Hearing Aid Prevalence and Factors Related to Use Among Older Adults From the Hispanic Community Health Study/Study of Latinos | Health Disparities | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Table 1.  Demographic Characteristics of Included Individuals From the HCHS/SOLa
Demographic Characteristics of Included Individuals From the HCHS/SOLa
Table 2.  Hearing Aid Prevalence Among Included Individuals From the HCHS/SOLa
Hearing Aid Prevalence Among Included Individuals From the HCHS/SOLa
Table 3.  Adjusted Odds Ratios (ORs) of Hearing Aid Use Among Included Individuals From the HCHS/SOLa
Adjusted Odds Ratios (ORs) of Hearing Aid Use Among Included Individuals From the HCHS/SOLa
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Original Investigation
April 18, 2019

Hearing Aid Prevalence and Factors Related to Use Among Older Adults From the Hispanic Community Health Study/Study of Latinos

Author Affiliations
  • 1College of Science & Mathematics, University of South Florida Sarasota-Manatee, Sarasota
  • 2School of Aging Studies, College of Behavioral and Community Sciences, University of South Florida, Tampa
  • 3Department of Communication Sciences & Disorders, College of Behavioral and Community Sciences, University of South Florida, Tampa
  • 4Eriksholm Research Centre, Snekkersten, Kingdom of Denmark
  • 5University of Miami Health System, University of Miami, Miami, Florida
  • 6Northwestern University, Evanston, Illinois
  • 7National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland
JAMA Otolaryngol Head Neck Surg. 2019;145(6):501-508. doi:10.1001/jamaoto.2019.0433
Key Points

Question  What is the prevalence of and factors associated with hearing aid use among older US adults from Hispanic/Latino backgrounds?

Findings  In this cross-sectional study of 1898 adults with hearing loss from varied Hispanic/Latino backgrounds, hearing aid use was reported in 87 individuals. Factors associated with higher odds of reported hearing aid use were poorer measured hearing, higher perceived need, access to health insurance, and place of residence.

Meaning  Hearing aid prevalence among US adults from Hispanic/Latino backgrounds was low compared with the general US population, and a primary factor associated with hearing aid use was access to health insurance.

Abstract

Importance  Hearing loss is highly prevalent in the rapidly growing and aging Hispanic/Latino population in the United States. However, little is known or understood about hearing aid use among US adults from Hispanic/Latino backgrounds.

Objective  To describe hearing aid prevalence and factors associated with hearing aid use among US adults of Hispanic/Latino backgrounds.

Design, Setting, and Participants  Cross-sectional data were collected between 2008 and 2011 from 4 field centers (Bronx, New York; Chicago, Illinois; Miami, Florida; and San Diego, California) as part of the multisite Hispanic Community Health Study/Study of Latinos. Included individuals were adults aged 45 to 76 years with hearing loss (pure-tone average ≥25 dB HL) from randomly selected households in the 4 field centers and were from self-reported Hispanic/Latino backgrounds, including Central American, Cuban, Dominican, Mexican, Puerto Rican, South American, and mixed or other backgrounds. Analysis, including age- and background-weighted prevalence estimates and multivariate logistic regression using survey methodology, was conducted from 2017 to 2018.

Main Outcomes and Measures  The primary outcome of interest was self-reported hearing aid use. The a priori hypothesis was that hearing aid prevalence estimates among included Hispanic/Latino adults would be less than recently published estimates of the general US population, and that poorer hearing, higher perceived need, older age, and higher acculturation would be associated with hearing aid use.

Results  Of 1898 individuals with hearing loss, 1064 (56.1%) were men, and the mean (SE) age was 60.3 (0.3) years. A total of 87 (4.6%) included individuals reported hearing aid use. Increased odds of self-reported use was associated with poorer measured hearing (odds ratio [OR], 1.06; 95% CI, 1.03-1.09), higher Hearing Handicap Inventory–Screening scores (OR, 1.06; 95% CI, 1.03-1.08), access to health insurance coverage (OR, 2.30; 95% CI, 1.20-4.37), and place of residence (OR, 2.42; 95% CI, 1.17-5.02) in an adjusted logistic regression model.

Conclusions and Relevance  Findings revealed underuse of hearing aids among adults from Hispanic/Latino backgrounds. A primary factor related to use was lack of health insurance, which suggests that access influenced hearing aid use. Changes to policy and clinical service provision are needed to increase hearing aid use among aging Hispanic/Latino adults in the United States.

