Sleep Quality among Hispanics of Mexican Descent and Non-Hispanic Whites: Results from the Sleep Health and Knowledge in US Hispanics Study

Xavier Soler, Carolina Diaz-Piedra, Wayne A. Bardwell, Sonia Ancoli-Israel, Lawrence A. Palinkas, Joel E. Dimsdale, Jose S. Loredo

University of California San Diego, San Diego, USA.
University of Granada, Granada, Spain.
University of Southern California, Los Angeles, USA.

DOI: 10.4236/ojrd.2013.32015                

Abstract

Objectives: To investigate differences in sleep quality between Hispanics of Mexican descent (HMD) and Non-Hispanic Whites (NHW) and evaluate the effect of acculturation to the US lifestyle in sleep health. We hypothesize that the detrimental effect of acculturation on health outcomes will impact sleep quality among HMD. Design: We performed a population-based random digit dialing telephone survey to determine sleep quality in HMD and NHW. We collected from 3667 subjects, demographics, previous diagnosis of depression or anxiety, past treatment for sleep disorders, the Pittsburgh Sleep Quality Index (PSQI) and the Short Acculturation Scale for Hispanics. Results: The prevalence of poor sleep quality (PSQI > 5) was 64.4% for HMD and 64.3% for NHW (p = 0.93). A prior diagnosis of depression or anxiety was an independent predictor of poor sleep quality in both groups (OR 3.4 and 2.7 for HMD and NHW. Ethnicity was not a predictor of poor sleep quality in HMD or NHW. Acculturation was not a predictor of poor sleep quality in HMD. However, highly acculturated young HMD males had significantly more prevalence of poor sleep quality compared to NHW (64.8% vs. 49.8%, p < 0.001). Conclusion: The absence of sleep quality differences in a large sample of HMD and NHW living in San Diego County is contrary to current data of having poorer sleep quality among Latinos. We found that neither ethnicity nor acculturation were predictors of poor sleep quality in HMD. However, we demonstrated a highly prevalent poor sleep quality among the two ethnic groups. The finding of significantly lower sleep quality in young highly acculturated HMD men may represent the heterogeneity of ethnicity related to sleep. Programs to improve sleep quality in subjects with depression and/or anxiety, and in young highly-acculturated HMD seems warranted.

Keywords

Sleep Quality; Race/Ethnicity; Acculturation; Hispanics; Latinos; Mexican-Americans; PSQI

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	M. Vandekerckhove and R. Cluydts, “The Emotional Brain and Sleep: An Intimate Relationship,” Sleep Medicine Reviews, Vol. 14, No. 4, 2010, pp. 219-226. doi:10.1016/j.smrv.2010.01.002
[2]	M. D. Althuis, L. Fredman, P. W. Langenberg and J. Magaziner, “The Relationship between Insomnia and Mortality among Community-Dwelling Older Women,” Journal of the American Geriatrics Society, Vol. 46, No. 10, 1998, pp. 1270-1273.
[3]	D. F. Kripke, S. Ancoli-Israel, M. R. Klauber, D. L. Wingard, W. J. Mason and D. J. Mullaney, “Prevalence of Sleep-Disordered Breathing in Ages 40-64 Years: A Population-Based Survey,” Sleep, Vol. 20, No. 1, 1997, pp. 65-76.
[4]	J. W. Shepard, Jr., “Hypertension, Cardiac Arrhythmias, Myocardial Infarction, and Stroke in Relation to Obstructive Sleep Apnea,” Clinics in Chest Medicine, Vol. 13, No. 3, 1992, pp. 437-458.
