Abstract
Latinos represent almost 20% of the US population and face significant health and health care inequities. When compared with socioeconomically similar comparators, they demonstrate better all-cause mortality, a long-observed epidemiologic phenomenon known as the “Latino paradox.” In May 2023, we convened the inaugural Latino Primary Care Summit, focused on the theme, “Immigrant Paradox: Primary Care Roles, Implications and Future,” with the goal of helping to define a research agenda and recommendations for Latino primary care equity within the context of the Latino paradox. The Summit consisted of 8 expert presentations, including breakout discussion groups and report-outs to the entire Summit group. Six themes were identified from presentation content, and recommendations were drawn from these to better inform a primary care research agenda for Latino health equity. The 6 themes were organized into the following categories: 1) Latino Paradox Considerations, Limitations, and Implications (proper standardization and contextualization). 2) Data Issues (accurate and ethical categorization). 3) Bridging Clinic and Community (understanding partnership development and maintenance). 4) Primary Care Challenges (specific issues related to day-to-day delivery of primary care to Latino patients). 5) Social Needs (implementation and evaluation of social needs screening to Latino patients. 6) Workforce/Academics, Representation Inequities, and Innovation (research training, workforce diversity, and innovation approaches).
- Family Medicine
- Health Disparities
- Health Services Needs
- Hispanic or Latino
- Primary Health Care
- Workforce Diversity
Introduction
The Latino Population
In 2021, Hispanic/Latino people accounted for 18.9% (62.6 million) of the US population, making it the nation’s largest ethnic minority group.1 There are now 13 US states with at least 1 million Hispanic or Latino residents, and the Census Bureau estimates the Hispanic/Latino population will reach ∼75 million by 2030 and ∼111 million by 2060.2
The Hispanic/Latino population in the US has notable heterogeneity, including by country of origin, immigration status, and place of birth, among others. For example, according to the Pew Research Center, 61.5% of all Hispanic or Latino people in the US indicated they were of Mexican origin (that is, born in Mexico or with ancestral roots to Mexico).3 In US Census surveys, Hispanics/Latinos identify with ≥19 Latin American and Caribbean countries of which 8 (Mexico, Puerto Rico, Cuba, Dominican Republic, Guatemala, Honduras, El Salvador, Colombia) have at least 1 million people in the US as of 2021.4 As of 2021, 1 in 3 Hispanic/Latino people were immigrants and 81% of Hispanic or Latino people were US citizens.5
In this article, we use the term “Latino” instead of “Hispanic”6 or other more recent terms such as “Latinx” or “Latine.” We value the importance of “Latinx” or “Latine” terms but given the lack of use of such terms in historic federal/local surveys and administrative data (on which most Latino paradox studies are based) and the important needed work to understand the use of these terms in current scholarship,7 we opted to use “Latino” throughout this article.
The Latino Paradox
It is well established that lower socioeconomic status (SES), for example, low levels of income and education, is associated with greater mortality and morbidity. Relative to non-Latino whites, Latinos have a lower socioeconomic status profile. Yet, over the past many decades, the literature consistently shows that all-cause mortality is lower among Latinos than non-Latino whites. This finding is known as the Latino paradox.
It is important to note the over the years, the term “Latino paradox” has evolved to refer to better health outcomes among Latinos relative to non-Latino whites. Nevertheless, it is key to understand that the term is limited to all-cause mortality, not to general health outcomes or mortality from specific causes. Indeed, deaths from certain causes (for example, cancer of the liver) are higher among Latinos than non-Latino whites. Findings on the Latino all-cause mortality advantage are considered paradoxical because they contradict well-established observations that lower social status is associated with greater mortality (as well as poorer health). Much debate has centered on the paradox and its explanation. These include whether statistical artifacts, as migratory processes, or other factors account for the paradox.8 Other explanations center on differences in health behaviors (for example, smoking) among Latinos compared with non-Latino whites.
Primary Care Among US Latino Patients
Primary care accounted for 50.3% of the more than a billion physician office visits in 2019.9 Because of primary care’s comprehensiveness, studying the Latino paradox in the context of primary care allows for the use of multiple methods and approaches to understanding comprehensive health outcomes and social challenges and multilevel factors (for example, neighborhood-level information, social determinants of health) that may contribute to health outcomes in Latino populations.
