispanic professionals
have been historically un-
derrepresented in the health professions in the USA:
pharmacists make up 3.4%,
physicians 5%, physician assistants 3.7%, licensed registered
nurses 1.7%, and dentists
3.3% of health professionals [161]. In 2015–2016, medical
enrollment and graduation
remains at about 5%.
Hispanics comprise about 14% of the total US workforce in the
USA. About 50% of
the 22 million Hispanic workers in the USA are immigrants.
Immigrant workers are
often employed in high-risk jobs where they bear a high burden
of occupational injur-
ies, often holding temporary jobs with no health benefits. They
are also often geograph-
ically mobile, thus unable to have a usual care provider and
obtain continuity of care
[162]. Undocumented Hispanics make up about 5% of the US

workforce but they are
ineligible for health insurance and thus more likely to advance
to severe illness and use
emergency care services. A standardized approach to providing
emergency care is
through the Emergency Medical Treatment and Labor Act, a
long-standing act of Con-
gress that “imposes specific obligations on Medicare-
participating hospitals that offer
emergency services to provide a medical screening examination
when a request is made
for examination or treatment for an emergency medical
condition, including active
labor, regardless of an individual’s ability to pay” [163].
Recommendations
This scoping review provides an updated account of the social
determinants of health,
health inequalities, and risk factors shaping Hispanic morbidity
and mortality trends in
the one hand and the organized social response by health
services in the other. Our re-
view considers recent information on Hispanic subpopulation
types: Hispanics born in
the USA, foreign-born, undocumented, and migrant and

seasonal farm workers
(MSFW). The increasing heterogeneity of the Hispanic
population in the USA by
Page 19 of 27
country of origin is also taken into account. Additionally, we
provide brief updates on
the Hispanic Mortality Paradox and the Latina Birth Outcomes
Paradox.
A multilevel, multifaceted approach, from social policy to
health services, is needed
to improve the health of Hispanics in the USA. We identified
three priority policy and
programmatic areas to be pursued.
Adopt a Health in All Policies approach
Social, environmental, and biological forces have modified the
epidemiologic profile of
Hispanics in the USA [164]. Health in All Policies is an
initiative to frame collaborative
approaches among all social sectors towards embedding health
and equity into govern-
ment decision-making processes [165]. In the USA, the Healthy
People initiative pro-

vides science-based, 10-year national health promotion and
disease prevention goals.
Healthy People 2020 [150] goals for Hispanic health programs
should target improving
access to healthier food choices, preventing environmental
exposures, offering safe
environments for exercise and recreation, and increasing access
to primary and pre-
ventative health care access.
Initiatives like those proposed by the Social Determinants of
Health Work Group at
the CDC offer a roadmap to address SDHs and health
inequalities through five key do-
mains: (1) economic stability, (2) education, (3) health and
health care, (4) neighbor-
hood and built environment, and (5) social community context.
They identify national,
state, and local resources and point out national experiences of
interventions to im-
prove social determinants of health [166].
Intersectoral actions are key to address the diversity of social
determinants of health
and also involve partnering with communities to engage them
and increase the pertin-

ence of interventions. The interconnected nature of
determinants of health, health
inequalities, and risk factors herein presented require equally
comprehensive initiatives
that would not only target and help Hispanics but other ethnic
and vulnerable popula-
tions sharing similar contexts, through multidisciplinary,
multisectoral programs aim-
ing at generating sustainable local capacities [166].
The integrated approach presented in our conceptual framework
reflects the opportunity
for the different social sectors to share information and
collaborate with direct actions tar-
geting the different social determinants of health within their
area of responsibility. For ex-
ample, health authorities can collaborate with housing, urban
development counterparts to
generate comprehensive programs focusing on improving local
housing and the built envir-
onment, as well as indoor environmental conditions. Table 1
presents some of the most
prominent organizations and initiatives working on improving
Hispanic health in the USA.

Increase health care access
Unequal health insurance markets have created a variegated
array of health care access for
Hispanics in the USA. It is unclear how the final
implementation and shape of Medicaid eli-
gibility provided by the ACA will benefit Hispanics. Major
obstacles to health care access
for Hispanics should be addressed, particularly those
originating from substandard employ-
ment with limited health benefits, limited number of Hispanic
health care providers, cul-
tural sensitivity, geographic mobility, and undocumented status.
These barriers result in
Hispanics using fewer therapeutic and preventive health
services even with increased access
to, and utilization of, health services through the ACA [167,
168].
Page 20 of 27
The underrepresentation of Hispanic health care workers in
health professions pro-
grams must be addressed through pipeline education programs,
affirmative action admis-

sions, diversity requirements for school accreditation, tuition
loan repayment programs
and federal, and scholarship funding to support diversity
enrichment programs. Similar
Hispanic representation must be accomplished at all levels of
decision-making and
services, following the Health in All Policies framework
outlined above, to respond to the
changing demographic and health profiles of Hispanics in the
USA [169].
Enhancing cultural sensitivity and health literacy is needed to
increase Hispanics’
access to and utilization of health services, particularly for
controlling chronic diseases,
fostering healthy lifestyles, obesity prevention, workplace
safety, and utilization of pre-
ventive and screening services [170]. Spanish-speaking health
providers have been
shown to improve control of chronic diseases and improve
patients’ adherence to
health recommendations and patient satisfaction [171]. In the
USA, health care profes-
sionals are required by law to offer language translation and
interpretation services to

individuals with Limited Language Proficiency (LEP)—defined
as “LEP language group
that constitutes 5% or 1000 persons, whichever is less, of the
population served.” Title
IV of the Civil Rights Act of 1964 considers failure to provide
these services discrimin-
atory and results in losing eligibility status for federal funding
of health services. This
was expanded in 1997 through the Critical Access Hospital
Program which requires
that documents such as eligibility criteria for services, informed
consent documents,
discharge instructions, complaint forms, and other documents
are provided in the
language of LEP individuals; enforcement of these regulations
is the responsibility of
the Department of Health and Human Services Office for Civil
Rights [172].
Migration forces to the USA are diverse; multilateral country
collaborations between
migrant sender and recipient communities are needed to develop
health care programs
for Hispanics. Immigrants’ access to health services varies
among states according to