[5]	H. Schafer, U. Koehler, S. Ewig, E. Hasper, S. Tasci and B. Luderitz, “Obstructive Sleep Apnea as a Risk Marker in Coronary Artery Disease,” Cardiology, Vol. 92, No. 2, 1999, pp. 79-84. doi:10.1159/000006952
[6]	L. J. Findley, M. Fabrizio, G. Thommi and P. M. Suratt, “Severity of Sleep Apnea and Automobile Crashes,” New England Journal of Medicine, Vol. 320, No. 13, 1989, pp. 868-869. doi:10.1056/NEJM198903303201314
[7]	T. Young, M. Palta, J. Dempsey, J. Skatrud, S. Weber and S. Badr, “The Occurrence of Sleep-Disordered Breathing among Middle-Aged Adults,” England Journal of Medicine, Vol. 328, No. 17, 1993, pp. 1230-1235. doi:10.1056/NEJM199304293281704
[8]	S. D. Youngstedt, P. J. O’Connor and R. K. Dishman, “The Effects of Acute Exercise on Sleep: A Quantitative Synthesis,” Sleep, Vol. 20, No. 3, 1997, pp. 203-214.
[9]	G. Jean-Louis, C. Magai, G. J. Casimir, F. Zizi, F. Moise, D. McKenzie, et al., “Insomnia Symptoms in a Multiethnic Sample of American Women,” Journal of Women’s Health, Vol. 17, No. 1, 2008, pp. 15-25. doi:10.1089/jwh.2006.0310
[10]	J. Profant, S. Ancoli-Israel and J. E. Dimsdale, “Are There Ethnic Differences in Sleep Architecture?” American Journal of Human Biology, Vol. 14, No. 3, 2002, pp. 321-326. doi:10.1002/ajhb.10032
[11]	U. Rao, C. L. Hammen and R. E. Poland, “Ethnic Differences in Electroencephalographic Sleep Patterns in Adolescents,” Asian Journal of Psychiatry, Vol. 2, No. 1, 2009, pp. 17-24. doi:10.1016/j.ajp.2008.12.003
[12]	M. E. Ruiter, J. DeCoster, L. Jacobs and K. L. Lichstein, “Sleep Disorders in African Americans and Caucasian Americans: A Meta-Analysis,” Behavioral Sleep Medicine, No. 4, 2010, pp. 246-259. doi:10.1080/15402002.2010.509251
[13]	C. J. Stepnowsky Jr., P. J. Moore and J. E. Dimsdale, “Effect of Ethnicity on Sleep: Complexities for Epidemiologic Research,” Sleep, Vol. 26, No. 3, 2003, pp. 329-332.
[14]	S. F. Quan, J. L. Goodwin, S. I. Babar, K. L. Kaemingk, P. L. Enright, G. M. Rosen, et al., “Sleep Architecture in normal Caucasian and Hispanic Children Aged 6-11 Years Recorded during Unattended Home Polysomnography: Experience from the Tucson Children’s Assessment of Sleep Apnea Study (TuCASA),” Sleep Medicine, Vol. 4, No. 1, 2003, pp. 13-19. doi:10.1016/s1389-9457(02)00235-6
[15]	P. R. Castillo, J. Kaplan, S. C. Lin, P. A. Fredrickson and M. W. Mahowald, “Prevalence of Restless Legs Syndrome among Native South Americans Residing in Coastal and Mountainous Areas,” Mayo Clinic Proceedings, Vol. 81, No. 10, 2006, pp. 1345-1347. doi:10.4065/81.10.1345
[16]	S. Shafazand, D. M. Wallace, S. S. Vargas, Y. Del Toro, S. Dib, A. R. Abreu, et al., “Sleep Disordered Breathing, Insomnia Symptoms, and Sleep Quality in a Clinical Cohort of US Hispanics in South Florida,” Journal of Clinical Sleep Medicine, Vol. 8, No. 5, 2012, pp. 507-514.
[17]	S. Subramanian, B. Guntupalli, T. Murugan, S. Bopparaju, S. Chanamolu, L. Casturi, et al., “Gender and Ethnic Differences in Prevalence of Self-Reported Insomnia among patients with Obstructive Sleep Apnea,” Sleep & Breathing, Vol. 15, No. 4, 2011, pp. 711-715. doi:10.1007/s11325-010-0426-4
[18]	L. Tomfohr, M. A. Pung, K. M. Edwards and J. E. Dimsdale, “Racial Differences in Sleep Architecture: The Role of Ethnic Discrimination,” Biological Psychology, Vol. 89, No. 1, 2012, pp. 34-38. doi:10.1016/j.biopsycho.2011.09.002
[19]	Y. Song, X. Zhang, J. Ma, B. Zhang, P. J. Hu and B. Dong, “Behavioral Risk Factors for Overweight and Obesity among Chinese Primary and Middle School Students in 2010,” Chinese Journal of Preventive Medicine, Vol. 46, No. 9, 2012, pp. 789-795.
