THE 2023 HEALTH STATUS OF LATINOS IN GEORGIA REPORT : simplebooklet.com

6Report OverviewThis report is a snapshot of the health status of Hispanic/Latino residents in Georgia and reports the outcomes by Hispanic/Latino heritage. Heritage is deﬁned by how someone identiﬁes, regardless of where they were born. Unless noted as country of birth, all data refer to Hispanic/Latino heritage. To highlight differences among the Hispanic/Latino community and to use a common reference, the Hispanic/Latino population overall or each heritage/country of origin group is compared with the overall non-Hispanic or Latino Georgia population (indicated as non-Hispanic/Latino). Heritage/Country Of Origin Groups:· Mexican· Puerto Rican· Other Hispanic or Latino· Central American· South American· All other available Hispanic or LatinoA Note on Identity TermsThere are many terms for Latino identity. This report uses “Hispanic/Latino” as these are the terms used by the U.S. Census Bureau and multiple government agencies when tracking and reporting data. Hispanic/Latino refers to communities that are Spanish speaking or descended from Spanish-speaking ancestors and those of Latin American ancestry - including non-Spanish-speaking groups, without regard to race. We acknowledge that there are multiple terms used to identify Hispanic/Latino groups and as language continues to evolve to reﬂect societal changes, so will the terms to identify as Hispanic/Latino. Deﬁnitions of terms used in this report include: Hispanic In 1970, this term became popular within the U.S. government to identify populations with ancestral roots in Spanish-speaking countries. In the U.S., this term is the oldest and most-used term used to describe Spanish speakers and people of Latin American origin.

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8A Note on Demographic Choices for Health Disparity Analysis in GeorgiaThe categories of non-Hispanic white, non-Hispanic Black, and Hispanic/Latino were selected for comparison throughout this report due to their distinct demographic representation, which allows for a more comprehensive understanding of the health disparities and trends across these groups. These groups also constitute a signiﬁcant portion of the population in Georgia, thus providing a meaningful comparison. Furthermore, by analyzing these speciﬁc racial and ethnic categories, we can highlight unique challenges faced by these communities, thereby informing targeted public health interventions and policymaking. Please note that the categorization is not intended to oversimplify or ignore the diversity within these groups but serves to provide a broad overview of the health status in these demographics.A Note on Gender Inclusive LanguageOur team acknowledges that individuals may have diverse gender identities that extend beyond the binary terms of male and female. However, as we reference various external research in this report, when describing study populations or citing research ﬁndings, we use the gender terminology reported by the original investigators.In instances where we use ‘woman’ or female pronouns, we are generally referring to individuals whose sex assigned at birth was female, regardless of their current gender identity. However, we recognize and acknowledge that not all individuals with these anatomical characteristics identify as women or female. We understand that people of various gender identities can also become pregnant and seek reproductive health services.We encourage readers to consider this context when interpreting our use of gendered

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9terms in this report and to understand that our aim is to promote inclusive, equitable healthcare for all.Community Reports and Documents Reviewed to Inform this Report2023 What Happens When you Give The Community The Resources They Need, National Center for Farmworker Health featuring LCF Georgia 2023 State of Latino Funding, LCF Georgia, Omar Rodriguez-Vila, Ph.D., Emory University, Goizueta Business School2022 Farmer’s Mental WellBeing Project: Statewide Survey Report, Georgia Rural HealthInnovation Center at Mercer University School of Medicine2022 15 Facts about Latinos in Georgia, UCLA Latino Policy and Politics Initiative2021 Examining the Psychosocial Impact of COVID-19 on Undocumented Latinx Immigrant Families, Ser Familia, Briana Woods-Jaeger, MPH, PhD |Emory University Rollins School of Public Health2021 Impact of COVID in Diverse Communities, LCF Georgia, Omar Rodriguez-Vila, Ph.D., Emory University, Goizueta Business School 2015 Pathogenic Policy: Health-Related Consequences of Immigrant Policing in Atlanta, GA, Nolan Kline 2012 Georgia Status of Latino Health - Hispanic Health Coalition of Georgia2008 Georgia Latino Health Report - NCLROur appreciation and special mention to Dr. Karen L. Andes, Director of School of Public Health, Associate Professor of Behavioral and Social Sciences at Brown University who helped spearhead this research project.

