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Advances in Social Sciences Research Journal – Vol. 8, No. 12
Publication Date: December 25, 2021
DOI:10.14738/assrj.812.11476. Sandoval, B., Hem-Lee-Forsyth, S., & Bryant, H. (2021). A Tridimensional View of the Hispanic Health Paradox: Its Relationship with
Faith, the Enclave Theory, and Familism. Advances in Social Sciences Research Journal, 8(12). 317-345.
Services for Science and Education – United Kingdom
A Tridimensional View of the Hispanic Health Paradox: Its
Relationship with Faith, the Enclave Theory, and Familism
Bibiana Sandoval, MD, MPH, MBMS
AltaMed Health Services, South Gate, California, U.S.A.
Shivaughn Hem-Lee-Forsyth, PhD, MPH, FRSPH
Department of Public Health and Preventive Medicine, School of Medicine
St. George’s University, Grenada
Hanna Bryant, MD
Department of Public Health and Preventive Medicine, School of Medicine
St. George’s University, Grenada
ABSTRACT
This paper examines the "Hispanic (American) Health Paradox," the juxtaposition
of Hispanics’ longer lifespan than the average American amid numerous inequities
regarding social determinants of health. Hispanic Americans endure multiple
health disparities with a higher incidence and prevalence of chronic conditions.
They also experience multiple psychosocial and physical health challenges,
including higher rates of food insecurity, poverty, segregation, discrimination, and
limited or no access to medical care. Nevertheless, Hispanics enjoy better physical
well-being and lower mortality rates when compared to non-Hispanics in the
United States (Ruiz et al., 2021). This project aims to analyze the sources of this
group’s biosocial advantages and resilience, allowing them to have a longer lifespan
amidst their lower health status and increased risk for chronic conditions. It
explores the political and social justice implications of these inequities. It also
examines the strategies to close the gap on Latinos' current health care disparities
via public policy aspects of federal and state legislature. A narrative review method
was utilized to examine the existing literature on this paradoxical effect. Keywords
based on Medical Subject Headings (MeSH) used to search resources for relevant
studies included: Hispanic health paradox (health paradox, immigrant paradox),
ethnic minorities (Latinos, LatinX), health disparities (disproportionate health,
health inequities), social justice (healthcare stakeholders, health inequities
solutions, inequities recommendations), mental health, physical health, and co- morbidities. A quality assessment of full-text peer-reviewed articles yielded 80
articles to compile this narrative review. The research revealed that, despite glaring
disparities in social determinants of health, Hispanic Americans have overall
experienced better health outcomes through a culture that emphasizes spirituality,
community support, and strong family ties.
Keywords: Hispanic health paradox, Hispanic mental health paradox, Hispanic
homelessness paradox, social determinants of health, social inequity, health disparities,
Latino
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INTRODUCTION
A Hispanic person is defined as "a person of Cuban, Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin regardless of race"(Statista Research Department,
2021). In this paper, the terms ‘Hispanic’ and ‘Latino’ will be used interchangeably, although
nuances in the different meanings of the two terms exist. Latinos are the largest ethnic minority
group in the United States. It is estimated that almost 112 million Hispanics will be residing in
the country in the next four decades, constituting the fastest-growing minority group. The most
sizable portion of Latinos is of Mexican descent, amounting to over 35 million in 2018. Puerto
Ricans and Cubans comprise the second and third largest Hispanic groups, totaling 6 million
and 2 million individuals, respectively (Statista Research Department, 2021). This article seeks
to address the health and social disparities that burden Hispanics, the risk factors for these
inequities, and the most relevant social determinants of health (SDOH) that contribute to these
inequalities. The Hispanic health paradox was examined in three realms: physical health,
mental health, and homelessness. Despite the existing inequities in these areas, the research
revealed that members of this ethnic group often enjoy longer and better-quality lives. Lastly,
potential policy and access improvements were explored to help bridge the gap in services and
health outcomes.
Health disparities were defined as “differences in health which are not only unnecessary and
avoidable but, in addition, are considered unfair and unjust” (Braveman, 2006, p. 168). SDOH,
according to the Healthy People 2020’s definition,"are conditions in the environments in which
people are born, live, learn, work, play, worship, and age that affect a wide range of health,
functioning, and quality-of-life outcomes and risks” (Office of Disease Prevention and Health
Promotion [ODPHP], 2021). Social, economic, and physical conditions in these various
environments and settings, such as school, church, workplace, and neighborhood, have been
referred to as "place." (Office of Disease Prevention and Health Promotion [ODPHP], 2021).