Introduction

Hearing loss prevalence among US adults 70 years and older, including those from Hispanic/Latino backgrounds, is approximately 63%.1 The number of individuals with hearing loss in the United States is expected to grow from an estimated 44.1 million in 2020 to 73.5 million in 2060.2 Negative outcomes related to untreated hearing loss include increased risks for cognitive decline,3-5 falls,6 and hospitalization.7 Hearing loss is also associated with negative psychosocial consequences (eg, social isolation).8,9 Consequently, untreated hearing loss poses a growing public health issue that deserves attention as the population ages. The most efficacious management option for the majority of individuals with hearing loss is the use of hearing aids, which can improve communication and health-related quality of life in users.10 However, hearing aid uptake is relatively low among those who could benefit from their use, with estimates ranging between 14.2% and 33.1%.11,12

Numerous factors influence hearing aid use, particularly income and costs, education, hearing loss severity, and perceived need.1,11,13,14 Findings from studies that investigated cost and income as determinants of hearing aid uptake are mixed. Several studies that included income as a predictor reveal no associations between income and hearing aid use,1,13,15-17 and participants who reported higher levels of income were more likely to also report using hearing aids.1,11,15,18 In contrast, meaningful associations between concerns related to cost and hearing aid use have been demonstrated in other studies.19,20 Much of the previous research investigating cost and income as factors related to hearing aid use is limited to primarily non-Hispanic or non-Latino white samples.

Perceived need, on the other hand, is a robust determinant of hearing aid uptake; individuals who experience greater difficulties as a result of a hearing loss are more likely to report hearing aid use.11,13,14 However, the majority of literature focuses on non-Hispanic and non-Latino individuals, and there is a gap in knowledge of hearing aid use determinants, including perceived need, in the US Hispanic/Latino population. The concept of familism (the reliance and expectation of the family unit for health care, social, emotional, and material support) is thought to influence the use of formal health care services by people from Hispanic/Latino backgrounds.21-23 Few researchers have investigated the role of familism on health care use by individuals from Hispanic/Latino backgrounds. Studies examining familism have demonstrated that mental health service use is lower,21 and family caregivers of older Hispanic/Latino adults tend to use fewer formal long-term care services for conditions requiring long-term care.24,25

Related to the concept of familism is acculturation (the tendency to acclimate into a “host” culture, including its beliefs, values, and practices), which gradually happens as a result of prolonged exposure. Acculturation is largely viewed as a bidirectional process that occurs along a continuum, with most individuals maintaining some aspects of their native cultural identity.26 Higher acculturation is associated with lower feelings of familism.22 Among the Hispanic/Latino population, it is suggested that higher acculturation leads to a poorer health-related lifestyle but is associated with improved access to insurance and health care,26,27 including Medicaid coverage for hearing health care. Adults from Hispanic/Latino backgrounds with higher acculturation may be less reliant on family members for support and more likely to seek out certain health services; however, it is unknown whether acculturation is associated with hearing aid use. For older adults from Hispanic/Latino backgrounds with hearing loss, it is possible that reliance on family to accept and accommodate a hearing loss results in fewer hearing-related difficulties and less perceived need to seek hearing health care.

Studies focused on hearing aid use among adults from varied Hispanic/Latino backgrounds are dated. The 1982 and 1984 waves of the Hispanic Health and Nutrition Examination Survey (HHANES) estimated hearing aid use in fewer than 12% of participants, though hearing loss prevalence ranged from 24% to 48%.28 Using the same data from HHANES, Lee and colleagues29 reported a 9-fold increase in hearing aid use among Mexican American individuals living below the poverty line, which they suggested was because of the introduction of Medicaid for eligible individuals. Enrollment in Medicare or Medicaid is a potential indicator of greater acculturation, likely owing to the citizenship requirements necessary to access these programs and recognition of state-specific Medicaid benefits.18 Therefore, acculturation may be associated with hearing aid use among adults from Hispanic/Latino backgrounds who are able to navigate this system.

Hearing aid use among Hispanic/Latino adults is likely unchanged since the HHANES reports; recent data from the National Health and Nutrition Examination Survey demonstrated that only 13% of older US adults from Hispanic/Latino backgrounds (primarily Mexican adults) reported hearing aid use despite a hearing loss prevalence of 65%.1 The number of individuals who reported hearing aid use in these studies was small, and there was poor representation of individuals from varied Hispanic/Latino backgrounds. Whether hearing aid use rates differ between Hispanic/Latino backgrounds is largely unknown.

