MILESTONE 3: LITERATURE REVIEW 1

Milestone 3: Literature Review

Ruby Guevara and Adriana Turtura

School of Occupational Therapy, Pacific Northwest University

OTH 540: Foundations of Inquiry II

Dr. Malcolm Cutchin

February 27, 2024

MILESTONE 3: LITERATURE REVIEW 2

Milestone 3: Literature Review

Problem Statement

Mexican Americans are at greater risk of developing multiple chronic diseases than the

general population (Fisher-Hoch et al., 2012). Morbidity and mortality rates among Mexican

Americans are higher than those among non-Hispanic whites, a phenomenon known as health

disparities (Fisher-Hoch et al., 2012). Hispanic health is often shaped by factors such as

language/cultural barriers, lack of access to preventive care, and the lack of health insurance

(Fisher-Hoch et al., 2012). According to 2019 data from the Centers for Disease Control and

Prevention, some of the leading causes of death among Hispanics include cancer, heart disease,

unintentional injuries, stroke and other cerebrovascular diseases, diabetes, and Alzheimer’s

disease (Offices of Minority Health, n.d.) and may be explained by differences in social

determinants of health (SDOH). SDOH are the conditions in the environments where 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 (Ferraro & Shippee, 2009). A person's trajectory may be

shaped by resource mobilization and human agency over the course of their lifetime, yet

intergenerational inequality accumulates over time (Offices of Minority Health, n.d.). Having

access to resources can enhance an individual's ability to cope with or overcome adversity

(Ferraro & Shippee, 2009). Samper-Ternent et al. (2012), examined factors associated with two-

year mortality among older Hispanic Americans and estimated the prevalence of physical and

mental health conditions among various ethnic groups. According to their research, medical

conditions are more prevalent in certain ethnic groups than in others. For instance, non-Hispanic

Blacks have a higher rate of osteoarthritis than non-Hispanic Whites (NHW); WHS whites have
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a higher incidence of lupus nephritis than other groups; Mexican Americans (MA) have a higher

incidence of diabetes than NHW.

The Hispanic population in the United States is the fastest growing group of older adults,

with older MA representing the largest group (65%) and showing higher disability rates than

their non-Hispanic white counterparts (USCB, 2020). A study by Rodriguez et al. (2022)

demonstrated that arthritis is independently correlated with decreased mobility and ADL

abilities, as well as diminished physical function in older Mexican Americans. The results of the

study indicate that in older Mexican Americans reporting arthritis and living in the United States,

they experienced decreased mobility, increased ADL disability, and decreased physical function

over the course of 23 years. To diminish the proportion of years spent living with disabilities

among older Mexican Americans, it is desirable to identify this condition early and to implement

preventative measures at the appropriate time (Rodriguez et al., 2022).

Although each individual experiences pain at some point, older adults are in general at a

higher risk of suffering from chronic pain. In addition to reducing quality of life and affecting

activities of daily living (ADL), instrumental activities of daily living (IADL) and mobility;

musculoskeletal pain contributes to decreased quality of life. In a study carried out by Sodhi et

al. (2020), it was found that the prevalence of pain ranges from 24% to 72% among older adults,

with the highest prevalence of pain among non-Hispanic whites (31%), non-Hispanic blacks

(26%) and Hispanics (18%). Older Mexican Americans are particularly prone to pain for several

reasons. The prevalence of diabetes, obesity, and disability is highest among NHW, all of which

are risk factors for the development of pain syndromes. There is also a lack of access to medical

care for a variety of conditions (e.g., arthritis and diabetes) associated with pain (Sodhi et al.,

(2020). Thus, in a changing health care system in the United States, the high level of low health
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literacy affects their ability to manage complex comorbidities. The impact of these health

disparities for aging Mexican Americans equates to higher disease burden, disproportionate

suffering, barriers to managing chronic disease, and increased risk of worse health outcomes.

Significance of the Problem

As a result of the literature’s recognition of SDOH's multifaceted nature and impact on

health, theyit haves prompted collaboration with a number of different sectors and types of

organizations (such as the transportation sector, education sector, housing sector, and healthcare

sector) to address prevention-oriented population health issues (Offices of Minority Health, n.d.).