Hispanics tend to experience many difficulties and obstacles influenced by economic and
biosocial factors such as financial instability and occupation, limited academic advances,
disparate culture, language barriers, lack of social support, structural discrimination,
immigration status, and insufficient healthcare access. These obstacles perpetuate a cycle of
untreated or poorly managed chronic conditions, leading to a continuous "fight or flight" state
with cortisol-mediated immunosuppression (Velasco-Mondragon et al., 2016). The American
Public Health Association advised that Hispanics' lack of access to community-based health
determinants results in poor diet, sedentarism, substance use, and chronic stress, contributing
to the physical and mental health burdens facing them. Inadequate access to affordable housing,
transportation, and green spaces limits Latinos' ability to develop healthy and active exercise
routines while placing them at a lower socioeconomic status with negative implications
regarding reliable food access, stable and well-paying jobs, and academic and career
opportunities, all of which make up the basics of health justice and equity (Krisberg, 2021).
Hence, there is a critical need for legislative changes and the involvement of the pertinent
stakeholders to modify current policies and laws toward reducing these discrepancies in SDOH.
METHODOLOGY
A narrative review of the literature was conducted between 2020 and 202 to identify sources
discussing the Hispanic health paradox. The databases MEDLINE, PubMed, ScienceDirect,
Elsevier, Google Scholar, CORE, and Bielefeld Academic Search Engine (BASE) were searched
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Sandoval, B., Hem-Lee-Forsyth, S., & Bryant, H. (2021). A Tridimensional View of the Hispanic Health Paradox: Its Relationship with Faith, the
Enclave Theory, and Familism. Advances in Social Sciences Research Journal, 8(12). 317-345.
URL: http://dx.doi.org/10.14738/assrj.812.11476
using the keywords “Hispanic health paradox,” “health paradox,” “immigrant paradox,” “ethnic
minorities,” “Latinos,” “Latin X,” “health disparities,” “disproportionate health,” “health
inequities,” “social justice, “healthcare stakeholders,” “health inequities solutions,” “inequities
recommendations,” “mental health,” physical health,” and “co-morbidities.” Articles were
deemed relevant and included in the initial evaluation based on the review of titles, abstracts,
and conclusions. The inclusion criteria required full-text availability and publication between
2002 and 2021. Articles were excluded if they were published before 2001. A total of 800
relevant articles were generated from the initial search. Paper titles and abstracts were
subsequently studied and analyzed, and 100 articles were then selected from the search. A total
of 80 research articles were selected for this narrative review. Supplementary information was
gathered from governmental and public health agency websites and included as relevant and
timely sources, generating 20 articles.
Findings were organized and discussed in four main categories: barriers to optimal health
status and social determinants of health (food, physical environment, economic instability,
education, healthcare, community and social contexts); health outcomes and their
corresponding paradoxes (physical health, mental health, homelessness); and sources of
Hispanic resiliency (faith, the enclave theory, familism).
FINDINGS
Barriers to Optimal Health Status and Social Determinants of Health
Food: Living in a Food Desert or Living with Food Insecurity
Food deserts are areas typically found in low-income neighborhoods where access to more
nutritious options, such as fresh fruits and vegetables, is limited due to the absence of grocery
stores or financial attainability. Currently, the United States has over 24 million people living in
food desert areas, with the most significant disparity among Hispanics, who have access to only
one-third of the grocery stores that non-Hispanics do. Further, Hispanics are exposed to up to
three times more fast-food restaurants than those who reside in non-food desert
neighborhoods (DoSomething.org, 2021). For this reason, low-income Latinos in these food
desert neighborhoods have a higher prevalence of poor dietary intake, empty calories, and
saturated fats, carving a direct line to the high incidence of obesity, diabetes, chronic
cardiovascular conditions, and up to twice the likelihood of death due to uncontrolled pre- existing chronic conditions compared to residents of non-food desert neighborhoods
(DoSomething.org, 2021). For example, the multivariate logistic regression model by
Hernandez et al. (2017) demonstrated that food insecurity was most prevalent in minority
groups, especially Hispanics, with women exhibiting higher rates of obesity compared to food- secure women across all races and ethnicities. In addition, this study's covariate-adjusted
model revealed an over 40% association between food insecurity and obesity and 30% odds of
being overweight among Hispanic women (Hernandez et al., 2017).