[20]	K. Ladenheim, “Collecting from the Uninsured: Hospital Billing Practices,” NCSL Legisbrief, Vol. 14, No. 34, 2006, pp. 1-2.
[21]	B. Guzman and E. D. McConnell, “The Hispanic population: 1990-2000 Growth and Change,” Population Research and Policy Review, Vol. 21, No. 1-2, 2002, pp. 109-128. doi:10.1023/A:1016541906218
[22]	L. E. Skolarus, L. D. Lisabeth, L. B. Morgenstern, W. Burgin and D. L. Brown, “Sleep Apnea Risk among Mexican American and Non-Hispanic White Stroke Survivors,” A Journal of Cerebral Circulation, Vol. 43, No. 4, 2012, pp. 1143-1145.
[23]	M. R. Benjamins, J. Hirschman, J. Hirschtick and S. Whitman, “Exploring Differences in Self-Rated Health among Blacks, Whites, Mexicans, and Puerto Ricans,” Ethnicity & Health, Vol. 17, No. 5, 2012, pp. 463-476. doi:10.1080/13557858.2012.654769
[24]	J. Waksberg, “Sampling Methods for Random Digit Dialing,” Journal of the American Statistical Association, Vol. 73, No. 361, 1978, pp. 40-46. doi:10.1080/01621459.1978.10479995
[25]	G. Marin, F. Sabogal, B. V. Marin, R. Otero-Sabogal and E. J. Perez-Stable, “Development of a Short Acculturation Scale for Hispanics,” Hispanic Journal of Behavioral Sciences, Vol. 9, No. 2, 1987, pp. 183-205. doi:10.1177/07399863870092005
[26]	D. J. Buysse, C. F. Reynolds, 3rd, T. H. Monk, S. R. Berman and D. J. Kupfer, “The Pittsburgh Sleep Quality Index: A New Instrument for Psychiatric Practice and Research,” Psychiatry Research, Vol. 28, No. 2, 1989, pp. 193-213. doi:10.1016/0165-1781(89)90047-4
[27]	A. M. J. Royuela, “Propiedades Clinimétricas de la Versión Castellana del Cuestionario de Pittsburgh,” Vigilia-Sueno, No. 9, 1997, pp. 81-94.
[28]	F. Escobar-Cordoba and J. Eslava-Schmalbach, “Colombian validation of the Pittsburgh Sleep Quality Index,” Revista de Neurologia, Vol. 40, No. 3, 2005, pp. 150-155.
[29]	A. Jimenez-Genchi, E. Monteverde-Maldonado, A. Nenclares-Portocarrero, G. Esquivel-Adame and A. de la Vega-Pacheco, “Reliability and Factorial Analysis of the Spanish Version of the Pittsburg Sleep Quality Index among Psychiatric Patients,” Gaceta medica de Mexico, Vol. 144, No. 6, 2008, pp. 491-496.
[30]	F. C. Baker, A. R. Wolfson and K. A. Lee, “Association of Sociodemographic, Lifestyle, and Health Factors with Sleep Quality and Daytime Sleepiness in Women: Findings from the 2007 National Sleep Foundation ‘Sleep in America Poll’,” Journal of Women’s Health (Larchmt), Vol. 18, No. 6, 2009, pp. 841-849. doi:10.1089/jwh.2008.0986
[31]	H. J. Ramsawh, M. B. Stein, S. L. Belik, F. Jacobi and J. Sareen, “Relationship of Anxiety Disorders, Sleep Quality, and Functional Impairment in a Community Sample,” Journal of Psychiatric Research, Vol. 43, No. 10, 2009, pp. 926-933. doi:10.1016/j.jpsychires.2009.01.009
[32]	D. J. Buysse, M. L. Hall, P. J. Strollo, T. W. Kamarck, J. Owens, L. Lee, et al., “Relationships between the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and Clinical/Polysomnographic Measures in a Community Sample,” Journal of Clinical Sleep Medicine, Vol. 4, No. 6, 2008, pp. 563-571.