Understanding determinants of hearing aid use in the rapidly growing Hispanic/Latino population will guide public health efforts, as well as research and clinical practice, to address the needs of older adults with hearing loss in the US Hispanic/Latino population. The purpose of this study is to describe hearing aid prevalence and to identify factors related to use among older adults from varied Hispanic/Latino backgrounds. We hypothesize that prevalence of hearing aid use will be lower than use in the general US population and that poorer measured hearing loss, greater perceived need, older age, and higher acculturation will be associated with use.

Methods
Data Source

The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) is a community-based prospective cohort study of 16 415 Hispanic/Latino persons from randomly selected households in 4 field centers (Bronx, New York; Chicago, Illinois; Miami, Florida; and San Diego, California) who were 18 to 74 years of age at screening. All participants underwent a baseline examination between 2008 and 2011, followed by yearly telephone follow-up assessment for at least 3 years. The HCHS/SOL cohort includes participants who self-identified as having a Hispanic/Latino background, including Central American, Cuban, Dominican, Mexican, Puerto Rican, South American, and mixed or other backgrounds. The HCHS/SOL is suited to address questions related to hearing loss and hearing health care use in the US Hispanic/Latino population because it includes a full audiometric test battery, comprehensive hearing health questionnaire, and hearing aid use information for all included participants.

The sample design and cohort selection have been previously described.30 Briefly, a stratified 2-stage area probability sample of household addresses was selected in each of the 4 field centers. The first stage randomly selected census block groups with stratification based on Hispanic/Latino concentration and proportion of high or low socioeconomic status. The second stage randomly selected households, with stratification, based on US Postal Service registries covering the selected census block groups. The HCHS/SOL reported estimates (means and prevalence rates) are weighted to account for the disproportionate selection of the sample and to partially adjust for any bias effects owing to differential nonresponse in the sample at the household and person levels. The adjusted weights are also trimmed to limit precision losses owing to the variability of the adjusted weights and are calibrated to the 2010 US Census characteristics by age, sex, and Hispanic or Latino background in each field site’s target population. All analyses account for cluster sampling and use of stratification in sample selection. The institutional review board at the University of South Florida provided approval and waived patient written informed consent for deidentified data before any study data was accessed or analyzed.

Individuals included in this study were 45 years and older, from any Hispanic/Latino background, and had at least mild hearing loss (≥25 dB HL) in either ear (defined by a 500, 1000, 2000, and 4000 Hz pure-tone average).

Measures

Included individuals’ age, sex, specific Hispanic/Latino background, education level, annual household income, and city of residence were recorded. Right and left ear thresholds were tested in a sound-treated booth using a Grason-Stadler 61 Clinical Audiometer and TDH-50 supra-aural or E-A-RTONE 3A insert earphones. Pure-tone air conduction thresholds were measured at octaves between 500 and 8000 Hz, and pure-tone bone conduction thresholds were measured at 500, 2000, and 4000 Hz using masking as needed. Better-ear pure-tone averages at 500, 1000, 2000, and 4000 Hz were used for the present study.

Results from the Hearing Handicap Inventory–Screening (HHI-S)31 questionnaire were used as a proxy for perceived need. The HHI-S is a highly reliable 10-item questionnaire that measures perceived hearing difficulties. Scores on the HHI-S can range from 0 to 40, with higher scores indicating greater self-perceived handicap.25 Separate versions for adults and older adults were administered based on age. Participants in HCHS/SOL who preferred Spanish as a primary language received the cross-culturally adapted version of the HHI-S.32 The Spanish-language HHI-S has demonstrated high correlation and test equivalence with the English-language version.32

The Short Acculturation Scale for Hispanics (SASH)33 assesses language use, media, and ethnic and social relations. Items are scored on a 5-point Likert scale ranging from “Only Spanish” to “Only English” or “Very Latino/Hispanic” to “Very American,” and higher scores suggest greater degrees of acculturation. SASH does not rely on sociodemographic proxies as estimates of acculturation, which makes it a preferred tool for measurement.26 For the present study, a 2-factor modified SASH34 consisting of language and social subscales was used. The modified SASH language subtest consisted of 5 items measuring proficiency and preferences for speaking Spanish vs English, and the SASH social subtest consisted of 4 items measuring the preferred ethnicity of friends, visitors, and acquaintances of the respondent.34

Results from 2 items addressing hearing aid use at the baseline audiometric examination are reported. The yes/no question “Have you ever worn a hearing aid?” was the primary dependent variable for the present study. The second question asked, “In the past 12 months, have you worn a hearing aid?” with a required response of yes or no.