legal status, country of origin, and cultural and linguistic issues.
For example, Puerto
Ricans have citizenship rights in the USA and refugees and
asylees in the USA are
granted Medicaid coverage in the USA [173]. Undocumented
immigrants are banned
from purchasing health care services under the ACA. In June
2015, California passed a
bill to allow undocumented immigrants to purchase ACA
insurance [174]. Proponents
of access to undocumented workers believe that allowing access
to health care would
reward this workforce for their contributions to society and
advance social justice for
this vulnerable population [19, 81]. International epidemiologic
intelligence information
must be shared across borders among migrant sender and
recipient communities of
migrant workers to prevent and respond to health risks [175].
Generate and disseminate knowledge
Efforts should continue to disseminate the results of health
disparities research and
promotion and risk prevention strategies among Hispanics.
Research must capture and

interpret the sociocultural factors to explain Hispanic health
inequalities by improving
the terminology to identify Hispanics [176] and increasing
participation of Hispanics in
health research. To this end, new research paradigms must use
multilevel models and
implementation science to incorporate the continuum of social
determinants of health,
health inequalities, and risk factors that modulate the
epidemiologic profile of
Hispanics in the USA. Research constructs must adapt to the
changing dynamics of
Page 21 of 27
Hispanic demographics and social conditions, in addition to the
effects of policy
changes introduced by the ACA for eligible and ineligible
Hispanics. Translating re-
search findings into practice will require funding
multidisciplinary collaborations
between Hispanic community stakeholders, government, and
non-governmental orga-
nizations [177].

Conclusions
The complexity of factors impinging on Hispanic health
requires addressing the social
determinants of health related to the quality of the social and
physical environment
where Hispanics live and work, including neighborhoods,
housing, transportation, and
environmental and employment conditions.
The changing profile of Hispanic morbidity and mortality offers
new opportunities to
further address the main morbidity and mortality causes and
further the health out-
comes underlying the Hispanic and Latina Birth Outcomes
Paradoxes by curbing the
obesity epidemic, expanding antenatal and perinatal care,
preventing and ceasing smok-
ing, and decreasing workplace hazards.
Limited cultural sensitivity, health illiteracy, and a shortage of
Hispanic health care
providers remain as the main barriers to access to health
services for Hispanics. Even
for those with access to health care services, underutilization of
preventive care is still
a challenge. Migrant and undocumented workers are

disproportionately exposed to
health risks in the workplace, with limited access to health
services.
Multiple gaps are evident regarding knowledge needed to
improve Hispanic health.
The weight of the evidence on Hispanic health is mostly from
cross-sectional studies
that offer nationwide averages, obscuring focalized health
disparities and inequalities.
The health of Hispanics in the USA differs by demographic,
ethnic, and cultural sub-
groups. Understanding and addressing Hispanic health issues in
a comprehensive way
requires a targeted approach to country of origin and
idiosyncrasy.
The framework and scoping methodology guiding this review
allow a comprehensive
approach to assessing and monitoring Hispanic health in the
USA and may be repli-
cated at the state and local levels to evaluate the impact of
social and health policies.
Endnotes
1“Superfund sites” are the most polluted hazardous waste sites
managed by the US
Environmental Protection Agency as cleanup areas, with

potential threats to human
health and the environment (https://www.epa.gov/superfund).
2Federal requirement waivers to implement demonstration
projects to pilot-test
Medicaid eligibility, managed care, cost sharing, benefit
packages, and other types of
healthcare.
Additional file
Additional file 1: Supplemental Material. Review papers on
Hispanic Health cited in PubMed from 2006 through
September 2016. (DOCX 36 kb)
Acknowledgements
We would like to acknowledge the excellent comments and
suggestions issued by peer-reviewers to improve the
quality of our manuscript.
https://www.epa.gov/superfund
dx.doi.org/10.1186/s40985-016-0043-2
Page 22 of 27
Funding
Not applicable. No funding was needed or obtained.
Availability of data and materials
Not applicable. Data sharing is not applicable to this article as
no datasets were generated or analyzed during the
current study.

Authors’ contributions
EVM led the conception of the paper and the writing of the
introduction, cancer section, health services section, and
recommendations. AJ led the writing of the “Diabetes” section
and the “Risk factors” section: the “Cancer,” “Diabetes,”
“Tobacco,” and “Alcohol” sections. APD led the writing of the
“The Latina Birth Outcomes and the Hispanic Mortality
Paradoxes” section. She coordinated the preliminary and final
editing of the manuscript. DD collaborated and wrote
the “Obesity” section, “Cardiovascular disease” section, and the
“Liver disease” section. JAEC collaborated and wrote the
“Social determinants of health and health inequalities” section
and managed the References. All authors collaborated
equally in reviewing all sections and the editing and approval of
the final manuscript. This paper offers a scoping
review of the literature and highlights priorities and
recommendations that should help inform to make the case to
further health care access, health policies, and research on
Hispanic health in the USA. Also, we offer an analytical
framework that should serve to guide future research on
Hispanic health at the national, state, and local levels.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable. Our paper does not contain any individual
person’s data in any form.
Ethics approval and consent to participate
Not applicable. Our study does not report on or involve the use
of any animal or human data or tissue.
Author details
1College of Osteopathic Medicine, Touro University California,
1310 Johnson Lane; H-82, Rm. 213, Vallejo, CA 94592,