[33]	E. J. Mezick, K. A. Matthews, M. Hall, P. J. Strollo, Jr., D. J. Buysse, T. W. Kamarck, et al., “Influence of Race and Socioeconomic Status on Sleep: Pittsburgh Sleep SCORE Project,” Psychosomatic Medicine, Vol. 70 No. 4, 2008, pp. 410-416. doi:10.1097/PSY.0b013e31816fdf21
[34]	National Sleep Foundation, “2010 Sleep in America Poll.” http://www.sleepfoundation.org/article/sleep-america-polls/2010-sleep-and-ethnicity
[35]	P. P. Chowdhury, L. Balluz and T. W. Strine, “Health-Related Quality of Life among Minority Populations in the United States, BRFSS 2001-2002,” Ethnicity & Disease, Vol. 18, No. 4, 2008, pp. 483-487.
[36]	M. A. Grandner, N. P. Patel, P. R. Gehrman, D. Xie, D. Sha, T. Weaver, et al., “Who Gets the Best Sleep? Ethnic and Socioeconomic Factors Related to Sleep Complaints,” Sleep Medicine, Vol. 11, No. 5, 2010, pp. 470-478. doi:10.1016/j.sleep.2009.10.006
[37]	S. Ram, H. Seirawan, S. K. Kumar and G. T. Clark, “Prevalence and Impact of Sleep Disorders and Sleep Habits in the United States,” Sleep & Breathing, Vol. 14, No. 1, 2010, pp. 63-70. doi:10.1007/s11325-009-0281-3
[38]	E. P. Cherniack, J. Ceron-Fuentes, H. Florez, L. Sandals, O. Rodriguez and J. C. Palacios, “Influence of Race and Ethnicity on Alternative Medicine as a Self-Treatment Preference for Common Medical Conditions in a Population of Multi-Ethnic Urban Elderly,” Complementary Therapies in Clinical Practice, Vol. 14, No. 2, 2008, pp. 116-123. doi:10.1016/j.ctcp.2007.11.002
[39]	M. A. Clark, M. L. Rogers and S. M. Allen, “Conducting Telephone Interviews with Community-Dwelling Older Adults in a State Medicaid Program: Differences by Ethnicity and Language Preference,” Journal of Health Care for the Poor and Underserved, Vol. 21, No. 4, 2010, pp. 1304-1317.
[40]	S. Redline, H. L. Kirchner, S. F. Quan, D. J. Gottlieb, V. Kapur and A. Newman, “The Effects of Age, Sex, Ethnicity, and Sleep-Disordered Breathing on Sleep Architecture,” Archives of Internal Medicine, Vol. 164, No. 4, 2004, pp. 406-418. doi:10.1001/archinte.164.4.406
[41]	M. E. Ruiter, J. Decoster, L. Jacobs and K. L. Lichstein, “Normal Sleep in African-Americans and Caucasian-Americans: A Meta-Analysis,” Sleep Medicine, Vol. 12, No. 3, 2011, pp. 209-214. doi:10.1016/j.sleep.2010.12.010
[42]	“2003 National Sleep Disorders Research Plan,” Sleep, Vol. 26, No. 3, 2003, pp. 253-257.
[43]	W. A. Bardwell, J. Profant, D. R. Casden, J. E. Dimsdale, S. Ancoli-Israel, L. Natarajan, C. L. Rock, J. P. Pierce, and Women’s Healthy Eating & Living (WHEL) Study Group, “The Relative Importance of Specific Risk Factors for Insomnia in Women Treated for Early-Stage Breast Cancer,” Psychooncology, Vol. 17, No. 1, 2008, pp. 9-18.