Statistical Analysis

First, prevalence and descriptive statistics for hearing aid use were calculated. Next, the data normality, multicollinearity, and missingness were assessed. A 3-step multiple imputation process was performed for covariates used in the analysis models. In the first stage, a fully conditional specification model was fitted to generate 10 imputed data sets. In the second stage, the analysis models on all 10 imputed data sets were conducted using survey procedures. In the third stage, results were pooled from the imputed data sets to account for uncertainty in the imputation.

Multivariate regression modeling estimated the strength of association between independent variables and the occurrence of hearing aid use. For the response of the question, “Have you ever worn a hearing aid?” estimates were calculated for the target population of Hispanic/Latino individuals in the 4 HCHS/SOL field centers using logistic regression, adjusting each subgroup to the age distribution of the target population. Given the low numbers of participants who reported hearing aid use, binary variables were created for annual household income, Hispanic/Latino background, and place of residence. Odds ratios (ORs) and corresponding 95% CIs were estimated by exponentiating the unstandardized pooled beta coefficients and lower and upper confidence limits. All analyses were performed using survey procedures in SAS version 9.4 (SAS Institute Inc).

Results

Table 1 displays the weighted descriptive characteristics of the included adults. The analytic sample consisted of 1898 individuals aged 45 to 76 years old. Of those included, 1064 (56.1%) were men, and the mean (SE) age was 60.3 (0.3) years. Nearly one-third of included individuals reported annual income of $10 001 to $20 000 (583 [30.7%]), and nearly two-thirds reported having some form of health insurance coverage (1244 [65.5%]). Nearly half of included individuals reported less than high school education (898 [47.3%]). Of the 4 study sites, the largest sample was recruited from Miami, Florida (752 [39.6%]). The mean modified SASH language and social subtest scores were 1.69 and 2.11, respectively, which was consistent with the average scores of first-generation US residents from Hispanic/Latino backgrounds33 and suggests that those included in the present study tended to think and speak in Spanish and preferred social contacts from Hispanic/Latino backgrounds.

Hearing Aid Prevalence

Table 2 displays results for reported hearing aid use and use within the past 12 months. Among 1898 included individuals with at least a mild hearing loss in either ear, 87 (4.6%) reported ever using a hearing aid. Prevalence of hearing aid use varied across Hispanic/Latino groups, with the smallest proportion of use among those from Central American backgrounds (1 of 117 [0.8%]) and the largest proportion among those from mixed or other backgrounds (4 of 52 [7.7%]). Of the 87 individuals who reported ever using a hearing aid, the majority (53 [60.9%]) used a hearing aid within the past 12 months.

Factors Related to Hearing Aid Use

To determine factors related to hearing aid use, we fit a logistic regression model including better-ear pure-tone average, HHI-S score, age, sex, education, income, health insurance status, city of residence, SASH language and social subtest scores, and Hispanic/Latino background. Consistent with our hypothesis, results revealed that increased odds of reported hearing aid use was significantly associated with poorer pure-tone average of the better ear (OR, 1.06; 95% CI, 1.03-1.09) and higher HHI-S scores (OR, 1.06; 95% CI, 1.03-1.08). Health insurance status was associated with reported hearing aid use (OR, 2.30; 95% CI, 1.20-4.37). Individuals with health insurance were significantly more likely to report hearing aid use than those without insurance. Finally, residence in San Diego was associated with hearing aid use, and individuals from San Diego were more likely to report hearing aid use than those at other sites (OR, 2.42; 95% CI, 1.17-5.02). Table 3 displays the complete ORs and 95% CIs from the logistic regression analysis.

