1. Introduction

Despite efforts to reduce the disease burden among United States(U.S.) Hispanics, the disparity gap between Hispanics and other ethnicities still exists and the implications of this reality are alarming. Approximately half of Hispanics in the U.S. suffer from pre-diabetes and an additional 11% have type 2 diabetes, a figure that is disproportionately larger than the proportion among non-Hispanic whites. ^[1] Furthermore, Hispanic adults experience higher morbidity and mortality resulting from transient ischemic attack ^[1] and chronic kidney disease, ^[2] and children experience a higher prevalence of metabolic syndrome ^[3] and obesity. ^[4] Hispanics differ in their approach to disease screening, management, and treatment. Hispanics are less likely to undergo screening tests for cardiovascular disease, ^[5] or treat high blood pressure. ^[6] Treatment practices among type 2 diabetics further emphasizes this point; Hispanic diabetics are less likely than non-Hispanic white diabetics to self-monitor blood glucose, ^{[7, 8, 9]} have their dyslipidemia diagnosed, ^{[10, 11]} and/or obtain an annual diabetic foot examination ^[12].

Limited access to healthcare is often cited as a leading cause of the disproportional incidence of chronic health conditions among minority populations. This may be precipitated due to stigmas in minority status, lack of resources (or knowledge of resources), unemployment, lack of health insurance, lack of time, limited access to transportation and inadequate health literacy. ^{[13, 14, 15, 16]} Heisler et al. ^[17] have suggested that health disparities are explained by the quality of healthcare facilities, as Hispanics are more likely to receive care at lower-performing facilities as compared to non-Hispanics whites. Other sociocultural barriers that discourage the use of healthcare include language barriers, cultural ties to family and religion, and a lack of cultural competence by healthcare providers. ^{[17, 18]} Furthermore, among Hispanics living near the U.S.-Mexico border, the mere geographic proximity to the border may exacerbate the limited healthcare access and utilization ^{[8, 11, 19]}.

Due to their design and structure, community clinics often serve proportionately more low-income, unemployed, or uninsured individuals than private for-profit healthcare facilities. ^[20] The Affordable Care Act recently emphasized the need for quality-driven, cost-effective healthcare clinics; provisions in the bill have authorized state funding for the support of primary healthcare practices that can serve as medical homes (e.g. community clinics). ^[21] Furthermore, community clinics often attenuate the healthcare barriers experienced by Hispanics, including unemployment, lack of health insurance, and limited supply of Spanish-speaking healthcare providers/interpreters. ^[22] Three types of community clinics that serve low-income, unemployed, or uninsured individuals may include: Federally Qualified Health Centers (FQHCs), Community Health Centers (CHCs), and Faith-Based Organizations (FBOs) operating as community clinics. Under the supervision of the U.S. Department of Health and Human Services, FQHCs provide a cost-effective means of primary healthcare and improves equity in health. ^{[23, 24]} Operated through local governments or non-profit organizations, community health clinics may be useful for reducing disparities among Hispanics. Compared with Health Maintenance Organization (HMO) patients, CHC patients are more likely to rate their healthcare experience favorably ^{[25, 26]} and establish the clinic as their regular healthcare facility. ^[27] Similar to community health clinics, FBOs are privately funded, non-profit organizations that offer distinct advantages in reducing dyslipidemia and hypertension among patients. ^[26] Another advantage is the holistic integration of faith and health, ^[28] which may be particularly important among Hispanics who hold to orthodox (Catholic) or evangelical views about health ^{[13, 17]}.

Among Hispanic adults, the lack of primary healthcare access and utilization are important factors contributing to health disparities within this ethnic group.^[29]It is critical to identify educational opportunities for community clinics serving low income, unemployed and/or uninsured individuals in order to reduce the health disparity gap. The purpose of this study was to evaluate the associations of sex, age and community clinic(a Federal Qualified Health clinic, a Community Health Center and a Faith-Based Organization) with hypertension and dyslipidemia among Hispanics in Northeast Texas.