In the United States, Hispanics make up 19% of the population, which and represents a growing

segment of the population (Offices of Minority Health, n.d.). It is important to note that, despite

this growththe longstanding knowledge about SDOH, health disparities persist for Hispanics,

reflecting issues such as a lack of access to high-quality care, language and cultural barriers, and

a lack of preventive care (Offices of Minority Health, n.d.).

In addition to its adverse impact on Hispanic health, (SDOH) also include poverty,

inadequate access to health care, educational inequalities, language barriers, personal and

environmental factors, and bias within the medical profession (Cigna Group, 2022). Social

determinants of health are important in determining a person's well-being, health, and quality of

life (Cigna Group, 2022). It is also likely that the lack of safe and reliable transportation will

impair the accessibility of health care. In the absence of access to health care, timely health

screenings and appropriate management of health conditions compound the barrier to care

(Cigna Group, 2022).

There are some areas of SDOH that can help identify and address possible health

behavioral risks (Maness & Branscum, 2017). It is possible to predict unhealthy physical activity
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by analyzing SDOH factors, such as neighborhood and built environment, or to predict diet

behavior by analyzing finances (Maness & Branscum, 2017). There is a wide range of

predictability depending on the type of SDOH and the type of health behaviors employed.

However, not all SDOH will be predictive of all types of health behaviors (Maness & Branscum,

2017). It is possible to demonstrate how social determinants of health affect health by

incorporating social determinants of health, health equity, and health disparities at various levels

of measurement (Penman-Aguilar et al., 2016). Likewise, the multifactorial construct of health

disparities, including social, economic, and cultural influences, greatly influences physician

interpretations and interventions (Riley, 2012). The authors of Fox et al. (2015) concluded that

physicians lack the ability to influence social and behavioral changes that are necessary for better

outcomes for patients, and this demonstrates the importance of SDOH in ameliorating health

disparities. Moreover, low-income, diverse, and immigrant families, including those with

Mexican heritage, were not meeting Healthy People 2020 objectives (Berge et al., 2018).

Adaptation to a different, more dominant culture may affect the magnitude of cultural

factors observed within a Mexican American community (Arandia et al., 2018). It is possible for

Mexican Americans who immigrate to a foreign country to find ways to adapt to the culture of

that country (Arandia et al., 2018). In this case, the American culture being the new dominant

one. Cultural acculturation can have an impact on strong traditional cultural values (Arandia et

al., 2018). Nevertheless, most Mexican American communities continue to preserve their strong

traditional values and cultural traditions over the generations.

The United States Census Bureau (USCB) estimates that only 42% of Hispanics

considered native speakers speak English only. Of those native speakers who speak another

language, 84% could speak English very well, while 16% spoke English less than very well
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(USCB, 2020). Foreign-born Hispanics have a different percentage than those born in the United

States. The percentage of Hispanics who speak only English is only 5.2%. In contrast, 33.7% of

foreign-born individuals speak English very well and 66.3% speak English less well (USCB,

2020). Mexican Americans have limited employment and income opportunities because of their

language proficiency. Furthermore, there is an association between language proficiency and

health behaviors (DuBard & Gizlice, 2008). It has been documented is well known that persons

whose primary language is Spanish receive less preventative care and exhibit poor health

behaviors regardless of their socioeconomic situation and demographics (DuBard & Gizlice,

2008). Cultural factors vary by country of origin (Arredondo et al., 2016).

The cultural factors that may cause friction during their health care encounters may affect

Mexican Americans' access to and satisfaction with health care (Gauri et al., 2017). There is a

strong collectivist culture in Mexican American culture that values the value of group activities,

family, responsibility, relationships, and accountability (Choi et al., 2019; Komen, 2016). It is

important to understand cultural factors that influence access to and satisfaction with health care

in the Mexican American population (Gauri et al., 2017; Komen, 2016).

Overall, the health behaviors of Hispanic adults were reported and correlated with SDOH

variables. SDOH is associated with the extent to which Hispanics are at risk of developing

harmful health behaviors or having a greater opportunity to establish positive health behaviors. A

disproportionate number of Hispanics continue to suffer from this problem. To increase equal

opportunities for Hispanic adults and promote healthy behavior, efforts should be directed at the

health care community and policy makers in the United States.

Scientific Knowledge About the Problem

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Medicine has traditionally focused on diagnosing and treating specific clinical conditions.