Discussion

To our knowledge, this study is the first to describe hearing aid prevalence and to identify potential barriers and facilitators to use among older adults from varied Hispanic and Latino backgrounds. The findings reveal a striking underuse of hearing aids among adults with hearing loss from Hispanic/Latino backgrounds. Of 1898 adults who posed to benefit from hearing aid use, only 87 (4.6%) reported ever doing so, and of those individuals, only 53 (61%) reported use within the past 12 months. These results are consistent with our hypothesis that hearing aid prevalence among adults from varied Hispanic/Latino backgrounds is lower than recent published estimates of use11,12,18 among the general US population, as well as lower than a recent study by Nieman and colleagues18 that used National Health and Nutrition Examination Survey data to examine hearing aid use rates among adults from Hispanic/Latino backgrounds. Nieman and colleagues additionally demonstrated that adults from Mexican backgrounds who were included in their analysis were 78% less likely to use hearing aids than non-Hispanic and non-Latino white adults,18 which suggests a disparity in hearing health care use between these 2 populations. Although we did not directly compare this study’s results with use rates of the general US population, this study’s findings provide further evidence that hearing health care disparities exist between adults from Hispanic/Latino backgrounds and those from non-Hispanic and non-Latino white backgrounds.

The majority of respondents from Hispanic/Latino backgrounds reported hearing aid use between 3% and 5%, and hearing aid use among adults from Hispanic/Latino backgrounds with clinically significant hearing loss varied considerably. People with hearing loss from Central American backgrounds were far less likely (<1%) and those from mixed or other backgrounds were slightly more likely (7.7%) to report hearing aid use. It is difficult to draw conclusions based on Hispanic/Latino backgrounds given the small numbers of individuals within each group reporting hearing aid use.

Unsurprisingly, measured hearing loss and HHI-S scores were significantly associated with reported hearing aid use. This is consistent with a large body of research,1,11,13-15,17 including studies examining individuals from Hispanic/Latino backgrounds.1,18,28 The findings from this study add to the literature by confirming that hearing aid use is also more likely in individuals from varied Hispanic/Latino backgrounds with poorer measured hearing and greater perceived need. It should be noted that although perceived need was associated with reported hearing aid use, individuals included in the present study had overall low perceived need (mean HHI-S score, 5.72). A question remains as to why perceived need was low despite the objective clinically significant hearing loss.

We were also interested as to whether acculturation related to hearing aid uptake and found that SASH scores were not associated with reported use. However, health insurance status was related to use, and those who reported coverage had significantly higher odds of reporting use. This suggests that insurance access is a barrier to hearing health care use among older adults from Hispanic/Latino backgrounds. Although SASH language scores did not significantly characterize use, language may have a secondary effect on overall health care access, including access to insurance. This is consistent with a growing body of work that shows that access factors, particularly language access, result in reduced health care use among people from Hispanic/Latino backgrounds when controlling for variables related to acculturation.35-37 In other words, access, and not culture, characterizes health care use.

Public Health and Clinical Implications

The trajectory of aging adults with hearing loss from Hispanic/Latino backgrounds carries several public health and clinical implications. The findings from this study reveal remarkably low prevalence of hearing aid use. Although SASH language scores did not significantly characterize hearing aid use, multiple previous studies have demonstrated the relationship between English proficiency and access to health insurance.35,37 In the present study, those with health insurance were 2.3 times more likely to report hearing aid use. Reduced access to hearing health care for adults from Hispanic/Latino backgrounds is a health disparity and should be addressed as such. From a public health standpoint, reducing barriers to Medicare and Medicaid access is an important step to lessening this disparity. Increasing access to hearing health care through insurance is another step in lessening this disparity. Although Medicare Part B does not cover the cost of hearing aids, some Medicare Part C plans include coverage, and hearing aids are covered by Medicaid for adults meeting specific criteria in 28 states.38 Indeed, we found that individuals residing in San Diego were significantly more likely to report hearing aid use. This is perhaps related to the quality and availability of hearing aid benefits for Medicaid beneficiaries in the state of California.38 Alternatively, residents in San Diego may be able to seek more affordable services in Mexico owing to the city’s proximity to the border. Further research is needed to determine what differences exist regarding access to services for US residents from Hispanic/Latino backgrounds who are able to use the Mexican health system. To address the needs of those living in states where hearing aids are not covered by Medicaid, strategies are needed to enhance access to lower-cost hearing devices, including over-the-counter service delivery models.39,40

Audiologists in the United States must be prepared to deliver culturally and linguistically appropriate services to adults from Hispanic and Latino backgrounds. Patient and health care provider language concordance has shown to result in improved health-related outcomes, particularly for the management of chronic conditions (eg, diabetes).41 An initial step is the facilitation of communication and language assistance for those with low English proficiency. Although there is a severe lack of Spanish-speaking audiologists in the United States,42 the use of bilingual support staff is one way to accomplish this. In particular, the recruitment and training of bilingual audiology assistants has potential to not only provide better language access for clients with low English proficiency or other language preferences, but also increase clinical productivity.43 Professional interpreting services are another (more costly) option and include in-person and phone and video services.