USA. 2Fay W. Boozman College of Public Health, University of
Arkansas for Medical Sciences, Little Rock, USA. 3Bezley
Institute for Health Law and Policy, Loyola University Chicago,
Chicago, USA. 4St. Louis University School of Medicine,
St. Louis, USA. 5Regional Advisor on Health Information and
Analysis, Pan American Health Organization/World Health
Organization, Foggy Bottom, USA.
Received: 14 April 2016 Accepted: 16 November 2016
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kits/redistricting.htmlAbstractBackgroundConceptual
frameworkMethodsSocial determinants of health and health
inequalitiesDemographyEnvironmentOccupationMobilityCulture
and languagePoverty and household incomePoverty and health
careGenderMigrant seasonal farm workers
(MSFW)Undocumented immigrant workersRisk
factorsObesityTobaccoAlcoholMorbidity and
mortalityCardiovascular diseaseDiabetesCancerLiver
diseaseUnintentional injuriesThe Latina Birth Outcomes and the
Hispanic Mortality ParadoxesInfant mortality and the Latina
Birth Outcomes ParadoxThe Hispanic Mortality ParadoxHealth
servicesRecommendationsAdopt a Health in All Policies
approachIncrease health care accessGenerate and disseminate
knowledgeConclusions“Superfund sites” are the most polluted
hazardous waste sites managed by the US Environmental
Protection Agency as cleanup areas, with potential threats to

human health and the environment
(https://www.epa.gov/superfund).Additional
fileAcknowledgementsFundingAvailability of data and
materialsAuthors’ contributionsCompeting interestsConsent for
publicationEthics approval and consent to participateAuthor
detailsReferences
Grief and Cultural
Competence: Hispanic
Traditions
1 CE Hour
Dr. Candi K. Cann, Ph.D.
Funeral Service Academy
PO Box 449
Pewaukee, WI 53072
www.funeralcourse.com
[email protected]
888-909-5906
Funeral Service Academy
PO Box 449 Pewaukee, WI 53072
[email protected]
Final Exam

Course Name: Grief and Cultural Competence: Hispanic
Traditions (1 Contact Hour = .1 CEU)
1. Currently, Hispanics are the largest minority in the United
States: ________ of the total
United States population in the 2013 census.
a. 38.7%
b. 29.4%
c. 21.6%
d. 17.1%
2. In the Hispanic tradition, the dead continue to play a role in
the world of the living, and
are generally ________.
a. Remembered with fondness and love
b. Feared and placated
c. Honored and worshipped
d. Spoken of in low voices
3. According to the CDC, leading causes of death in the

Hispanic community include
________.
a. Kidney failure
b. Heart disease
c. Suicide
d. Autoimmune diseases
4. ________ function much like prayer cards, in that they also
display an image of a favored
saint and a prayer to that saint.
a. Rosary beads
b. Funeral masses
c. Last rites
d. Votive candles
mailto:[email protected]
5. The body of the deceased plays an active role in the Hispanic

tradition, from the wake
and rosary to the funeral mass and burial, and is a central
“actor” in the religious rituals
remembering the dead. ________ is thus fairly common among
Hispanics in the United
States.
a. Green burial
b. Embalming
c. Closed-casket service
d. Cremation
6. Often, if permitted, Hispanic families like to hold ________,
sometimes all night and
during the hours leading to the funeral mass.
a. Prayer vigils
b. Rites of committal
c. Extended visitations
d. Private wakes
7. In total, funeral services generally last ________ days,

followed by nine days of rosary
prayers and regular commemorative masses for the dead.
a. Four to six
b. Three to four
c. Seven
d. Nine
8. Funeral directors can expect Hispanic wakes/visitations and
services to include
________.
a. Immediate family only
b. Immediate and extended family only
c. Immediate family and close personal friends only
d. The entire extended family in addition to friends and
colleagues
9. According to E.R. Shapiro, grieving models in the Hispanic
tradition emphasize
________.
a. A reintegration of the dead in a world without the deceased

b. A dismissal of the dead from the world of the living
c. Working through stages of detachment from the deceased
d. Minimal mourning and remembrance
10. Many traditional Hispanic remembrance practices are
increasingly ________.
a. Limited to the immediate family
b. Focused on a belief in Hell as a possible outcome for the
afterlife of the dead
c. Moving online
d. Exclusive and secular
Grief and Cultural Competence: Hispanic Traditions
Learning Objectives
This course is intended to increase funeral directors’ awareness
of, and sensitivity to,
Hispanic cultural traditions with regard to grief and mourning.
By the end of the course,
learners should be familiar with:
General demographics, language, and religious beliefs
pertaining to Hispanic

culture
Hispanic attitudes towards sickness, dying, and the deceased
Deathbed rituals and traditions in Hispanic culture
Hispanic interment traditions
Common Hispanic beliefs regarding the afterlife
Hispanic mourning and remembrance rituals, including All
Souls’ Day and Dia de
los Muertos
Additional points of cultural sensitivity
PLEASE NOTE:
The facts laid out in this module are presented as a general
guideline to dominant
cultural characteristics: they are not, and are not intended to be,
applicable to all people
of Hispanic origin. This module in no way diminishes the
diversity of the many different
Hispanic populations in the United States.
The integration of cultural characteristics into funeral practices
is in part dependent on
levels of acculturation, or the assimilation of Hispanic
communities into local culture.
Funeral directors need be sensitive to the difference in Hispanic
acculturation, with first
generation Hispanics usually more traditional and more closely
aligned with the cultural
practices of their country of origin, while second, third and

fourth generation Hispanic
Americans may more closely reflect Anglo-American
practices.1 Additionally, generally
Hispanic and Latino are terms that are used interchangeably, but
Latino refers to those
from Latin American, which includes Portuguese speaking
Brazil, and the creole
populations of Haiti and the Caribbean. This module addresses
only the Spanish
speaking population of Latin America.
You will want to ascertain the extent to which Hispanic patrons
wish to incorporate
1 Whitaker et al, “Perinatal Grief in Latino Parents,”
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3648338/ last
accessed June 11, 2015.
cultural beliefs and practices, just as you would with any
patron.
Introduction: Demographics, Language, Religious Beliefs
The United States census states that Hispanics are those of
Cuban, Mexican, Puerto
Rican, South or Central American descent regardless of
ethnicity. However, Brazilians,
who speak Portuguese, are not always classified as Hispanic, as
Hispanic connotes
one who is Spanish speaking. The Spanish used in various