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10Qualitative MethodsUnderstanding the health needs, challenges, and unique perspectives of the Georgia Latino community is essential for developing effective strategies to improve their health outcomes. By engaging with individuals within the Latino community and listening to their stories, beliefs, and challenges, the qualitative component of this report aims to shed light on the contextual factors inﬂuencing health inequities and to uncover potential solutions that resonate with the community. This report will provide a rich and comprehensive understanding of the complex dynamics surrounding Georgia Latino healthMethodologyA Community Accountability Board (CAB) was established to promote transparency, integrity, and trust between the research team and the Georgia Latino community with the goal of improving services and outcomes for the community. Comprising community leaders with expertise in health access, services, and social determinants of health, the CAB assisted in designing questions for qualitative data collection, provided context and feedback to the research team, hosted focus groups to complement existing data, and reviewed the draft report.The study collaborated with Latino Community Fund (LCF Georgia) to conduct key informant interviews with leaders of community-based organizations serving Latinos in Georgia. Eligibility requirements for key informants included being over 18 years old, directly serving Georgia Latinos, and providing informed consent. Nine key informants from Latino serving community organizations participated.Sample and RecruitmentKey informants also helped recruit diverse focus groups, targeting underrepresented populations within the Latino community like Mayan leaders, LGBTQIA+ members, and rural residents. Recruitment methods varied, including word of mouth, direct outreach, and distributing bilingual study ﬂyers. Eligible individuals identiﬁed as Latino/a in Georgia, were 18 years or older, and capable of giving consent.Study procedures Instrument DevelopmentThe CAB collaborated extensively to develop interview and focus group guides, drawing from community leaders’ valuable insights and experiences. The questions covered a wide range of topics, carefully selected with input from comprehensive research and secondary data ﬁndings for an evidence-based approach (see Appendix Table 1 and 2). The guides were drafted in English, reviewed and revised by CAB members, then professionally translated into Spanish and reviewed by native speakers for clarity.Key Informant Interviews & Focus Group Discussion

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11To understand participants’ backgrounds comprehensively, the CAB also assisted in creating a demographic survey to crucial socio-demographic information and delved into cultural aspects related to health problems, cultural remedies, and engagement with community healers. This holistic approach facilitated a comprehensive exploration of contextual factors inﬂuencing health experiences within the community.Informed consent was obtained from all interested participants. Interviews were conducted on Zoom in either Spanish or English, with only audio recordings retained for conﬁdentiality. FGDs were held in various Georgia locations to capture diverse perspectives. One virtual FGD focused on the LGBTQIA+ community. Participants received compensation for their time and contribution.Data CollectionKey Informant Interviews (KI)To ensure the inclusion of vital perspectives, the research staff proactively reached out to eligible key informants. The emails articulated the purpose and signiﬁcance of the study but also provided an illustrative overview of example questions. Subsequently, research staff gathered consent from interested individuals, and coordinated a mutually convenient date and time to schedule interviews.Key informant interviews were conducted via Zoom Video, a secure and privacy-conscious video conferencing service. The interviews were conducted in either Spanish or English, to accommodate participants, and only audio recordings were retained to safeguard conﬁdentiality and anonymity. The KI interviews lasted 60-90 mins, which allowed for in-depth discussions and meaningful exchanges. Participants were compensated for their time and essential role in advancing knowledge and understanding within the ﬁeld.Focus Group Discussion (FGD) Research staff worked closely with community organizations and partnered with dedicated lead contact staff members to organize and coordinate focus groups. Six focus groups were conducted in community venues, with two research staff members facilitating each session. Additionally, two virtual focus groups were conducted on the secure Zoom platform. The Canton focus group was not audio recorded to maintain conﬁdentiality, as the participants were from a small Mayan community that has historically faced political and social discrimination (Brown, 2011). Focus group participants from diverse areas in Georgia were selected to understand evolving dynamics in the community. Participants came from Dalton, Canton, Tifton, Cobb, Clayton County and were also leaders from different regions. A separate virtual focus group was conducted for the Lesbian, Gay, Bisexual, Transgender, Queer or Questioning and More (LGBTQIA+) community. The FGDs lasted 60-90 mins, which allowed for in-depth discussions and meaningful exchanges. Participants were compensated for their time and efforts in advancing knowledge and understanding within the ﬁeld.