Potential behavioral mechanisms of the previous relationships include what MacNeil et al.
(2017) indicated in their study of low-income Latina women and caregivers of young children.
These women reported unaffordable prices, lack of transportation to health-food grocery
stores, and lack of financial attainment or inability to utilize the Supplemental Nutrition
Assistance Program (SNAP) as primary determinants of their grocery shopping patterns
(MacNeil et al., 2017). In other words, Latino families are limited in accessing healthy foods due
to the lack of available grocery stores, their neighborhood's environmental factors, and
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financial limitations. Cabral (2018) conducted a One-Way ANOVA that deduced a statistically
significant relationship between Hispanics' educational attainment and food insecurity in
California. Currently, Latinos face significant barriers to advancing academically compared to
individuals of other ethnicities due to language, immigration, and other social issues, putting
them at higher risks of food deficiency and hunger.
FOOD: HUNGER
Besides food deserts in Hispanic-dense neighborhoods reducing the ability for Latinos to access
healthy foods, lack of financial means is another leading contributor to the current hunger,
obesity, and malnutrition issue among this ethnic group. Among the pediatric Hispanic
population in the United States, over 35% of children are considered overweight or obese – the
country's highest proportion of childhood obesity. However, due to the food insecurity that
most Hispanic households endure, almost 40% of children experience hunger and malnutrition,
revealing a simultaneous yet contrasting phenomenon (National Council of La Raza, 2011).
One mechanism that explains these issues is the job instability that most Hispanic caregivers
experience, resulting in living below the poverty line. Moreover, many have inadequate access
to medical care and experience forced living in neighborhoods with poor community support
systems. Most parents reported that their limited household income caused multiple
restrictions in rent and electricity payments, and the only means to cut down and save money
was to buy low-quality food or less food overall. For this reason, most of them described federal
nutritional programs such as WIC or SNAP as an essential means of avoiding hunger and buying
otherwise unaffordable, healthy essential foods such as milk, eggs, and fruit (National Council
of La Raza, 2011). However, not all Hispanic caregivers can enroll in these federally subsidized
programs and lack the proper community, and social support needed to obtain food stamps and
quality health care.
In summary, Hispanics face many barriers to obtaining healthy foods, and when available, work
instability and poverty cause hunger and food insecurity, with higher incidence and prevalence
among children. In addition, only some Latino caregivers obtain the necessary social support
to enroll in federal nutritional programs to help them maintain a consistent and healthy diet –
and this is the exception, not the norm.
PHYSICAL ENVIRONMENT: HOUSING AND SAFETY
Hispanics are typically forced into poor and low-income neighborhoods that carry with them
negative implications for safety, social and community support, and air quality. Lack of
neighborhood safety, described as the perception of unsafe areas and high crime rates, has been
associated with obesity among children and adults even after adjusting for socioeconomic
factors. In addition, several reports have demonstrated strong associations between high crime
rates and sedentarism among women only (Suglia et al., 2016). Unsafe Latin-dense
neighborhoods are also associated with poor social network development and poor community
support. A lack of neighborhood safety reduced social connections among residents and
negatively impacted physical health via increased Body Mass Index (BMI) (Suglia et al., 2016).
In addition to the lack of community support mentioned above, perceived residential distrust
also decreases the probability of outdoor physical activity and reduces opportunities for
community engagement and support to promote healthy behaviors. Furthermore, the constant
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Sandoval, B., Hem-Lee-Forsyth, S., & Bryant, H. (2021). A Tridimensional View of the Hispanic Health Paradox: Its Relationship with Faith, the
Enclave Theory, and Familism. Advances in Social Sciences Research Journal, 8(12). 317-345.