2. Methods

Our study examined data from three community clinics in Northeast Texas. We selected the clinics based on their primary goal of catering to low income, unemployed and/or uninsured individuals. All data were collected, analyzed, and documented by a licensed healthcare professional from each facility in 2006. The first clinic, a FQHC, offered data only from adult Hispanics with type 2 diabetes. The researchers utilized systematic randomized sampling for every tenth participant from an alphabetized list; the final sample size for this clinic was 93 participants. The second clinic, a faith-based organization, required participants to provide proof of employment prior to admission. The researchers utilized systematic randomized sampling, for every fifth participant. The third clinic, a CHC, had an organizational goal to provide healthcare to seasonal/migrant workers. This last clinic collected data in rural locations outside of the local Metropolitan Statistical Area (MSA) of Gregg/Smith counties but within 100 miles of the other clinics. The distribution of Hispanic adults from the community clincs are as follows: 93 from the FQHC (40.3%), 180 from the CHC (20.8%), and 174 from the FBO (38.9%).

Data from the three community clinics were merged into one dataset. Information included demographic variables, such as sex and age (collapsed into three categories: 18-30, 31-50, or 51+). Other measures included employment (unemployed or employed), highest level of education attained (completed high school or did not complete high school), country of birth (U.S., Mexico, or Central America), primary language spoken in the home (Spanish or English) and marital status (married/single). Access to healthcare was measured in terms of health insurance status (none, Medicare/Medicaid or private insurance). Clinicians recorded the self-report of physician-diagnosed type 2 diabetes and date of diagnosis. Due to the heterogeneity of type 2 diabetes status across community clinics, we excluded fasting plasma glucose from our analyses.

Blood pressure, cholesterol and glucose measures were obtained through the use of standard protocols during a single visit to each community clinic. Blood pressure was taken by trained physicians using manual sphygmomanometers in accordance with the standardized procedures ^[30]. Each participant took one blood pressure reading after resting quietly in a sitting position for five minutes. Blood specimens were collected for the determination of high density lipoprotein (HDL), low density lipoprotein (LDL), triglycerides, total cholesterol and glucose levels.

Systolic blood pressure, diastolic blood pressure, HDL, LDL, triglycerides, and total cholesterol were dichotomized prior to analyses. Systolic hypertension was dichotomized based a systolic reading of ≥140 mm Hg and diastolic hypertension was dichotomized based a diastolic reading of ≥90 mm Hg. ^[30] Low HDL was defined as serum levels <40 mg/dL for men and <50 mg/dL for women, which represents a high risk for coronary heart disease. ^[31] High LDL, high total cholesterol, and high triglyceride levels were defined as having serum levels of ≥160 mg/dL, ≥200 mg/dL, and ≥150 mg/dL, respectively.

Proportions for demographic characteristics were computed. One-way ANOVA analyses examined the mean differences in systolic blood pressure, diastolic blood pressure, total cholesterol, triglycerides, LDL, and HDL levels across community clinics. We also evaluated mean differences by community clinics, stratified by sex. Logistic regression models evaluated the independent associations between the age, sex and community clinic with systolic blood pressure, diastolic blood pressure, total cholesterol, triglycerides, LDL, and HDL levels, adjusting for type 2 diabetes, employment, marital status, and age category. Due to missing information, fifty-nine cases were excluded from logistic regression models. Our results are presented in terms of crude and adjusted odds ratios (ORs) and 95% confidence intervals. An alpha level was set a priori at 0.05. All analyses were performed using Stata, v. 12 ^[32].

Upon admittance to each community clinic, each participant gave written informed consent to participate in the study, offered in English or Spanish. The institutional review board of The University of Texas at Tyler approved this study.