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12Executive SummaryIn the state of Georgia, recent health assessments indicate varying health status among members of the Hispanic/Latino population. The community exhibits unique health outcomes in several areas, including chronic disease, mental health, and maternal-child health. Notably, the prevalence of diabetes and obesity are higher in the Hispanic/Latino population compared to the state average, contributing to increased rates of heart disease and other related complications. A signiﬁcant ﬁnding, however, is the under-diagnosis of these conditions due to barriers in healthcare service access, a challenge that needs immediate attention within the healthcare community and in state policy.A signiﬁcant ﬁnding, however, is the under-diagnosis of these conditions due to barriers in healthcare service access, a challenge that needs immediate attention within the healthcare community and in state policy. Similarly, mental health data suggests a growing concern within the Hispanic/Latino community. Factors such as language barriers, cultural stigma, lack of health insurance, and the limited availability of culturally and linguistically competent care providers intensify this access challenge. Additionally, the stress response experienced in association with the immigration and acculturation process has been linked to an increase in mental health issues, including anxiety and depression.Additionally, the stress response experienced in association with the immigration and acculturation process has been linked to an increase in mental health issues, including anxiety and depression.The social determinants of health, including income, education, and housing, signiﬁcantly impact the health status of Hispanics/Latinos in Georgia. Studies indicate that this community experiences higher levels of poverty and lower educational attainment compared to other ethnic groups in the state, factors linked to poor health outcomes. Additionally, the population experiences higher rates of uninsured individuals, impeding access to preventive and early intervention services. Housing insecurity and overcrowded living conditions further complicate the situation, often exacerbating existing health conditions and limiting opportunities for comprehensive, consistent care.In terms of maternal-child health, the Hispanic/Latino community in Georgia faces dire challenges. The community is grappling

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13with high rates of maternal mortality and morbidity and lower rates of prenatal care, despite having higher fertility rates compared to other ethnic groups. Furthermore, Hispanic/Latino children exhibit higher rates of obesity compared to their non-Hispanic peers. These health disparities are concerning, but the strong family and community networks within the Hispanic/Latino population offer many opportunities for culturally tailored interventions and community-based health promotion strategies to improve maternal-child health.Migrant farmworkers, a majority of whom identify as Hispanic/Latino, face unique health challenges in Georgia. This group is often exposed to physically demanding work conditions, hazardous substances, and inadequate access to healthcare, which signiﬁcantly increases the risk of occupational injuries and illnesses. The prevalence of chronic conditions is high among this population, but due to the transient nature of their work, language barriers, and fear of job loss or deportation often prevent these individuals from seeking or accessing timely healthcare, leading to late diagnoses and poor management of health conditions.Georgia also is home to a growing Mayan community, primarily originating from Guatemala. This group faces unique health challenges, often compounded by language barriers, as many individuals primarily speak indigenous languages rather than Spanish or English. These barriers hinder access to health services and limit the effectiveness of health education programs aimed at Spanish speakers. Additionally, the Mayan community experiences health disparities related to poverty, limited access to nutritious food, and low rates of health insurance coverage. However, their rich cultural heritage and close-knit community structure can serve as strengths to build upon. Culturally tailored interventions, focusing on community engagement and the use of indigenous languages, could enhance healthcare access and outcomes for this population.Strong family and community networks within the Hispanic/Latino population offer many opportunities for culturally tailored interventions and community-based health promotion strategies to improve maternal-child health.Migrant farmworkers, a majority of whom identify as Hispanic/Latino, face unique health challenges in georgia. This group is often exposed to physically demanding work conditions, hazardous substances, and inadequate access to healthcare, which signiﬁcantly increases the risk of occupational injuries and illnesses.