URL: http://dx.doi.org/10.14738/assrj.812.11476
perception of threats and insecurity causes chronic activation of the "fight or flight" system with
perpetual stress hormone secretion, precipitating cortisol-mediated immunosuppression, and
a diabetes-like state with adverse effects on the cardiovascular system. Lack of residential
safety also has detrimental effects on the mental health of Hispanic men, manifesting as a higher
incidence of depression and substance abuse (Squires et al., 2012). As a result, Hispanics' high
crime rates in neighborhoods hinder their ability to prevent obesity and exercise safely. This is
compounded by a threat to their immune system through perpetual cortisol-mediated
immunosuppression, resulting in central fat deposition and a diabetes-like state with adverse
effects on the cardiovascular system.
Similarly, Xiao & Graham (2019) described the relationship between chronic neighborhood
stressors and hypertension prevalence. Their study investigated chronic neighborhood
stressors, such as lack of safety and social networking, associated with the increased prevalence
of high blood pressure among Hispanics. In addition, premenopausal Hispanics who perceived
their neighborhood as unsafe had higher abdominal adipose deposits and higher BMI than
those who viewed their residential areas as safe (Xiao & Graham, 2019). In summation, high
residential crime rates in Latino neighborhoods increase susceptibility to cardiovascular
conditions such as hypertension, obesity, diabetes, and insulin resistance.
Xiao & Graham (2019) also found that Hispanic-dense neighborhoods (more than 50% Latinos
in the area) are disproportionately exposed to poor air quality: almost 10% higher fine
particulate matter with a diameter of fewer than 2.5 μm (PM2.5), with 30% more types of nitrous
oxides compared to majority Caucasian neighborhoods (less than 25% Latinos in the area).
PM2.5 is a major public health concern as studies investigating short-term exposure of up to only
24 hours in length found a solid correlation to increased respiratory co-morbidities and
premature death, resulting in an increased need for emergency room visits and restricted
activities of daily living (California Air Resources Board, 2021). Due to the small diameter of
this particulate matter, it has been strongly implicated in damage to the delicate bronchioles
and small functional lung cells, which partially explains the respiratory pathology seen in high
concentration exposures, including asthma exacerbations and chronic bronchitis. Similar
effects have been documented with exposure to nitrous oxides such as nitric oxide, nitrogen
dioxide, nitrous acid, and nitric acid (United States Environmental Protection Agency [EPA],
2021). Consequently, Hispanics are more susceptible to respiratory illness and worse
pulmonary outcomes due to the poor air quality and high pollutant exposure in their built
environment.
Regarding housing, Hispanics have a higher likelihood of crowded living situations. Mora et al.
(2016) reported on the mental health effects that crowded housing imposes on Latinos, citing
an association between more than five individuals sleeping in the same room, lack of a safe
place to store belongings, and lack of bed storage with depression scores higher than ten on
each category per the Center for Epidemiologic Studies Depression Scale (CES-D). The study
also found strong associations between severe anxiety scores higher than 27 based on the
Personality Assessment Inventory (PAI) and those without a key for their house or room (Mora
et al., 2016). Therefore, the mental health of Hispanics is jeopardized when multiple people
share the same room and lack adequate storage, leading to an increased probability of
depression and anxiety. Besides mental health problems, crowded living conditions among
Latinos also affect sleep quality, generating increased susceptibility to many chronic conditions.
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Housing and neighborhood turmoil and perceptions of infrastructure problems were linked to
more significant sleep disruption and reduced quality of overnight rest (Chambers et al., 2016).
Hispanics are thus at risk of multiple preventable chronic conditions associated with poor sleep
outcomes, including inferior quality living conditions and frequently disturbed sleeping
periods.
PHYSICAL ENVIRONMENT: GREEN SPACES
Hispanics also endure environmental injustices regarding green spaces in their built
environment. One study by Rigolon et al. (2018) reported inequities in scores for park systems
and their quality based on income and ethnic groups, noting lower scores in low-income
Hispanic-predominant cities. One probable cause of this inequity was the change in the political
economy of parks with reduced local tax contributions and greater dependency on national
nonprofits and public support. With Hispanics persisting as a low-income ethnic group with
little to no advocacy agencies in their neighborhood, they faced many barriers to accessing
national sources of financial support for green spaces in their cities (Rigolon et al., 2018). For
this reason, the Latino-predominant cities continue to exhibit a high incidence of cardiovascular
disease, diabetes, and obesity secondary, in part, to a sedentary lifestyle.