Hispanic countries can vary
widely: the Spanish used in Mexico sounds very different from
that used in Argentina or
Cuba, with different terms for common items.
Currently, Hispanics are the largest minority in the United
States: 17.1% of the total
United States population in the 2013 census. This number is
expected to grow; by
2060, it is estimated that Hispanics will make up 31% of the
total population. California
is the state with the highest number of Hispanics, at 14.7
million Spanish-speaking
inhabitants; New Mexico has the largest percentage by
population with 47.3 % of its
total population of Hispanic origin. More than one-third of the
total Hispanic population
in the United States resides in states that border Mexico,
including Arizona, California,
New Mexico, and Texas.2 Outside of the American Southwest,
substantial Hispanic
populations are found in the Northeast – in New York, New
Jersey, Massachusetts,
New Hampshire and Connecticut – and also in Illinois and
Florida. Florida is expanding
in growth because of its proximity to Latin America, while the
other states are growing
largely due to their urban centers and job availability.3
Generally, Hispanics practice Roman Catholicism; the specific
version is usually
influenced by local indigenous cultures, resulting in Catholic
folk practices that may
seem very different from traditional European and American
Catholicism. The Hispanic
Catholic tradition embraces a rich plethora of saints and

martyrs, although specifics can
vary by location. Each country in Latin America, for example,
tends to favor particular
saints, martyrs, and icons depending on cultural values: in
Mexico, for example, Saint
Death – or Santa Muerte – is growing more popular, though she
enjoys little to no
recognition in Argentina, Chile, and Uruguay. With an
estimated ten to twelve million
followers, Saint Death ties together some traditional indigenous
beliefs with Catholic
thought, becoming known as the patron saint of healing,
protection, and safe passage
to the afterlife. Particularly favored by people on the margins
of society, she is most
notorious for being the preferred saint of drug cartel members,
but is also popular with
undocumented migrants, those of trans-gender, and others who
perceive themselves as
on the fringes. Despite – or perhaps because of – her steadily
increasing following,
Santa Muerte has been officially denounced by the Catholic
Church because she is not
a recognized saint from the Catholic cannon. Other saints
popular with the Hispanic
2 http://www.cnn.com/2013/09/20/us/hispanics-in-the-u-s-/ last
accessed May 8, 2015.
3 For individual state demographics see “State and County
Databases, Latinos as Percent of
Population, By State, 2011,” http://www.pewhispanic.org/states/
last accessed May 25,
2015.

community include St. Peregrine, patron saint of cancer; St.
Joseph, saint of the dying;
Our Lady of Lourdes, the saint most often prayed to for various
bodily ills; and Saint
Juliana Falconieri, the saint of chronic illness. These are in
addition to the popular
figures of Sacred Heart Jesus (representing the heart that
suffers, yet lives love more
purely) and the Virgin Mary (who represents purity and
suffering. Each country has its
own particular favorite version of the Virgin that is popular; for
example, in Mexico, the
most popular Virgin Mary is the Virgin of Guadalupe, while in
Argentina, the Virgin Mary
of Lujan is the most revered). These saints and local variations
of Jesus and Mary are
important markers of cultural and ethnic identity, so it is
important that they be
acknowledged if one is to be sensitive to the specific Hispanic
tradition. Statues and
prayer cards with the pictures of these saints are often placed in
the sickroom, along
with candles (preferably electric, which can constantly “burn”),
so that the saints may
intercede on the behalf of the ill.
Though the majority of Hispanics are Catholic, Protestantism is
growing in Latin
America. Among Protestant Hispanics, Pentecostalism is the
dominant branch
practiced, with literal and evangelical interpretations of the
Bible, and a rejection of
Roman Catholicism. Additionally, some countries in Latin
America (such as Argentina

or Chile) are culturally or nationally Catholic, but have
significant populations who are in
fact non-observant, or non-practicing. However, many continue
to adopt culturally
Catholic traditions (the rejection of cremation in favor of burial,
for instance), so
important aspects of Hispanic Catholic traditions have been
emphasized here.
Attitudes towards Sickness, Dying, and the Deceased
In the Hispanic tradition, the dead continue to play a role in the
world of the living, and
are generally remembered with fondness and love (this is in
stark contrast to European
and American Protestant views that generally fear or avoid the
dead). Dying is
considered to be part of the cycle of life, and is accepted,
though perhaps with some
fatalism that is not found in contemporary American culture.
Hispanics, particularly in Latin America, often believe that
illness is an emotional and/or
social issue: one can become sick and die from being out of
balance – either with
oneself or with one’s environment – and from the curses of
others. For example, it is
strongly believed that if a Hispanic woman does not satisfy her
pregnancy cravings she
will do damage to the baby, leading to injury, or even to the
death of the infant.
Nervousness is often attributed to an excess of bile in the
bloodstream. In susto, or
soul loss (which is associated with a wide variety of illnesses),
it is generally thought

that severe fright or worry causes one to disassociate with one’s
soul, leading to chronic
or severe illness and possibly death; the “cure” is returning to
the place of separation
from one’s soul and restoring unity with body and spirit. Belief
in the “evil eye” (mal de
ojo) is pervasive in Hispanic culture, and is often used to
explain mysterious or sudden
death. Mal de ojo is attributed to a person looking at another
person with admiration or
envy, causing a curse leading to sickness and/or death. Many
people believe that
infants, especially, are susceptible to evil eye, and thus it is not
encouraged to overly
admire a child, as it could lead to their early death or illness.
Because of these folk beliefs, Hispanics tend to be somewhat
fatalistic in regards to
illness and death – believing that there is nothing that one can
personally do to prevent
them – which can sometimes lead to a strong reliance on God
and religious tradition in
coping with both.
According to the CDC, leading causes of death in the Hispanic
community are cancer,
heart disease, unintentional injuries, stroke, diabetes, and
chronic liver disease.4
Though death itself is not a taboo topic in the Hispanic
community, it has been noted
that discussions regarding end of life care and the death process
are frequently