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14Mayan community experiences health disparities related to poverty, limited access to nutritious food, and low rates of health insurance coverage. However, their rich cultural heritage and close-knit community structure can serve as strengths to build upon. Despite these health disparities, the Hispanic/Latino community in Georgia has demonstrated resilience and a strong collective ethos, which can be leveraged to improve health outcomes. Community-based interventions, culturally responsive health education programs, and policy changes aimed at increasing access to quality, affordable healthcare can signiﬁcantly impact health disparities. Furthermore, the involvement of community health workers who understand the cultural nuances and language of this population can bridge the gap between the Hispanic/Latino community and health care providers. Overall, a comprehensive linguistically and culturally sensitive approach is needed to effectively address the health challenges within the Hispanic/Latino population in Georgia.The Hispanic/Latino community in Georgia has demonstrated resilience and a strong collective ethos, which can be leveraged to improve health outcomes. Community-based interventions, culturally responsive health education programs, and policy changes aimed at increasing access to quality, affordable healthcare can signiﬁcantly impact health disparities.

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15Hispanic/Latino Georgia HistoryHistorical Overview Of Latinx People In Georgia Over the past half century, Latinos from all national-origin backgrounds have settled in and established communities across the state of Georgia. While Spanish was the ﬁrst colonial European language spoken in Georgia during the ﬁfteenth century, there were no large, sustained settlements of Latino populations in the state until the mid-twentieth century. Between the late 1950s through 1990s, Georgia’s Latino population grew dramatically and reshaped the state’s demographic, political, cultural, and economic dimensions. Today, in the twenty-ﬁrst century, over one million Latinos call Georgia home and play key roles in all aspects of state’s society (U.S. Census Bureau, 2022d).The history of Latinos in Georgia spans decades and envelops people of varying national, class, and racial backgrounds that have distinct experiences of migration and settlement. This diversity of experiences necessitates a discussion of distinct national-origin groups prior to the growth of a broader Latino community. For example, Cuban elites, business leaders, and students had long been enveloped in traveling to and studying in Georgia, due to the economic, political, and educational links established between the state and the island beginning in the late nineteenth century (Bayala, 2006). This connection was made visible in 1949 when the “Havalanta” games were held for youth athletes in Atlanta (McDonough & Moore, 1951). The history of Latinos in Georgia spans decades and envelops people of varying national, class, and racial backgrounds that have distinct experiences of migration and settlement. This cultural and athletic exchange that brought Atlanta and Havana together continued into the following decade and garnered widespread media attention in Georgia as visiting Cuban students and families participated in sporting events, meals, and celebrations around the city. While these visits were transient in nature, they played a role in establishing a visible presence of Latinos in Georgia. The games ended by the late 1950s, however, and the Cuban Revolution resulted in the permanent resettlement of many Cuban individuals and families in the US, including in the state of Georgia. Cubans, then, were amongst the ﬁrst sizeable group of Latinos to arrive to Georgia in the mid twentieth century. This cohort of early arrivals was made up primarily of upper- and middle-class individuals and families who arrived in the Metropolitan Atlanta region. The following two decades were marked by slow, but sustained, Latino community growth. Throughout the 1960s and 1970s Cubans and other Latino migrants established social, cultural, and political community networks in the state. The Cuban Club of Atlanta, for example, opened its doors in 1979. As the Latino population grew and diversiﬁed in

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16this era, so did the community’s needs and responses by local institutions and leaders. Organizations such as the Latin American Association (founded 1976 by a Puerto Rican sheriff and allies) and the Spanish-language newspaper Mundo Hispánico (co-founded 1979 by a Peruvian researcher and a US-born Spanish and Portuguese speaking journalist) created resources and addressed some of the needs of the rapidly growing Latino population. Close to 30,000 Latinos called Georgia home by the end of the 1970s, with Cuban and Mexican migrants being amongst the most represented in the census data (U.S. Census Bureau, 1973).Metropolitan Atlanta served as a primary destination and as a site of sprawled Latino community formation in the 1960s through 1970s. Though Latino migration to Georgia remained steady in the 1970s, the populations remained small at the local city-level and, with that, came challenges for migrant arrivals attempting to integrate into their new home. Therefore, in 1979, the Georgia State University for Public and Urban Research conducted the ﬁrst large-scale study to understand the demographic characteristics, residential living patterns, and social service needs of the Latino population in Metropolitan Atlanta (Hutcheson & Dominguez, 1986). Researchers found that more afﬂuent Latinos lived in suburban areas of the region, while lower-income individuals and families tended to live in residential apartment clusters closer to the city center. These residential patterns shifted as the community continued to grow in the coming years. Between the 1960s and 1970s, Latino laborers also arrived in northern and southern parts of the state to work in poultry processing, manufacturing, and agricultural industries. Latino migrants, however, were not just choosing to settle in the metropolitan region. Between the 1960s and 1970s Latino laborers also arrived in northern and southern parts of the state to work in poultry processing, manufacturing, and agricultural industries. Poultry processing and carpet manufacturing companies in north Georgia were two industries that played central roles in directly and indirectly recruiting Latino, primarily Mexican, laborers to the region (Murphy et al., 2001). Mexican American - mainly Tejanos - and Mexican farmworkers were also enveloped in circular migration practices between southern Georgia, Mexico and Texas by the 1960s, which laid the foundation for the rapid growth of Latino farmworkers working and living in the state during the coming decades (Weise, 2015).During the 1980s, Latino migrants engaged increasingly in chain migration practices which saw the exponential growth of the population across the state as people arrived from Latin America, the Caribbean, and other US states in search of economic opportunities in Georgia. A combination of economic decline in Mexico, civil unrest and violence in Central America, and signiﬁcant changes to US federal immigration policies saw large numbers