As medical knowledge evolves and the health care system shifts to more value-based and

population-focused medicine, the medical community is beginning to take a more comprehensive

approach to patient care. Increasingly, practices are examining how patients' physical and social

environments affect their health. According to the World Health Organization (2020), the impact

of social determinants on health has been shown to be 6 times greater than clinical care.

Collaboration across multiple sectors is instrumental in addressing social determinants of health,

including but not limited to medical care, public health, and social service providers. The

Occupational Therapy Practice Framework: Domain and Process (4th ed.; OTPF–4; American

Occupational Therapy Association, 2020) is grounded in “achieving health, well-being, and

participation in life through engagement in occupation” (p. 5). Structural issues directly either

enable occupational engagement or inhibit it. Recognizing, understanding, and addressing SDOH

directly influences the capability to meet the intent of the OTPF–4 and opens a role for

occupational therapy practitioners in evolving SDOH efforts.

Individuals with chronic conditions receive the most primary care services and account

for the most healthcare spending in the United States (Lambdin-Pattavina & Pyatak, 2020). In

the United States, 150 million people have one or more chronic conditions, and 80% of those are

55 or older (Hayes et al., 2023). By 2030, older adults will make up 21% of the total population

in the United States (Vespa, Medina & Armstrong, 2020). As this age demographic has the most

chronic conditions diagnosed, the number of chronically ill individuals will increase. Despite

high spending on this population, poor health outcomes persist, leading to continued care and

expenditures (Dahl-Popolizio et al., 2017). Occupational therapy as a profession is well suited to

contribute to the primary care team because of the clear knowledge they have regarding
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occupational performance, healthy routines, habits, and prevention (AOTA, 2020). To improve

health outcomes and reduce healthcare spending, primary care settings are incorporating

occupational therapists into their service delivery models.

To date, occupational therapy services in primary care settings are mainly related to

cognition, falls prevention, self-management programs for chronic conditions, and case

management (Donnelly et al., 2014). Clients who received these services reported an improved

quality of life, an increase in activity participation, a decrease in adverse health events, and an

improvement in their ability to function in their daily lives (Halle et al., 2018). Adding to the

body of knowledge on occupational therapy's effectiveness for managing and preventing chronic

conditions, Pyatak et al. (2019) demonstrate the relevance of occupational therapy in primary

care when it comes to managing diabetes. Comprehensive care models that include occupational

therapy have demonstrated improvements in quality of life, participation, and self-efficacy

(Garvey et al., 2015).

Key Gaps in the Scientific Knowledge

While it is clear there is a theoretical commitment to equity and social justice within the

occupational therapy profession, review of the literature revealed a lack of evidence related to

how occupational therapists address SDOH in their clinical practice. Several articles published in

the United States highlight issues related to access and occupational therapy in primary care

(Dahl-Popolzio et al., 2017; Jordan, 2019; AOTA,2020). However, only one article (Murphy et

al.,2017) discussed a working model to provide occupation-based services to those who may

previously have had little or no opportunity to receive regular, non-emergency care. Murphy and

colleagues (2017) examined the role occupational therapists can play in supporting access to

medically underserved populations through federally qualified health centers (FQHC). There is
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some evidence that a full-time occupational therapist embedded within a (FQHC) has the

potential to decrease disparities in access to occupation-based services. Clients were from

underserved communities, and many had not previously had access to occupational therapy

services as well as improve health for people with low incomes, people of color, and people

without health insurance (Murphy et al., 2017).

Additionally, while there is a clear fit between occupational therapy and primary care,

little is known about how occupational therapists address the SDOH that impact chronic disease

self-management among older Mexican American. SDOH ocial determinant screening,

collecting and reporting on SDOH information, and provider training on SDOH are some

methods currently used to address barriers to care for older adults with chronic conditions in

primary care settings (Jordan, 2019) but further practice research is needed to determine their

efficacy.

Gap This Study Will AddressAims

Occupational therapy as a profession provides a distinctive value to address the barriers

in the US healthcare system, which is primarily based on a medical model. Practitioners offer a

unique approach to health care that goes beyond the conventional medical model by emphasizing

holistic well-being and meaningful participation in daily activities. The purpose of this study is

to explore how occupational therapy can address the SDOH that impact chronic disease

management among aging Mexican Americans in a primary care setting. The proposed study will

contribute to a greater knowledge base of how an occupational therapy practice that includesing

SDOH in care coordination can promotes health equity for aging Mexican Americans.
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