avoided; in sickness, many prefer to learn the “bad news” from
a family member, rather
than a doctor.5
Organ donation in the Hispanic community is viewed with a
degree of skepticism, and
generally Hispanics are far less likely to donate organs
posthumously than their
Caucasian counterparts (15% Hispanic donors vs. 63.8%
Caucasian donors of all
organs donated in 2015).6 It is generally believed that these
low numbers are a result of
both religious beliefs and a (correctly) perceived inequity of
organ recipients: although
Hispanics tend to be more in need of organ transplants than
other ethnicities,
Caucasian Americans top the list of organ recipients.
Additionally, autopsy is generally
frowned upon, and in fact, pre-planning funeral directors should
be aware that many
Hispanics believe that discussing events such as autopsy prior
to death is believed to
hasten death.7
Deathbed Rituals and Traditions
As mentioned earlier, in the Hispanic tradition it is generally
considered to be bad luck
and in poor taste to talk of death in front of the sick – many
believe this will hasten the
death.
4 Centers for Disease Control and Prevention, Hispanic or

Latino Populations,
http://www.cdc.gov/minorityhealth/populations/REMP/hispanic.
html, last accessed May
13, 2015.
5 “Reluctant Realism,” by Margaret R. McLean and Margaret A.
Graham,
http://www.scu.edu/ethics/publications/iie/v14n1/elipse.html
2015.
6 Organ Procurement and Transplantation Network [OPTN],
Deceased Donors Recovered in
the U.S. by Ethnicity, Last accessed May 14, 2015.
http://optn.transplant.hrsa.gov/converge/latestData/rptData.asp
2015
7 See “End of Life Care: The Latino Culture”
https://depts.washington.edu/pfes/PDFs/End%20of%20Life%20
Care-Latino.pdf last
accessed May 25, 2015
Some folk practices note that the spirits of those who die in
hospitals can become
confused or lost and have a difficult time finding their way in
the afterlife; thus the dying
patient is most often cared for in the home, if possible. (A
general mistrust of the
medical system, coupled with the high percentage of Hispanics
who lack sufficient
healthcare coverage (the CDC put the number in the United
States at 29.1% in 2012,
though these numbers will change under the Affordable
Healthcare Act), have also

contributed to the number of Hispanics who receive care at
home rather than in the
hospital.)
Tending the sick or dying is generally regarded as the
responsibility of female relatives
(with the exception of pregnant women, who are not supposed
to be around the dying
as it is considered bad luck for the new baby and expectant
mother). Additionally, both
sickness and death are viewed as social events, and it is
common for extended families
to gather on these occasions.
Strong folk practices, mixed with Catholic saint reverence and a
reliance on material
relics (charms, candle lighting, amulets, etc.), generally
characterize Hispanic practices
surrounding sickness and dying. Depending on the illness and
preference, small
statues and charms of a favored saint will generally be placed
near the dying person’s
bed, along with rosary beads, prayer cards, and candles, to offer
comfort in the
awareness of God’s presence in the room with the afflicted.
Prayer cards usually have
a picture with a short prayer and blessing. Votive candles
function much like prayer
cards, in that they also display an image of a favored saint and a
prayer to that saint;
when the candle is lit, many believe the patron saint is being
called to offer protection
and blessings on the room and the people in it.
Because the majority of Hispanics are Catholic, sickness and
death are often viewed as

tests of one’s faith, and both anointing of the sick and last rites
will be performed.
These are two of Catholicism’s seven sacraments, so their
importance cannot be
understated. Previous to Vatican II, anointing of the sick was
almost exclusively
considered the domain of near death and was given in
conjunction with last rites; now it
is more common to give these at two different times. Currently,
anointing of the sick
usually occurs when the sick person has been informed they are
ill: the sick person’s
family and friends are invited to participate in a mass in which
the sick person is blessed
and a general prayer is made asking for God’s blessing and
healing on him or her. The
last rites (or Extreme Unction), usually made at one’s deathbed,
consists of a blessing
and a final confession if the person is still conscious; if not,
then the person is forgiven
assuming that they would have made the confession if they had
been able.
After death, some families may wish to care for and tend the
body of their deceased
loved one, seeing this as an opportunity to offer love and
respect one last time.
Interment Traditions
The body of the deceased plays an active role in the Hispanic
tradition, from the wake

and rosary to the funeral mass and burial, and is a central
“actor” in the religious rituals
remembering the dead. Embalming is thus fairly common
among Hispanics in the
United States (it is not as common in Latin America, where
frequently it is too great a
financial burden). Though cremation is permitted, most
Hispanics are buried, according
to traditional Catholic beliefs that the body should be buried so
that it may return to dust
and be resurrected for its afterlife.
In Hispanic culture, it is common to hold a large wake or
visitation with the extended
family, children, and friends in attendance. Flowers and
candles will be placed near the
body where the visitation occurs. Usually food is brought to the
wake: traditions vary
dependent on culture and country, but often the foods serve to
reinforce ethnic ties and
identity. Sometimes there are even card games and tables for
dominoes as the older
members of the family sit, eat, play, and exchange stories about
the deceased. The
wake is not typically a quiet affair, and can often be a loud and
emotional one: women in
particular are generally allowed and expected to be expressive
in their emotions, while
men are stoic, but this is not always the case.
Often, if permitted, Hispanic families like to hold extended
visitations, sometimes all
night and during the hours leading to the funeral mass. Family
and friends will also
bring small gifts and tokens to place in the casket with the

deceased, and thus many
Hispanic families prefer to purchase caskets that come with
memory drawers to hold
photos, jewelry, and keepsakes, in addition to choosing cap
panel inserts that allow for
the insertion of photos, pictures and letters to the deceased.
Following a death, Catholics pray the rosary as a way to request
the intercession of God
on behalf of the deceased’s soul: in other words, the rosary is
intended to help the soul
of the deceased secure their place in heaven. Rosaries are
usually recited in the
presence of the deceased the first and /or second night, and then
continue to be recited
for nine nights following the funeral at the home of the family
of the deceased. This is
generally followed by a rosary that is said once a month for a
year following a death,
and annually repeated after that. Reciting the rosary generally
takes half an hour,
though this depends on the speed of the prayers and the amount
of time given to pause
and reflect in between the prayers.
The term "rosary" refers to both a form of devotion and the
string of beads used for
keeping count during the devotion.
The rosary (i.e. the string of beads) consists of a crucifix and
five beads, attached to a
string of fifty small beads, grouped into five groups of ten
beads separated by five
additional large beads. One prays various prayers while holding
to each bead and
moving through the beads in succession.