One of the most thoroughly studied neighborhood social features is poverty, which has severe
implications for obesity and a sedentary lifestyle. Neighborhoods with little to no governmental
financial support typically have fewer resources for green spaces. The absence of parks,
playgrounds, and sidewalks contributes to higher obesity rates. This scarcity is also associated
with higher crime rates, poor social infrastructure, diminished community, social cohesion,
social capital, and overall low aesthetic features of limited recreational areas (Suglia et al.,
2016). The neighborhood poverty theory establishes the clear connection between absent
green spaces, sedentarism, and obesity in Hispanics.
PHYSICAL ENVIRONMENT: LACK OF TRANSPORTATION AND PHYSICAL MEANS TO
HEALTH AND HUMAN SERVICES
In the United States, over 3.5 million people annually cannot access medical care due to lack of
transportation, such as inability to buy or rent a vehicle; insufficient transportation systems;
long commuting time to health care facilities; transportation expenses; and unfavorable
policies that affect ease and availability of transportation (American Hospital Association
[AHA], 2021). Wolfe et al. (2020) reported that those most affected are Latinos living below
poverty levels, Medicaid patients, and those with disabilities. Therefore, transportation
barriers disproportionately affect low-income Hispanics, resulting in adverse effects on
medical plan compliance, timely and adequate access to medical care, management of pre- existing chronic conditions, and reliable preventative care.
ECONOMIC INSTABILITY: FINANCIAL STATUS AND OCCUPATION
Hispanics have twice the likelihood of poverty compared to Caucasians. Some of the
contributing factors to their poor financial status include work instability, occupation type, and
dependent children in the household with low educational attainments (Gradín, 2012).
Moreover, the recently elevated rates of Hispanic immigration have created changes in the
current employment situation towards greater instability and informality with no employment
benefits and little to no short- or long-term assurances (Flippen, 2012). For example, with the
current COVID-19 pandemic, Latinos make up a disproportionally substantial percentage
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Enclave Theory, and Familism. Advances in Social Sciences Research Journal, 8(12). 317-345.
URL: http://dx.doi.org/10.14738/assrj.812.11476
across essential working positions with the risk of continuous, first-line exposure to potentially
infected individuals. Despite making up a little over 15% of the American population, Latino
employees comprise around one-third of all construction workers, one of the first fields to
return to regular working hours during the pandemic. This situation is compounded with no
sick paid days off, no insurance coverage, or short- and long-term disability benefits (Williams
et al., 2020). With no paid time-off, Hispanics face a dilemma trying to quarantine yet provide a
consistent income to their families. This reality proves that low-paying jobs held by many
Hispanics create financial instability and pose a threat to their economic vitality.
Additionally, Hispanics with Limited English Proficiency (LEP) are often employed in jobs with
high occupational risks and little to no worker's compensation than those who speak English
fluently. One explanation is that undocumented Latinos have no choice but to hold low-paying,
high-risk jobs. Many have already suffered dangerous situations during their migration path
and are monolingual Spanish-speakers (Dávila et al., 2011). What is more, immigrant workers
have lower rates of reporting work-related injuries due to their fear of retaliation from
employers based on immigration status and their LEP (Madera & Chang, 2011). Therefore,
Hispanics have jobs with absent or limited employee benefits and perform dangerous jobs that
threaten their health. Deficient employment opportunities for Hispanics, especially recent
immigrants, put them at risk of contagious illness, unintentional injury, and living below the
poverty line with low-paying jobs and no short- and long-term disability benefits in case of
occupational accidents.
ECONOMIC INSTABILITY: INCOME INEQUALITY
Hispanics experience financial and income racial disparities and are at the lower end of the
wealth accumulation than other racial groups. Income inequality partially explains this effect,
but it does not fully explain the Racial Wealth Gap. Wealth is not just money accumulation, but
it also includes compensation from medical insurance, tuition funds, retirement benefits
offered at work, and financial opportunities for physical, mental, and social well-being
(McKernan et al., 2013). Recently, the wealth gap has been widening, with the collective wealth
of Whites being six times that of Latinos. As the income and wealth for Whites continue to
increase, the wealth of Latinos diminishes, and they continue to accrue more debt with the same
or lower income. Consequently, the rich become more affluent, while the poor plunge deeper
into poverty.