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17of Mexican, Salvadoran, and other Central American migrants choosing “nontraditional” destination sites with promises of work and low-cost of living. Made up of young, solo men, this cohort entered various industries across the state, including the service, manufacturing, and construction sectors. The passage of the 1986 Immigration Reform and Control Act (IRCA) also facilitated increased social mobility for formerly undocumented migrants, as the legislation allowed migrants to apply to regularize their status if they had previously worked in an accepted ﬁeld. IRCA applicants were overwhelmingly from Mexico, Central America, and South America and submitted their petitions in at least eight counties across southern Georgia and Metropolitan Atlanta (Sabet & Winter, 2019). Those who could regularize their legal status could gain residency and, eventually, citizenship. By the late 1980s the national-origin and class backgrounds of the Latino population were distinct when compared to the early arrivals of the 1950s. Early arrivals often held more ﬁnancial, legal, and educational privileges as opposed to those who arrived after the 1970s. While the ﬁrst large group of Cubans were made up of middle and upper-class people, for example, the 1980s saw the arrival of Cuban refugees called “Marielitos.” This later cohort of Cubans, like other poor and working-class Latinos, faced signiﬁcant challenges in Georgia, including experiencing higher rates of policing, incarceration, and deportation. The 1987 Atlanta prison riots, for example, saw detained Cubans protest due to threats of deportation (Davis, 2012). There were also some cases of police and vigilante violence against Latinos, often non-English speakers, documented in Spanish-language news and by organizations such as the American Civil Liberties Union (ACLU) and the Center for Democratic Renewal (Wells, 1986). The following decade saw the most dramatic growth for Georgia’s Latino population. Whereas the population was estimated at a little under 30,000 across the state in 1970, the total grew to over 100,000 by 1990 (U.S. Census Bureau, 2001). This demographic boom was impacted in part by preparations for the 1996 Centennial Olympic Games held in Atlanta. Construction projects related to the games and to metropolitan development, as well as the growing service industry in the region, resulted in further formal and informal recruitment of Latino laborers to the state. The 1986 IRCA legislation had also established a new process that would facilitate further Latino labor migration to Georgia. The introduction of the H-2A visa program allowed temporary agricultural workers to apply to work for US employers who anticipated or claimed a domestic labor shortage. The 1996 Centennial Olympic Games held in Atlanta. Construction projects related to the games and to metropolitan development, as well as the growing service industry in the region, resulted in further formal and informal recruitment of Latino laborers to the state.