At each of the beads and at the crucifix, the petitioner prayers a
particular prayer,
including the Apostles’ Creed, Lord’s Prayer (Our Father), the
Hail Mary prayer, and the
Glory Be prayer, meditating on particular events that occurred
in the Bible (for specifics,
see “How to Pray the Rosary” by the United States Catholic
Conference of Bishops ).
The rosary (i.e. this set of prayers) is intended to help focus the
petitioner’s mind on
particular events in the Bible, while utilizing prayer as a way to
come closer to God.
Following the wake and the rosary, there will also be a funeral
mass, or requiem mass,
to which the larger community of the deceased is invited and
expected to attend (the
obituary is often utilized in the Hispanic community to let
family and friends know about
the timing of this mass). The purpose of the funeral mass is not
only the remembrance
of the deceased; it is also considered a rite of worship. For this
reason, funeral masses
may only be performed by priests; however, the Rite of
Committal (discussed below)
may be performed by either Catholic deacons or chaplains since
the Eucharist is not
involved. Funeral masses consist of four parts – the receiving
of the body, the liturgy,
the Eucharist, and the final committal – and differ from
traditional Catholic services in

that they have no exchange of the peace.
Funeral masses may not conflict with other church holidays, and
are not celebrated on
Holy Thursday, Good Friday, Holy Saturday, Easter, Sundays
during the Advent season
(the preceding four Sundays prior to Christmas), Sundays
during Lent (the forty days
preceding Easter), and Sundays during Easter season (the fifty
days following Easter).
When a funeral mass must be celebrated on Ash Wednesday (the
first day of Lent), this
is permitted, but ashes will then not be distributed. When a
mass cannot be celebrated,
a Catholic funeral liturgy is offered for the deceased, consisting
of readings, prayers and
music. In general, only confirmed Catholics may read the
readings or the prayers
during a mass or liturgy.
Unlike wakes, which may be casual occasions, masses and
funeral liturgies are much
more formal and solemn affairs – they are religious services,
after all, and usually take
place in the church itself. The function of the funeral mass is to
bring the deceased into
the presence of God.
Eulogies generally occur during the wake before the funeral
mass. Though some
churches are now allowing family members to briefly remember
the deceased following
the Eucharist and before the final committal, opinions vary on
this practice. Most
traditional Hispanic Catholics still prefer not to allow families
and friends to eulogize the

deceased during the mass, as many believe it takes the focus
away from the worship of
God and praying for the intercession on behalf of the dead. (In
contrast, Protestant
Hispanics allow for the reflection and remembrance of the dead
within the funeral
service, and generally encourage the family and friends to share
their thoughts on the
deceased as a way to honor the dead. This is an important
distinction between the
Catholic and Protestant faiths, so funeral directors should be
sensitive to this
difference.)
If the deceased IS cremated rather than buried, s/he is generally
cremated following the
funeral mass – so that the body itself is present during the
service – but prior to
interment. (Again, this is in contrast to the Protestant tradition,
which allows for
cremation directly following the wake and prior to the funeral
service itself; funeral
directors should be aware of, and prepared to accommodate,
both practices.)
Following the mass or service, the young men closest to the
deceased (usually either
family relations or close friends) will be asked to help carry the
casket from the church
to the hearse, and once again from the hearse to the burial site.
At the site of burial, if the family is Catholic, the Rite of

Committal is performed, which
consists mainly of a blessing of the interment site with a spoken
prayer, the sprinkling of
holy water, and a final blessing over the deceased. If the family
is Protestant, a final
prayer is recited, and a short text is sometimes read. Hispanic
families generally
accompany the deceased to his/her final resting spot; the
extended community often will
also participate in this aspect of disposal.
It is common practice to pass out prayer cards in remembrance
of the dead at the
funeral mass, to assist attendees in their prayers for the
deceased. Often these contain
a picture of the deceased, with their birth and death dates on
one side and a prayer of
intercession for their soul on the other.
In total, funeral services generally last three to four days,
followed by nine days of
rosary prayers and regular commemorative masses for the dead.
Frequently the funeral home must work in close connection with
the deceased’s family’s
parish priest to arrange the wake, rosary, funeral mass, and
blessing of the burial.
Depending on the resources of the local church and the
community, the church may
host the majority of the events; in other cases events will be
split, with the wake at the
funeral home, followed by the rosary and/or mass at the church.
Funeral directors can expect Hispanic wakes/visitations and
services to include the
entire extended family network (including aunts, uncles,

cousins, etc.) in addition to
friends and colleagues. Sickness and death in the Hispanic
communities are viewed as
social events, not merely private ones. Thus, wakes are seen as
social occasions, and
are usually viewed as opportunities to reassert the social
structure without the
deceased, while funeral services will likely be opportunities to
stress one’s social and
blood relationship with the dead.
Beliefs Regarding the Afterlife
The foundational views of the afterlife in the Hispanic
worldview are informed by the
Christian tradition; most often, that of the Roman Catholic
Church.
As discussed briefly in the introduction, the majority of
Hispanics are Catholic – if not in
practice, then in culture – though there is also a rising
Protestant population, particularly
among Hispanic families that have resided in the United States
for several generations.8
In Latin America, the most influential Protestant denomination
has been Pentecostalism;
likewise, in the United States, the Hispanic Pentecostal
population is growing. Many
Pentecostals define themselves in opposition to Catholic
practices, preferring a literal
interpretation of scripture instead of the traditional practices of