[44]	M. M. Ohayon, “Epidemiology of Insomnia: What We Know and What We Still Need to Learn,” Sleep Medicine Reviews, Vol. 6, No. 2, 2002, pp. 97-111. doi:10.1053/smrv.2002.0186
[45]	O. Dogan, S. Ertekin and S. Dogan, “Sleep Quality in Hospitalized Patients,” Journal of Clinical Nursing, Vol. 14, No. 1, 2005, pp. 107-113. doi:10.1111/j.1365-2702.2004.01011.x
[46]	J. F. Owens and K. A. Matthews, “Sleep Disturbance in Healthy Middle-Aged Women,” Maturitas, Vol. 30, No. 1, 1998, pp. 41-50. doi:10.1016/S0378-5122(98)00039-5
[47]	A. G. Wheaton, G. S. Perry, D. P. Chapman and J. B. Croft, “Sleep Disordered Breathing and Depression among US Adults: National Health and Nutrition Examination Survey, 2005-2008,” Sleep, Vol. 35, No. 4, 2012, pp. 461-467.
[48]	C. L. Ehlers, D. A. Gilder, J. R. Criado and R. Caetano, “Sleep Quality and Alcohol-Use Disorders in a Select Population of Young-Adult Mexican Americans,” Journal of Studies on Alcohol and Drugs, Vol. 71, No. 6, 2010, pp. 879-884.
[49]	A. Dzaja, S. Arber, J. Hislop, M. Kerkhofs, C. Kopp, T. Pollmacher, et al., “Women’s Sleep in Health and Disease,” Journal of Psychiatric Research, Vol. 39, No. 1, 2005, pp. 55-76. doi:10.1016/j.jpsychires.2004.05.008
[50]	M. L. Unruh and S. Redline, M. W. An, D. J. Buysse, F. J. Nieto, J. L. Yeh, et al., “Subjective and Objective Sleep Quality and Aging in the Sleep Heart Health Study,” Journal of the American Geriatrics Society, Vol. 56, No. 7, 2008, pp. 1218-1227. doi:10.1111/j.1532-5415.2008.01755.x
[51]	B. Zhang and Y. K. Wing, “Sex Differences in Insomnia: A Meta-Analysis,” Sleep, Vol. 29, No. 1, 2006, pp. 85-93.
[52]	M. H. Hall, K. A. Matthews, H. M. Kravitz, E. B. Gold, D. J. Buysse, J. T. Bromberger, et al., “Race and Financial Strain Are Independent Correlates of Sleep in Midlife Women: The SWAN Sleep Study,” Sleep, Vol. 32, No. 1, 2009, pp. 73-82.
[53]	H. Hachul, M. L. Andersen, L. R. A. Bittencourt, R. Santos-Silva, S. G. Conway and S. Tufik, “Does the Reproductive Cycle Influence Sleep Patterns in Women with Sleep Complaints?” Climacteric, Vol. 13, No. 6, 2010, pp. 594-603. doi:10.3109/13697130903450147
[54]	M. M. Ohayon, M. A. Carskadon, C. Guilleminault and M. V. Vitiello, “Meta-Analysis of Quantitative Sleep Parameters from Childhood to Old Age in Healthy Individuals: Developing Normative Sleep Values across the Human Lifespan,” Sleep, Vol. 27, No. 7, 2004, pp. 1255-1273.
[55]	H. P. Hazuda, S. M. Haffner, M. P. Stern and C. W. Eifler, “Effects of Acculturation and Socioeconomic Status on Obesity and Diabetes in Mexican Americans. The San Antonio Heart Study,” American Journal of Epidemiology, Vol. 128, No. 6, 1988, pp. 1289-1301.
[56]	I. G. Pawson, R. Martorell and F. E. Mendozam, “Prevalence of Overweight and Obesity in US Hispanic Populations,” The American Journal of Clinical Nutrition, Vol. 53, Suppl. 6, 1991, pp. 1522S-1528S.
[57]	L. K. Khan, J. Sobal and R. Martorell, “Acculturation, Socioeconomic Status, and Obesity in Mexican Americans, Cuban Americans, and Puerto Ricans,” International Journal of Obesity and Related Metabolic Disorders, Vol. 21, No. 2, 1997, pp. 91-96. doi:10.1038/sj.ijo.0800367
[58]	J. Sundquist and M. Winkleby, “Country of Birth, Acculturation Status and Abdominal Obesity in a National Sample of Mexican-American Women and Men,” International Journal of Epidemiology, Vol. 29, No. 3, 2000, pp. 470-477. doi:10.1093/ije/29.3.470
[59]	J. M. Samet, D. B. Coultas, C. A. Howard, B. J. Skipper and C. L. Hanis, “Diabetes, Gallbladder Disease, Obesity, and Hypertension among Hispanics in New Mexico,” American Journal of Epidemiology, Vol. 128, No. 6, 1988, pp. 1302-1311.