Table 1. Characteristics of Hispanics in Northeast Texas across community clinics

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3. Results

The proportion of participants with high systolic blood pressure, diastolic blood pressure and total cholesterol in our study (prevalence of 29%, 38%, and 60%, respectively) are consistent with previous studies evaluating health outcomes among a low income, unemployed, and/or uninsured Hispanic population. ^{[8, 33]} A majority of the participants did not complete high school, were uninsured, were born in Mexico or Central America and indicated that Spanish is the primary language spoken within the home (Table 1). Furthermore, 37% of the participants reported current unemployment and 21% reported a type 2 diabetes diagnosis.

The proportion of participants with high systolic blood pressure, diastolic blood pressure and total cholesterol in our study (prevalence of 29%, 38%, and 60%, respectively) are consistent with previous studies evaluating health outcomes among a low income, unemployed, and/or uninsured Hispanic population. ^{[8, 33]} A majority of the participants did not complete high school, were uninsured, were born in Mexico or Central America and indicated that Spanish is the primary language spoken within the home. Furthermore, 37% of the participants reported current unemployment and 21% reported a type 2 diabetes diagnosis.

We further stratified the proportions by systolic hypertension status and by diastolic hypertension status. Compared to participants without systolic hypertension, participants with systolic hypertension had a higher percentage of participants who were men, were among the oldest age category, attended the CHC clinic, were born in Central America, and were unemployed. As expected, a majority of participants with systolic hypertension also had diastolic blood pressure (75.2%), high triglyceride levels (88.3%), and high total cholesterol levels (70.8%). Compared to participants without diastolic hypertension, participants with diastolic hypertension had a higher percentage of participants who were men, were among the oldest age category, attended the CHC clinic, were born in Central America, and had type 2 diabetes. A majority of participants with diastolic hypertension also had systolic blood pressure (85.1%), high LDL levels (82.6%), high triglyceride levels (90.9%), and high total cholesterol levels (75.2%).

Significant differences in means were noted for systolic blood pressure, diastolic blood pressure, and HDL levels across the community clinics (Table 2). Participants from the FQHC had the highest mean systolic blood pressure levels. Compared to the FQHC, the participants from the CHC had higher mean diastolic blood pressure levels and lower mean HDL levels (p-values<0.05). After stratifying for sex, the mean differences across the community clinics remained. Among women, there were significant differences in means for diastolic blood pressure levels and HDL levels across the community clinics (p-value<0.05; results not presented). Among men, significant differences in means were noted for diastolic blood pressure and HDL levels across the community clinics (p-value<0.05; results not presented). In particular, the mean diastolic blood pressure levels were the highest among Hispanic men within the CHC (Mean 79.6; 95% CI 76.3-82.9), as compared to the FQHC (Mean 63.3; 95% CI 56.0-70.7). Similarly, the HDL levels were considerably lower among Hispanic men within the CHC (Mean 34.3; 95% CI 29.0-39.6) as compared to the FQHC (Mean 49.0; 95% CI 30.0-68.0).

Table 2. Mean differences of measures by community clinic

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Table 3 illustrates the associations between sex, age, and community clinic with systolic hypertension, diastolic hypertension, and low HDL. In general, men were more likely to experience poor health outcomes. Compared to women, men were about twice as likely to experience systolic hypertension (adjusted OR 1.85; 95% CI 1.14-3.02), diastolic hypertension (adjusted OR 1.67; 95% CI 1.01-2.76), and poor HDL control (adjusted OR 2.39;95% CI 1.25-4.59).

Table 3. Associations of sex, age and community clinic with systolic hypertension, diastolic hypertension and low HDL levels

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Compared to the participants within the 18-30 age group, participants within the 51+ age group were nearly four times more likely to experience systolic blood pressure compared with the 18-30 age group (95% CI 1.72-7.51). It was suggestive that participants within the oldest age group were more likely to experience diastolic hypertension and low HDL, albeit these associations were not statistically significant. We found no evidence of an association between hypertension or dyslipidemia with the middle age group.