Another strategy for improving access to care is the cross-cultural adaptation of hearing loss–specific outcomes for Hispanic/Latino adults to understand their perceptions of hearing-related disability, communication difficulties, and treatment outcomes. Currently, the only validated measure for use with Spanish speakers is the HHI-S.32 Finally, the development of Spanish language counseling materials addressing the needs, values, and goals of the target audience is also necessary for optimizing access and uptake.

Limitations

There were limitations to this study. The data analyzed were cross-sectional, so causality cannot be determined based on the findings. The majority of the data were collected prior to the passage of the Affordable Care Act in 2010 and subsequent Medicaid expansion. Each state included in the HCHS/SOL has hearing aid benefits for adults covered by Medicaid,38 and previous studies suggest that increased hearing aid use might be seen among Hispanic/Latino adults who use Medicaid.18,29 Three of the 4 states included in the HCHS/SOL participated in expansion; therefore, hearing aid prevalence among individuals from these states might now be greater. However, this is the most recent available data of hearing aid prevalence and related factors from a diverse Hispanic/Latino population. Future waves of the HCHS/SOL should include reported hearing aid use to determine what, if any, influence the passage of the Affordable Care Act has on uptake.

The HCHS/SOL is not a nationally representative data set, so results may not generalize to the broader US Hispanic and Latino populations. Although the target population is limited to the 4 field center communities, HCHS/SOL’s hybrid design, which uses probability sampling within preselected diverse regions, is preferred to convenience samples commonly used in epidemiological cohort studies. Finally, all of the test sites were located in large metropolitan areas. There may be substantial differences in hearing aid use among adults living in rural areas. However, based on the low hearing aid prevalence revealed in areas where access to hearing health care is more likely, we would not expect higher prevalence in a rural setting.

Conclusions

In summary, the findings of this study revealed low hearing aid use among older adults from multiple Hispanic and Latino backgrounds compared with the rates of hearing loss. Lack of health insurance was a barrier to reported hearing aid use. These results support changes to public health policy and clinical service provision to increase access to hearing health care for older adults with hearing loss from Hispanic/Latino backgrounds.

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Article Information

Accepted for Publication: February 19, 2019.

Corresponding Author: Michelle L. Arnold, AuD, PhD, College of Science & Mathematics, University of South Florida Sarasota-Manatee, 8350 North Tamiami Trail, B324, Sarasota, FL 34243 (mlarnold@sar.usf.edu).

Published Online: April 18, 2019. doi:10.1001/jamaoto.2019.0433

Author Contributions: Drs Arnold and Small had full access to all of the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis.

Study concept and design: Arnold, Hyer, Chisolm, McEvoy, Dhar.

Acquisition, analysis, or interpretation of data: Arnold, Hyer, Small, Saunders, McEvoy, Lee, Dhar, Bainbridge.

Drafting of the manuscript: Arnold, Hyer, Small, Saunders, McEvoy, Lee.

Critical revision of the manuscript for important intellectual content: Arnold, Hyer, Chisolm, Saunders, McEvoy, Lee, Dhar, Bainbridge.

Statistical analysis: Arnold, Small.

Administrative, technical, or material support: Hyer, Dhar, Bainbridge.

Study supervision: Arnold, Hyer, Chisolm, Saunders, Bainbridge.

Conflict of Interest Disclosures: None reported.

Funding/Support: The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) was carried out as a collaborative study supported by contracts from the National Heart, Lung, and Blood Institute (NHLBI) to the University of North Carolina (N01-HC65233), University of Miami (N01-HC65234), Albert Einstein College of Medicine (N01-HC65235), Northwestern University (N01-HC65236), and San Diego State University (N01-HC65237). The following institutions contribute to the HCHS/SOL through a transfer of funds to the NHLBI: the National Institute on Minority Health and Health Disparities, the National Institute on Deafness and Other Communication Disorders, the National Institute of Dental and Craniofacial Research, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute of Neurological Disorders and Stroke, and the National Institutes of Health Office of Dietary Supplements.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The authors thank the staff and participants of HCHS/SOL for their important contributions. A complete list of staff and investigators is available on the study website: http://www.cscc.unc.edu/hchs/.

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