Latino patients may encounter barriers to accessing primary care. Latinos in the US have the highest rates of uninsurance, at 18.3%, compared with 5.4% for non-Latino whites.10 Many factors contribute to discrepancies in care and access to care for Latinos including poor working environments, systemic discrimination, and increased social risks. However, many Latinos are also part of communities with strong social networks and demonstrate consistent patterns of positive health behaviors11 and high value engagement with health care services.12⇓–14
Much has been written about disparities in specific health outcomes in Latino patients. Cardiovascular disease drives a large proportion of mortality in US Latinos, and numerous publications have expertly outlined disparities (and sometimes advantages) in cardiovascular disease and risk factor prevalence and outcomes, risk factor control, and quality of care in Latino patients.15⇓⇓–18 Studies that show Latinos are more likely than non-Latino whites to develop type-2 diabetes mellitus (T2DM) at younger ages, show poorer glycemic control, and suffer higher rates of T2DM-related complications.19⇓–21 Latino patients face significant cancer morbidity/mortality, and recent reports have outlined the landscape of cancer care and outcomes in Latino populations.19,22,23 While numerous social forces impact disease outcomes and aspects of health, many of these arenas are the domain of primary care, where access to care, prevention, screening, and treatment may lengthen and improve life.24
Latino Primary Care Summit
To address these topics, we established an annual meeting, the Latino Primary Care Summit. The first annual Summit, focused on the theme “Immigrant Paradox: Primary Care Roles, Implications and Future,” was held at the Oregon Health & Science University in Portland, OR, on May 1 and 2, 2023. We convened a diverse group of 52 participants from interested and affected groups with expertise in the immigrant paradox across various disciplines, including: health care delivery, academia, policy, advocacy, leadership, patients and other community members. Of note, the concepts of immigrant paradox and Latino paradox are related but not equivalent, and given the that speakers/attendees discussed the Latino paradox specifically and more frequently, we have used that term consistently throughout the rest of the article.
The Summit consisted of 8 expert presentations with breakout discussions and report-outs to the entire Summit (Table 1). In post-Summit analyses of notes and transcripts from presentations (including an expert community partner panel and video interviews) and small group discussions that followed these presentations, we identified key themes to inform a primary care research agenda for Latino populations in the setting of the Latino paradox. These Summit proceedings are not to be viewed as scoping or complete review of the Latino paradox. Instead, by sharing personal, research and community engagement experience, Summit participants surfaced recommendations for understanding, assessing, and improving Latino health and health care delivery in primary care. A more detailed report of the Summit findings is included in supplementary materials.
Latino Primary Care Summit Speakers and Presentation Titles
Expert Presentations
Themes from the Summit and Research Agenda Recommendations
Six themes emerged from Summit discussions: 1) Latino Paradox Considerations Limitations and Implications. In medical literature, the term “Latino Paradox” has suffered from overgeneralization outside of all-cause mortality. Summit attendees provided discussion and recommendations on aspects of a research agenda to standardize the concept. 2) Data Issues. The ability to accurately and ethically understand the ethnic categories in which patients place themselves is vital in improving health equity. Racial and ethnic categories have either been historically oppressive, or overly broad, incomplete, or inaccurate. Summit attendees discussed and recommended approaches for data collection in primary care research to provide better and more consistent data categories on Latino patients. 3) Bridging Clinic and Community. Summit participants discussed that research, clinic, and community partnerships need to be forged, developed, and maintained to adequately generate and implement knowledge. Summit attendees provided recommendations on the funding mechanisms and research designs necessary for research, clinic, and community partnerships. 4) Primary Care Challenges. Primary care clinics must navigate numerous challenges to appropriately care for Latino patients. Summit attendees provided discussion and recommendations on the specific research approaches to maximize primary care equity for Latinos. 5) Social Needs. Social screening tools have been rapidly integrating into primary care workflows with minimal evidence to understand their implementation among Latino patients. Summit attendees provided discussion and recommendations on the implementation and evaluation of social need screening for Latino patients. 6) Workforce/Academics, Representation Inequities, & Innovation. The research workforce in Latino primary care equity continues to underrepresent the Latino community. Summit attendees provided discussion and recommendations on training programs and approaches to expand and diversify the workforce. Summit themes and recommendations in detail are presented in Table 2.
Themes and Recommendations
Conclusion
The Latino paradox is a long-observed epidemiologic phenomenon whereby Latino patients have lower all-cause mortality than socioeconomically similar comparators. Latino patients may also face disparities in primary care receipt; the delivery of care to Latino patients and populations may be impeded by numerous multi-level barriers. It is crucial for primary care providers and organizations to understand the paradox and its implications, as it may connect to many phenomena central to the delivery of primary care. Research in primary care, where frontline care is provided to millions of Latino patients, may give valuable insights to the Latino paradox and the health of Latino populations.
Recommendations to help shape a research agenda for Latino primary care equity, specifically in the context of Latino paradox, formed around 6 themes: 1) Latino Paradox Considerations, Limitations and Implications, 2) Data Issues, 3) Bridging Clinic and Community, 4) Primary Care Challenges, 5) Social Needs, and 6) Workforce/Academics Representation Inequities, & Innovation. These broad-ranging topics that emerged underscore the importance of the Latino Paradox to Family Medicine. Collecting accurate and health-vital information from Latino patients, tailoring care to community needs, and understanding unique Latino community features are all central to the discipline of Family Medicine. A more robust research agenda that addresses these 6 domains will be crucial in understanding, assessing, and improving Latino health and health care delivery in primary care.
Acknowledgments
The authors thank the Summit organizers and the partner organizations (Oregon Health and Science University Department of Family Medicine, Oregon Health and Science University Knight Cancer Institute) that supported the Summit. We extend our gratitude to the speakers and attendees for their invaluable contributions.
Notes
This article was externally peer reviewed.
Funding: This work was supported by the Silver Family Innovation Fund.
Conflict of interest: The authors do not have any conflicts to report.
To see this article online, please go to: http://jabfm.org/content/37/5/948.full.
- Received for publication February 21, 2024.
- Revision received April 10, 2024.
- Accepted for publication April 15, 2024.