Participants from the CHC were more likely to experience poor health outcomes. Compared to the FQHC, participants from the CHC thirteen times as likely to experience diastolic hypertension (95% CI 3.21-57.39); it was suggestive the CHC participants were more likely to experience systolic hypertension (adjust OR 3.16; 95% CI 0.94-10.64). Participants from the FBO were five times as likely to experience diastolic hypertension (95% CI 1.42-21.60) but there was no association with systolic hypertension. We found no evidence of an association between community clinics and HDL levels. These results are in agreement with the ANOVA results.

We also evaluated the influence of sex, age and community clinic on dyslipidemias (high cholesterol, high LDL, and high triglycerides); none of these associations were statistically significant (results not presented).

4. Discussion

This study is among the first to report the associations between sex, age and community clinic with hypertension and dyslipidemias among Hispanics in Northeast Texas. We provide evidence of increased odds for systolic hypertension among Hispanic men (as compared to women), participants from the CHC that served seasonal/migrant workers (as compared to FQHC), and older participants (as compared to participants in the youngest age group).

In general, Hispanic men are more likely to experience hypertension and dyslipidemia than Hispanic women. Hispanic men are twiceas likely to experience systolic hypertension and dyslipidemia (low HDL) as compared with Hispanic women. Previous studies addressing similar hypotheses have revealed mixed results. Fisher-Hoch et al. ^[11] demonstrated no difference in health outcomes by sex where as Lui et al. ^[34] found that Hispanic women had a higher prevalence of isolated systolic hypertension than Hispanic men. Still, other studies have demonstrated that Hispanic men have a higher prevalence of isolated systolic hypertension than Hispanic women. ^{[35, 36]} One explanation for the increased odds for systolic hypertension among men is the role of androgens, such as testosterone. Human and animal studies have demonstrated that androgens may alter blood pressure regulation. ^[37] It also possible that oxidative stress may be important in mediating hypertension. ^[38] Although oxidative stress could explain the dyslipidemia among Hispanic men, these mechanisms are not yet clear.

Our stratified results provide evidence of hypertension and dyslipidemia among Hispanic men from the CHC serving the seasonal/migrant workers. Consistent with our findings, a previous study has demonstrated similar health outcomes among Hispanics and U.S. born Mexican-Americans. ^[39] Among other factors mentioned previously, unmeasured dietary behaviors could explain the hypertension and dyslipidemia we observed. Doyle et al. ^[40] reported poor dietary behaviors among seasonal/migrant workers in Texas Hispanics. Similarly, Weigel et al. ^[33] reported that migrant/seasonal workers near the U.S.–Mexico border region were often unable to access or afford nutritional foods. As a result, Hispanic migrant/seasonal workers may be more susceptible to poor health outcomes than the general population. We suspect that CHC participants consume diets high in sodium and low in dietary fiber, which could lead to hypertension ^[41] and lower HDL levels ^[42].

As expected, there is a positive association between advancing age and hypertension. In particular, older participants are nearly four times as likely to experience systolic hypertension as compared to the younger participants. In support of our findings, a recent study noted that the prevalence of systolic hypertension (but not diastolic hypertension) was highest among older Hispanic adults. ^[34] Indeed, systolic hypertension is the predominant type of hypertension experienced among older adults. ^[43] Strong evidence exists to support the increasing prevalence of hypertension with age. The impact of advancing age on hypertension is well-documented and likely involves an increase in arterial stiffness and endothelial dysfunction ^[44].

Hispanic men and older Hispanics have a higher morbidity and mortality resulting from coronary heart disease, stroke and other chronic diseases, due to the stronger associations with systolic hypertension and dyslipidemia. Research has indicated that hypertension is closely associated with long-term cardiovascular risk among men (but not necessarily women). ^[45] In general, it is likely that Hispanics are less likely to undergo screening tests for chronic disease, ^[5] treat high blood pressure ^[6] or self-manage chronic disease; ^{[7, 8, 9]} we suspect that this is especially true for Hispanic men and older Hispanics. Therefore, it is likely that improved efforts to educate Hispanic men and/or older Hispanics could ameliorate the poor health outcomes observed in the present study.