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18However, it was not just Georgia’s expanding economy and labor opportunities that drew Latinos in this decade. The 1990s saw an increase in anti-immigrant policies across the nation, including in “traditional destinations” such as California and Texas. This resulted in many Latinos choosing to move to Georgia for its seemingly “tranquil” environment. In this era more women and children also migrated to Georgia, which was noted in the changing populations and student linguistic needs in schools across the state. In Dalton, for example, civic and public-school leaders launched the Georgia Project in 1997 to establish a teacher exchange with schools in Monterrey, Mexico to learn how to better support incoming Latino students (Hernández-León & Zúñiga, 2002).The 1990s overall marked a critical moment in Latino Georgia history. This decade saw the rapid expansion of Spanish-language services and resources across the state, including the establishment of radio stations, television programs, and cultural festivals. Latino migrants increasingly founded businesses, cultural associations, social service agencies, religious institutions, and advocacy organizations. The Latino population also diversiﬁed greatly: Mexicans remained the majority in the state, while the Puerto Rican community supplanted Cubans as the second largest group; each of the Dominican, Guatemalan, Honduran, Panamanian, Salvadoran, Colombian, and Peruvian communities had a population of at least 1,000 by the end of the decade; and at least 600 Ecuadorian and 700 Nicaraguans lived in the state.As the 21st century began, Georgia Latinos encountered new promises and challenges. Organizations such as the Coalition of Latino Leaders (CLILA), Georgia Association of Latino Election Ofﬁcials (GALEO), the Georgia Latino Alliance for Human Rights (GLAHR) were founded in the 2000s and established a critical Latino advocacy and political presence across the state. By the 2000s and 2010s many Latinos entered the world of “ﬁrsts” in Georgia, including the ﬁrst Latino (Rep. Pedro Marin; Sen. Sam Zamarripa) and Latina (Rep. Brenda Lopez Romero) legislators elected to the Georgia General Assembly. As Latinos began to consolidate some grassroots and political representation at the state level, immigration enforcement efforts in Georgia were criticized for practices that appeared to target non-white Latino community members believed to be undocumented by authorities. Efforts such as House Bill 87 and county-level 287(g) programs resulted in negative impacts on the community, and saw widespread detention, deportations, and voluntary departures of Latino migrants from the state (American Civil Liberties Union of Georgia, 2009). In the face of such challenges, those most impacted and their allies continued to mobilize and advocate for full inclusion into Georgia society, particularly in the arena of civic engagement and electoral politics. As of 2020, an estimated 385,185 Latinos were registered voters in the state (American Civil Liberties Union of Georgia, 2009). Today the state’s Latino population consists of ﬁrst, second, and third generation Georgians who speak English, Spanish, Mayan, Portuguese, and other languages of the Americas. The strong Latino economic presence is seen in the

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19state’s-built environment through the tiendas, panaderias, pupuserias, taquerias, carnicerias and other businesses that dot the region. Latinos’ cultural and social contributions are seen across the state at annual national independence days and Hispanic Heritage Month celebrations, within growing museum and art gallery collections, and on game days for Atlanta United and the Atlanta Braves. As the community continues to grow, it will be important to research, document, understand, and address the health needs of this diverse population that calls Georgia home. As the 21st century began, Georgia Latinos encountered new promises and challenges. Organizations such as the Coalition of Latino Leaders (CLILA), Georgia Association of Latino Election Ofﬁcials (GALEO), the Georgia Latino Alliance for Human Rights (GLAHR) were founded in the 2000s and established a critical Latino advocacy and political presence across the state. Today the state’s Latino population consists of ﬁrst, second, and third generation Georgians who speak English, Spanish, Mayan, Portuguese, and other languages of the Americas. The strong Latino economic presence is seen in the state’s-built environment through the tiendas, panaderias, pupuserias, taquerias, carnicerias and other businesses that dot the region. Latinos’ cultural and social contributions are seen across the state at annual national independence days and Hispanic Heritage Month celebrations, within growing museum and art gallery collections, and on game days for Atlanta United and the Atlanta Braves.

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20Hispanic/latino Population In The United StatesIn 2021, the U.S. national Hispanic/Latino population was 62.5 million – a 12 million increase from 2010 (Krogstad et al., 2022). Overall, the Hispanic/Latino population increased by 19% compared to the nation’s growth rate of 7% since 2010 (Figure 1) (Krogstad et al., 2022). Nineteen percent of the nation’s population is Hispanic/Latino.The Hispanic/latino Population In GeorgiaFrom 2010 to 2019, the Hispanic/Latino population increased by 26% in the South from 18.3 to 23.1 million (Noe-Bustamante, 2020). The South had the greatest Hispanic/Latino population growth of any region in the United States.As of 2022, the total population in Georgia was 10.9 million, of which over 10% (1.14 million) identify as Hispanic/Latino and comprise the third-largest racial and ethnic group in the state (U.S. Census Bureau, 2022d). Georgia is among the top 10 states with the largest Hispanic/Latino populations (Figure 2) (U.S. Department of Health and Human Services (HHS) Ofﬁce of Minority Health, 2023).Basic Demographics0,01970 1980 1990 2000 2010 202117,535,052,570,09,614,522,435,350,562,5Figure 1Hispanic/Latino population growth in the United States 1970-2021