[60]	M. P. Stern, J. A. Knapp, H. P. Hazuda, S. M. Haffner, J. K. Patterson and B. D. Mitchell, “Genetic and Environmental Determinants of Type II Diabetes in Mexican Americans. Is There a ‘Descending Limb’ to the Modernization/Diabetes Relationship?” Diabetes Care, Vol. 14, No. 7, 1991, pp. 649-654. doi:10.2337/diacare.14.7.649
[61]	J. Sundquist and M. A. Winkleby, “Cardiovascular Risk Factors in Mexican American Adults: A Transcultural Analysis of NHANES III, 1988-1994,” American Journal of Public Health, Vol. 89, No. 5, 1999, pp. 723-730. doi:10.2105/AJPH.89.5.723
[62]	P. W. Goslar, C. A. Macera, L. G. Castellanos, J. R. Hussey, F. S. Sy and P. A. Sharpe, “Blood Pressure in Hispanic Women: The Role of Diet, Acculturation, and Physical Activity,” Ethnicity & Disease, Vol. 7, No. 2, 1997, pp. 106-113.
[63]	C. J. Crespo, C. M. Loria and V. L. Burt, “Hypertension and Other Cardiovascular Disease Risk Factors among Mexican Americans, Cuban Americans, and Puerto Ricans from the Hispanic Health and Nutrition Examination Survey,” Public Health Reports, Vol. 111, Suppl. 2, 1996, pp. 7-10.
[64]	M. P. Stern, M. Rosenthal, S. M. Haffner, H. P. Hazuda and L. J. Franco, “Sex Difference in the Effects of Sociocultural Status on Diabetes and Cardiovascular Risk Factors in Mexican Americans. The San Antonio Heart Study,” American Journal of Epidemiology, Vol. 120, No. 6, 1984, pp. 834-851.
[65]	M. A. Burnam, R. L. Hough, M. Karno, J. I. Escobar and C. A. Telles, “Acculturation and Lifetime Prevalence of Psychiatric Disorders among Mexican Americans in Los Angeles,” Journal of Health and Social Behavior, Vol. 28, No. 1, 1987, pp. 89-102. doi:10.2307/2137143
[66]	E. Alderete, W. A. Vega, B. Kolody and S. Aguilar-Gaxiola, “Effects of Time in the United States and Indian Ethnicity on DSM-III-R Psychiatric Disorders among Mexican Americans in California,” Journal of Nervous and Mental Disease, Vol. 188, No. 2, 2000, pp. 90-100. doi:10.1097/00005053-200002000-00005
[67]	P. J. Cantero, J. L. Richardson, L. Baezconde-Garbanati and G. Marks, “The Association between Acculturation and Health Practices among Middle-Aged and Elderly Latinas,” Ethnicity & Disease, Vol. 9, No. 2, 1999, pp. 166-80.
[68]	V. J. Ebin, C. D. Sneed, D. E. Morisky, M. J. Rotheram-Borus, A. M. Magnusson and C. K. Malotte, “Acculturation and Interrelationships between Problem and Health-Promoting Behaviors among Latino Adolescents,” Journal of Adolescent Health, Vol. 28, No. 1, 2001, pp. 62-72. doi:10.1016/S1054-139X(00)00162-2
[69]	R. E. Roberts and E. S. Lee, “The Health of Mexican Americans: Evidence from the Human Population Laboratory Studies,” American Journal of Public Health, Vol. 70, No. 4, 1980, pp. 375-384. doi:10.2105/AJPH.70.4.375
[70]	R. E. Roberts, E. S. Lee, M. Hemandez and A. C. Solari, “Symptoms of Insomnia among Adolescents in the Lower Rio Grande Valley of Texas,” Sleep, Vol. 27, No. 4, 2004, pp. 751-760.