the Catholic Church, and
rejecting prayers to the Virgin Mary. In addition to Catholicism
and Protestantism, the
Hispanic countries in the Afro-Caribbean region (Cuba,
Dominican Republic, some parts
of Costa Rica, Nicaragua, Colombia, etc.) also incorporate
traditional Afro-Caribbean
beliefs and practices, sometimes practicing a syncretistic form
of indigenous
Catholicism.
Syncretism occurs when local indigenous beliefs mix with
Catholic beliefs, forming new
and often popular belief systems that may be more acceptable to
the local tradition, but
did not actually originate within the Catholic church. Saints
and martyrs have
traditionally been one way that the Catholic church has
incorporated local and popular
figures into the Church history and canon; in this way, the
figure is no longer seen as
competing for believers, but becomes incorporated into the
Catholic church itself.
Both Protestant and Catholic Hispanics believe in a final
judgment: when one dies, the
soul leaves the body to stand before God for a weighing of
one’s lifetime’s worth of
good and bad deeds. Based on this judgment, the soul is then
sent to reside in either
Heaven or in Hell; in addition, Catholicism provides for the in-
between state of
Purgatory. This singular belief informs nearly all the practices
surrounding the care for
and remembrance of the dead among Catholic Hispanics.

Purgatory is a place where one’s soul is sent if one’s positive
deeds do not necessarily
outweigh the negatives ones (or, in theological terms, if one’s
sins are too great to go
straight to Heaven). It is from the belief in purgatory that the
practices of saying
rosaries, celebrating masses for the dead, offering anniversary
masses for the
deceased, and observing the holidays of All Souls’ Day and Dia
de los Muertos emerge:
all of these practices are meant to help the deceased move from
purgatory into heaven,
while also allowing the functional purpose of giving the
bereaved something to actively
do in honor of the dead.
Protestants, on the other hand, assume the resurrection of the
dead, though there is
some debate over whether this occurs immediately following a
death or whether it takes
place at the end of time, with the second coming of Jesus
Christ; in either case, the
dead are not in need of assistance from the living (nor can they
offer assistance to the
living).
One of the big shifts in perception, particularly in the last
hundred years, has been a
decrease in the belief of Hell as a possible outcome for the
afterlife of the dead, though
8 See Pew Research Center’s surveys on “Religion in Latin
America” for more on this:
http://www.pewforum.org/2014/11/13/chapter-3-religious-
beliefs/ last accessed June

10, 2015.
Protestants tend to believe in Hell more than their Catholic
counterparts.9 This has led
to decreased participation in funerary practices; if the bereaved
believe their loved one
has moved straight to Heaven, then there is little need to spend
the time and/or money
committing to rituals surrounding the dead.
Finally, though not officially sanctioned by the church, there is
a popular belief in ghosts
and spirits in Hispanic culture, with the deceased often actively
invoked in both positive
and negative forms. The most common form of ghost seems to
be a woman who was
spurned in some way in her life, and who comes back to take
her revenge on the living:
because much of Hispanic culture is a machista society, in
which women are expected
to observe traditional gender roles, this may be one way in
which women are finally able
to assert their power.
Mourning and Remembrance
According to E.R. Shapiro, grieving models in the Hispanic
tradition emphasize a
reintegration of the dead in a world without the deceased, unlike
the traditional
Western/Anglo model of working through stages of detachment
from the deceased.10

Scholar Tony Walter calls this model a framework of mourning
based on “caring for the
dead,” rather than “remembering the dead.”11 For this reason,
most Hispanic traditions
of mourning and remembrance involve the (passive or active)
participation of the
deceased themselves in addition to the involvement of the
extended social family
structure.
Death, then, is viewed in social terms; mourning encompasses
the negotiation of, and
restructuring of, social relations without the physical presence
of the deceased.
Immediately following the final interment of the body, extended
family and friends
usually retreat to the house of the immediate family of the
deceased, where more food
is brought, and remembrance of the deceased occurs. Food,
flowers, and gifts of
money to help cover the funeral expenses are the most common
gifts given to the family
at and following the funeral.
Masses for the Dead
As mentioned above, unlike Protestantism – in which the
resurrection of the deceased
is emphasized – Catholicism encourages regular prayers for the
deceased, particularly
on significant dates following the death: while one might be
morally certain of the
deceased’s place in heaven, masses help provide additional
assurance through the
prayers of the living.

9 Ibid.
10 ER Shapiro. Grief in family and cultural context: Learning
from Latino families. Cultural
Diversity and Mental Health. 1995;1:159–176. doi:
10.1037/1099-9809.1.2.159.
11 Tony Walter. “Communicating with the Dead,” In C. Bryant
& D. Peck, eds Death and the
Human Experience, Sage 2009.
Towards this end, it is common to not only recite rosaries for
the deceased, but to
petition for masses to be dedicated in honor of the deceased.
On anniversaries of the
dead, or on the birthdays of the dead, some family members will
recite rosaries for the
dead and/or hold special remembrance masses in honor of the
deceased. Thus, if the
deceased is Catholic, usually one’s family will honor the dead
with masses on the third,
seventh, and thirtieth days following a death or a funeral (the
count of days begin with
the day immediately following the date of death or the day of
burial; both days are
appropriate starting points), and then annually after that. Small
stipends, usually $5-10,
are given to the priest to recite the mass. In addition, a card is
often given to the family
who has requested the mass for the dead: this card, somewhat
like a greeting card,
acknowledges that the deceased has had a mass recited in
his/her honor. Prayer
cards, similar to those passed out at the funeral mass, may also