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21WashingtonOregonMontanaIdahoWyomingNevadaUtahColoradoNew MexicoArizonaCaliforniaNebraskaIowaKansasNorth DakotaSouth DakotaMinnesotaWisconsinIllinoisMissouriArkansasOklahomaTexasLouisianaMississipiAlabamaGeorgiaSouthCarolinaNorth CarolinaVirginiaTennesseKentuckyWestVirginiaPennsylvania NewJerseyMarylandDelawareConnecticutRhodeIslandMassachussettsNewHamshireMaineVermontNew YorkFloridaMichiganIndianaOhio2012900.000962.5001.025.0001.087.5001.150.0002013 2014 2015 2016 2017 2018 2019 2020 2021 2022Georgia has experienced fast growth in the Hispanic/Latino population over the past few decades. From 2000 to 2010, the state’s Hispanic/Latino population grew by nearly 95% (Governor’s Ofﬁce of Planning and Budget, n.d.-a, n.d.-b). State-level data from the American Community Survey 1-Year Estimates from 2012-2021 show a growth within the Hispanic/Latino community of Georgia by 20% (U.S. Census Bureau, 2013, 2022a). Figure 1.2 displays the steady increase in population within this time frame.Note. (2023). Adapted from Online Analytical Statistical Information System (OASIS), Web Query Tool, Department of Public Health, Ofﬁce of Health Indicators for Planning (OHIP). https://oasis.state.ga.us 2012900.000962.5001.025.0001.087.5001.150.0002013 2014 2015 2016 2017 2018 2019 2020 2021 2022

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22U.S. Census Bureau’s Denition Of “Hispanic” Or “Latino” OriginThe U.S. Census Bureau adheres to the Ofce of Management and Budget (OMB) standards on the collection and presentation of data on race and ethnicity. The OMB denes these standards for all federal reporting. The designations for ‘race’ are: Black or African American, Native Hawaiian or Other Pacic Islander, American Indian or Alaska Native Asian and white. ‘Ethnicity’ reporting is dened as: Hispanic or Latino and Not Hispanic or Latino.Hispanic or Latino origin is dened by the OMB as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. The term “Hispanic” was rst adopted by the United States government in the early 1970s during the Richard Nixon administration and has since been used in local and national surveys, various media outlets, and other governmental and non-governmental reports (Simon, 2020).It’s important to note that “Hispanic” or “Latino” refers to ethnicity, not race, and the U.S. Census recognizes this fact. People identifying as Hispanic or Latino can be of any race and are identied as such based on self-identication. The terms “Hispanic” and “Latino” are sometimes used interchangeably in the U.S., but they don’t mean the same thing. “Hispanic” refers to people who speak Spanish or are descended from Spanish-speaking populations, while “Latino” refers to people who are from or descended from people from Latin America.Overview Of Hispanic/Latino Citizenship Status In GeorgiaAccording to the U.S. Census Bureau, 2021 American Community Survey (ACS) “2021 Subject Denitions” document (U.S. Census Bureau., 2021) - citizenship status is determined by the following terms when gathering demographic information: Of the top 5 Hispanic/Latino heritage groups in Georgia, the Mexican community is the largest at 57%. Followed by Puerto Ricans (10%), Guatemalans (6%), Salvadorans (5%), and South Americans (8%) are the remaining four majority Hispanic/Latino heritage groups in Georgia (Ahn et al., 2022).Top Hispanic / LatinoOrigin Groups in Georgia