[71]	E. Alderete, W. A. Vega, B. Kolody and S. Aguilar-Gaxiola, “Lifetime Prevalence of and Risk Factors for Psychiatric Disorders among Mexican Migrant Farmworkers in California,” American Journal of Public Health, Vol. 90, No. 4, 2000, pp. 608-614. doi:10.2105/AJPH.90.4.608
[72]	O. I. Bermudez, L. M. Falcon and K. L. Tucker, “Intake and Food Sources of Macronutrients among Older Hispanic Adults: Association with Ethnicity, Acculturation, and Length of Residence in the United States,” Journal of the American Dietetic Association, Vol. 100, No. 6, 2000, pp. 665-673. doi:10.1016/S0002-8223(00)00195-4
[73]	R. Caetano and M. E. Mora, “Acculturation and Drinking among People of Mexican Descent in Mexico and the United States,” Journal of Studies on Alcohol, Vol. 49, No. 5, 1988, pp. 462-471.
[74]	J. P. Elder, F. G. Castro, C. de Moor, J. Mayer, J. I. Candelaria, N. Campbell, et al., “Differences in Cancer-Risk-Related Behaviors in Latino and Anglo Adults,” Preventive Medicine, Vol. 20, No. 6, 1991, pp. 751-763. doi:10.1016/0091-7435(91)90069-G
[75]	D. V. Espino and D. Maldonado, “Hypertension and Acculturation in Elderly Mexican Americans: Results from 1982-84 Hispanic HANES,” Journal of Gerontology, Vol. 45, No. 6, 1990, pp. M209-M213. doi:10.1093/geronj/45.6.M209
[76]	G. Marin, E. J. Perez-Stable and B. V. Marin, “Cigarette Smoking among San Francisco Hispanics: The Role of Acculturation and Gender,” American Journal of Public Health, Vol. 79, No. 2, 1989, pp. 196-198. doi:10.2105/AJPH.79.2.196
[77]	K. S. Markides, N. Krause and C. F. Mendes de Leon, “Acculturation and Alcohol Consumption among Mexican Americans: A Three-Generation Study,” American Journal of Public Health, Vol. 78, No. 9, 1988, pp. 1178-1181. doi:10.2105/AJPH.78.9.1178
[78]	R. Otero-Sabogal, F. Sabogal, E. J. Perez-Stable and R. A. Hiatt, “Dietary Practices, Alcohol Consumption, and Smoking Behavior: Ethnic, Sex, and Acculturation Differences,” Journal of the National Cancer Institute. Monographs, No. 18, 1995, pp. 73-82.
[79]	L. A. Palinkas, J. Pierce, B. P. Rosbrook, S. Pickwell, M. Johnson and D. G. Bal, “Cigarette Smoking Behavior and Beliefs of Hispanics in California,” American Journal of Preventive Medicine, Vol. 9, No. 6, 1993, pp. 331-337.
[80]	R. E. Roberts and E. S. Lee, “Medical Care Use by Mexican-Americans: Evidence from the Human Population Laboratory Studies,” Medical Care, Vol. 18, No. 3, 1980, pp. 267-281. doi:10.1097/00005650-198003000-00002
[81]	J. M. Solis, G. Marks, M. Garcia and D. Shelton, “Acculturation, Access to Care, and Use of Preventive Services by Hispanics: Findings from HHANES 1982-84,” American Journal of Public Health, Vol. 80, Supplement, 1990, pp. 11-19. doi:10.2105/AJPH.80.Suppl.11
[82]	K. B. Wells, J. M. Golding, R. L. Hough, M. A. Burnam and M. Karno, “Factors Affecting the Probability of Use of General and Medical Health and Social/Community Services for Mexican Americans and Non-Hispanic Whites,” Medical Care, Vol. 26, No. 5, 1988, pp. 441-452. doi:10.1097/00005650-198805000-00001
[83]	M. A. Winkleby, S. P. Fortmann and B. Rockhill, “Health-Related Risk Factors in a Sample of Hispanics and Whites Matched on Sociodemographic Characteristics. The Stanford Five-City Project,” American Journal of Epidemiology, Vol. 137, No. 12, 1993, pp. 1365-1375.