be handed out at
anniversary masses.
Individual Remembrances
In between masses for the dead, it is common practice to light a
candle (with a small
token payment) at the church in honor of the deceased, and to
offer prayer in memory
of the dead in this way.
Finally, it is common for both Protestant and Catholic Hispanics
to place small notices in
the local paper on the occasion of important anniversaries of a
death (usually one, five,
ten, fifteen, etc.), in which the family honors the deceased with
a short message to and
about him/her. If the family is Catholic, they may also
announce the time and place of
the anniversary mass. Often the messages are short but
illuminating, and like
obituaries, tend to privilege immediate family members and
their relationship to the
deceased.
Interestingly, many traditional Hispanic remembrance practices
are increasingly moving
online. As access to the Internet becomes universal, families
are easily able to sign up
for intercessory masses, request that candles be lit for them in
prayer at churches
(usually for a small donation), and post mass announcements
and anniversary
remembrances of the dead online. Funeral directors looking to
extend their relationship
with the family beyond the immediate death of an individual
might want to make note of

this custom and offer memorial notices as a service.
Annual Remembrances
Apart from the annual anniversary of the death of the deceased,
November 2, or All
Souls’ Day, is the most important regular remembrance of the
dead, with Hispanic
families – both Catholic and Protestant – gathering in homes, at
gravesites, and in
churches to remember the dead. (While Dia de los Muertos, or
Day of the Dead, is
becoming widely known, it must be stressed that this holiday is
primarily a Mexican and
Mexican American holiday; many Hispanic countries celebrate
All Souls’ Day, but not
Dia de los Muertos. For this reason, these are both discussed
here.)
ALL SOULS’ DAY
Originating in Catholic beliefs in Purgatory, and the need to
intercede on behalf of the
dead, the practice of observing All Souls’ Day is first credited
to St. Cluny, on November
2, 998. The observation of this practice soon spread to the rest
of the Cluniac order,
then to Southern Europe, and finally, in the fourteenth century,
to Rome. Originally one
day of intercession for the dead, it was not long before the
November 2 observance
expanded to encompass the entire month of November, with
names of the deceased
prayed over in masses for the dead and including October 31,

All Saints’ Eve,
November 1, All Saints’ Day, and November 2, All Souls’ Day.
When the Spanish colonialists settled in Mexico in 1519, the
Roman Catholic tradition
was fused with indigenous Aztec tradition remembering the
dead through reverence of
the goddess Mictecacihuatl, known more contemporaneously as
the Lady of the Dead.
(The images of the Lady of the Dead are not that different from
those of the Grim
Reaper popular in Europe in the sixteenth century, with a
similar emphasis on the
macabre as an everyday occurrence: the reminder in both
images is that of death made
commonplace.) The indigenous summer holiday was moved to
coincide with the later
church date, and thus a new and indigenous interpretation of All
Souls’ Day was begun.
DIA DE LOS MUERTOS
The Mexican Day of the Dead ceremony emerged from the
popular Catholic practice of
memorializing the dead in the Catholic Feast celebrating All
Souls’ Day. The overall
purposes of Dia de los Muertos are to remind those who are
alive that life is short, and
to connect the living with the stories of the dead, specifying
their continuing place in this
world through narrative and the fixed location of the tomb.
Thus, even those Mexicans
and Mexican Americans who are Protestant may still participate
in the cultural aspects
of the Dia de los Muertos tradition, focusing on the parts of the
holiday that emphasize
Mexican heritage and culture.

History suggests that sugar skulls, so iconic to the celebration
of the remembrance of
the dead in Mexico, emerged from the socio-political landscape
at the time. Abundant
in sugar, but poor in capital, Mexicans wanted to adorn their
churches with decorations
similar to those popular with their colonialist conquerors; thus,
they made us of sugar’s
malleable properties to make colorful and edible decorations for
the church and home
altars.
It is also common to bake Pan de Muerto, or Day of the Dead
bread, made with flour,
butter, sugar, eggs, orange peel, anise, and yeast. (These Pan de
Muerto buns are not
unlike the Hot Cross buns found in American Easter
observances, down to the candied
citron and decorations across the tops of the bread. Perhaps the
yeast is symbolic of
life’s ultimate ability to overcome death; the rising of the bread,
a symbolic reenactment
of the resurrection of souls in the afterlife.) The bread is
kneaded, then shaped into little
buns, which are decorated with skull and crossbones laid across
their tops. The Pan de
Muerto and sugar skulls, along with oranges, are offered at the
family altars along with
pictures of the deceased and candles.
Marigold flowers often also adorn the graves, altars, and
churches in remembrance of

the dead: it is believed that the earth-tone colors help to guide
the dead safely home.
In Mexico, the graveyards are publicly owned, and it is the
community’s responsibility to
maintain them; because of its proximity to the church, the
graveyard is often situated at
the center of public space, making its maintenance doubly
important. Church members
and families come together to pull weeds and tend to the graves.
Families brings
chairs, tables, food, drink, flowers, candles, and pictures,
feasting in the cemetery with
extended family both alive and dead, spending the day telling
stories about the dead
family, saying prayers for the souls of the dead, and leaving
offerings of food, drink, and
flowers.
In the United States, on the other hand, most graveyards are
privately owned, and
many set visiting hours. In response, Mexican Americans have
trended towards setting
up a home altar where the deceased may be honored via picture;
the grave as the
nexus of the social sphere has been relegated to the more
private sphere of the nuclear
family home. Thus, while Mexican American graves are still
visited and maintained,
they have not retained the same function as gravesites in
Mexico, where the cemetery
is both literally and figuratively the center of the world of the
living and the dead.

Additional Points of Cultural Sensitivity
• The family network in Hispanic culture is very important;
generally the entire
family prefers to be involved in decision-making. Be sure that
all prominent
family members are present so that problems do not arise
regarding individual
choices such as coffins, etc.
• Hispanic culture tends towards traditional gender roles and
stereotypes: funeral
service providers should be aware that this may impact grieving
expectations and
demonstrations.
• The concept of “Respeto” or respect cannot be understated:
deference,
particularly in regards to elders, should always be shown
• As covered earlier in this course, some Hispanic cultures
believe in the power of
the “Evil Eye.” Funeral directors should be wary of overly
complimenting children
or babies, as their loved ones may fear that will bring
misfortune and illness to
them.

• Always use “Usted” if you are speaking Spanish to your
clients; “Tu” is
considered informal and should only be used with close friends
and family.
Hispanic CoverHispanic ExamHispanic Course

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