Similarly, Hispanic families are less likely to own a house and a retirement fund than Whites,
hindering their ability to profit from wealth-producing assets. Less than 50% of Latino families
were homeowners in the last decade, compared to 75% of Whites (McKernan et al., 2013). In
addition to home ownership, recent literature attributes this wealth gap to educational
advancement. Findings demonstrated that the White-Hispanic wealth gap at the mean and
median distributions are attributable to educational attainment (Thompson & Juarez, 2015).
Not surprisingly, most Whites achieve higher educational levels than Hispanics, who typically
only complete high school or vocational and technical training.
Despite Hispanics experiencing a favorable shift in opportunities for higher education and
women having the same or higher levels compared to men across all races, the distribution of
those with advanced degrees continues to be disproportionate for Latinos. For example, per the
American Medical Association, only 3% of current physicians are Hispanic, including first-
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Sandoval, B., Hem-Lee-Forsyth, S., & Bryant, H. (2021). A Tridimensional View of the Hispanic Health Paradox: Its Relationship with Faith, the
Enclave Theory, and Familism. Advances in Social Sciences Research Journal, 8(12). 317-345.
URL: http://dx.doi.org/10.14738/assrj.812.11476
intake, alcohol dependency, and unprotected sex when intoxicated. It can be argued that
migratory stressors for male-dominant figures in Hispanic culture carry additional mental
health burdens for fathers, husbands, and sons that predispose them to compensate for social,
financial, and migratory difficulties and uncertainty with readily accessible yet harmful
solutions.
Sánchez (2015) revealed Latino men's maladaptive patterns, given the societal and health
system barriers for accessing mental health services. Analogous to Hispanic men's direct
relationship between alcohol use and stress, Goldbach et al. (2015) conducted a study that shed
light on Latino teenagers facing similar situations in the United States. 901 Hispanic teenagers
aged 11-19 participated in his study of alcohol intake frequency and stressors. It was noted that
almost a quarter of the participants reported alcohol use within the last 30 days with higher
stress scores for factors such as acculturation issues, community and gang violence, family
finances, discrimination, and family- and drug-associated stress. Therefore, the two studies
above indicate that Hispanics' mental health concerns are strongly associated with the social
and physical environment regarding the host country, with increased obstacles to service
utilization. As a result, readily accessible harmful venues to cope with these stressors, such as
alcohol intake, are seen as feasible solutions (Goldbach et al., 2015).
Poor mental health is a significant medical and social barrier to wellness among Hispanics,
precipitating domestic violence toward Latina women. While domestic and intimate partner
violence affects individuals of different racial backgrounds and socioeconomic and educational
levels, Latinas are particularly vulnerable as they experience additional challenges. Reina and
Lohman (2015) conducted a study in Central Iowa among Latina immigrants and concluded
that this population is at risk of structural and institutional barriers that prevent Latina women
from responding appropriately to intimate partner violence. These barriers included
institutional discrimination, unstable housing, and economic inequality (Reina & Lohman,
2015).
Health Disparities and Outcomes
Hispanic Physical Health: Cancer
The American Cancer Society (2020) states that Latinos' leading cause of death is cancer.
Infection-related cancers such as liver cancer arising from viral infections, stomach cancer
secondary to chronic bacterial infections endemic to developing countries, and cervical cancer
resulting from chronic human papillomavirus infection emerge twice as often in Hispanics
compared to non-Hispanics. Infection-causing pathogens and processes can easily be treated if
diagnosed promptly with appropriate pharmacological management and vaccine
administration (American Cancer Society, 2020). Hence, this type of epidemiological data
shows the unfortunate cancer progression affecting Hispanics, which can be attributed
primarily to social factors related to migration, decreased access to health care, and failure to
take preventative measures. In other words, this data demonstrates that environmental, social,
and community challenges burden Hispanics with 100% preventable cancer diagnoses. Still,
incidence numbers continue to rise, with over 170,000 new cancer diagnoses expected this year
alone among Hispanics in the United States.
For example, the most common cancer among Hispanic males is prostate cancer, followed by
colorectal and lung cancer. On the other hand, Hispanic women are diagnosed primarily with