It is important to consider the limitations of our study. In order to address selection bias, we utilized systematic randomization for two clinics, the FQHC and the CHC. For FBO, we were not able to randomize the sample and we acknowledge the potential for selection bias. Although we attempted to adjust for important confounders (type 2 diabetes, employment, martial status), it is possible that residual confounding could have biased our findings. For instance, due to the large proportion of participants with missing height and weight information, we were unable to adjust for body mass index (BMI). We recognize the potential for residual confounding, as BMI is strongly associated with sex, age, and socioeconomic status, ^[46] as well as chronic disease morbidity and mortality. ^[47] Similarly, information on other important lifestyle factors (e.g. diet, alcohol, smoking) were unavailable and which may have a role in hypertension and dyslipidemia. ^{[41, 42, 48, 49, 50, 51, 52]} There may be other unmeasured psychological variables, such as acculturation, that that could bias our results. A recent study found that the prevalence of hypertension differs by acculturation status among Hispanics in Texas ^[53].

Strengths of this study include the large sample of low-income, unemployed and/or uninsured U.S. Hispanics, the use of established cutoff levels for biomarkers, and sufficient statistical power (as evidenced by narrow confidence intervals). Furthermore, it is likely that our findings are generalizable to the larger Hispanic population, as our data were in close agreement of demographic factors (education, birth country, insurance status) and health outcomes with a study evaluating a similar hypothesis among a low income, unemployed, or uninsured Hispanic population ^[8].

5. Perspectives

The poor health outcomes observed among the Hispanics in our study are not likely to improve following implementation of the Affordable Care Act without improved education and outreach. ^[29] Therefore, we propose that healthcare professionals develop health education campaigns that are culturally relevant and specifically targeted toward Hispanic men. Askim-Lovseth et al. ^[13] attend to health education among Hispanics on three levels: preventive disease campaigns, the health provider/client relationship, and perceptions of prescription medication usage. With respect to prevention campaigns, one tried-and-tested strategy is the effective use of promotor as (Spanish-speaking community healthcare workers). ^[54] Another useful strategy is to train Hispanic youth to educate family members, ^[13] which may be particularly helpful in educating older men within a family. As to the health provider/client relationship, better healthcare experience depends on both parties improving dialogue skills (assuming that a common language is spoken), ^[13] and increasing the availability of interpreters, with special emphasis on providers spending more time with men. ^[55] A qualitative study with Texas Hispanics found that men seemed more ‘stilted’ about their health during conversations with facilitators and with each other. ^[40] Sex differences in attitudes toward health could be explained by a strong sense of masculine pride (i.e. machismo) often observed among Hispanic men. Concerning prescription drug usage, there is a need to recognize the economic motivations within this community. Hispanics living near the U.S.-Mexico border often prefer purchasing prescription medication in Mexico with the perceived notion of securing a lower price; ^[13] however, they are likely unaware that many prescription drug medications are less expensive in the U.S. ^[56] We believe that culturally-relevant health campaigns within the Hispanic community could ameliorate the hypertension and dyslipidemia we observed among Hispanic men and older Hispanics.

Acknowledgement

We would like to thank Ms. Debora Bell, RN MSN C-APRN, Dr. John English, MD, and Dr. Craig Gunter, MD, for access to their records for this study.

Disclosures

The authors declare no conflicts of interest in this study.

List of Abbreviations

ANOVA: analysis of variance;

BMI: body mass index;

CHC: Commmunity Health Center;

CI: confidence interval;

FBO: Faith-Based Organization;

FQHCFederally Qualified Health Center;

HDL: high density lipoprotein;

HMO: Health Maintenance Organization;

LDL: low density lipoprotein;

MSA: Metropolitan Statistical Area;

OR: odds ratio;

U.S.: United States.

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