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23The nativity, naturalization status, and timing of entry breakdown of the Hispanic/Latino population residing in Georgia in 2021 is presented in Tables 1, 2, and 3. (U.S. Census Bureau, 2022a)U.S. CitizenThose who indicated that they were born in the United States, Puerto Rico, Guam, the Northern Marianas, or the U.S. Virgin Islands, as well as those born abroad of at least one U.S. citizen parent are considered U.S. citizens at birth. Foreign-born people who indicated that they were U.S. citizens through naturalization also are considered U.S. citizens.Not a U.S. CitizenIndividuals who indicate they were not U.S. citizens at the time of the survey. The population surveyed includes all people who indicated that the United States was their usual place of residence on the survey date. Individuals are not asked about their immigration status.Native The native population includes anyone who was a U.S. citizen at birth (see U.S. Citizen deﬁnition).Foreign born Includes anyone who was not a U.S. citi-zen at birth. This in-cludes respondents who indicated they were a U.S. citizen by naturalization or not a U.S. citizen. The foreign-born popu-lation includes nat-uralized U.S. citizens, lawful permanent residents (i.e., immi-grants), temporary migrants (e.g., for-eign students), hu-manitarian migrants (e.g., refugees), and unauthorized mi-grants (i.e., people illegally present in the United States). Individuals are not asked about their immigration status.

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24Foreign-Born Majority Arrival Into U.S. Before 2000 (Table 2): A signiﬁcant portion (42.3%) of the foreign-born Hispanic/Latino population in Georgia arrived before the year 2000. This suggests a substantial wave of immigration occurred at least two decades prior to the data year (2021). Immigration seems to have slowed in the subsequent decades, with 32.2% arriving between 2000 and 2009, and only 25.5% arriving in 2010 or later. This could indicate a slowing rate of immigration from Latin American countries into Georgia over the years, though it could also reﬂect changes in immigration policy, economic conditions, or other factors not directly observable from this data (i.e., newer immigrants have moved to other states or left the U.S.).Table 1Nativity by Sex and Hispanic/Latino origin in Georgia, 2021Note. Population of Hispanic/Latino individuals living in Georgia who were born in the United States. Adapted from the 2021 American Community Survey (ACS). ACS 1-Year Estimates Selected Population Proﬁles.Picture: From a Ser Familia focus group

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26Age & Sex Distribution The 2021 ACS U.S Census Bureau report reveals the following key points on the age AND sex distribution for the Hispanic/Latino population residing in Georgia (U.S. Census Bureau, 2022a): ·The age distribution reveals a relatively young population. The median age is 27.2 years, and a substantial portion of the population is under 45 years (76.5%).·Speciﬁcally, those under 18 years constitute 34.5% of the total Hispanic/Latino population in Georgia, while those between 18- and 44-years old form 42% of the population.·The proportion of the population aged 65 and over is relatively small, at only 4.6%. This again highlights the younger demographic proﬁle of the Hispanic/Latino population in Georgia. Notably, the gender distribution in this age bracket ﬂips, with females constituting a majority at 58.2% - a stark contrast to the male majority in younger age groups.·The total Hispanic/Latino population in Georgia shows a slight male majority, with males making up 52.0% of the population and females 48.0%. This slight skew towards males is also evident in age brackets under 65, though it becomes more pronounced among those under 18, where males constitute 53.1% of the population.Hispanic/Latino Population By Region/CountyGeorgia is divided into 159 counties. The counties range in population from less than 1,000 residents to over 1 million residents. As of 2021, over 1 million people live in Fulton County, the largest county in Georgia, which is home to the city of Atlanta. The smallest county in Georgia by population is Taliaferro County, which has a population of about 1,500 people. Each county in Georgia is responsible for providing basic services to their residents including law enforcement, public schools, and local government administration. The table below includes the counties in Georgia with the largest Hispanic/Latino populations in 2021 (Online Analytical Statistical Information System (OASIS), 2023). In addition to being the counties in the state with the highest numbers of Hispanic/Latino residents, they are also all classiﬁed as “non-rural” counties.The age distribution reveals a relatively young population. The median age is 27.2 years, and a substantial portion of the population is under 45 years

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28During the qualitative portion of the study, forty-four demographic surveys were completed by both key informant and focus group participants, providing valuable insights into the characteristics of the study sample. Table 1.3a (see Appendix) reveals signiﬁcant trends, with most participants identiﬁed as female, Mexican, and aged range of 31-40 years old. A signiﬁcant proportion of participants were married and did not specify their immigration status. Most identiﬁed themselves as heterosexual or straight, preferred Spanish as their primary language, and resided in Cobb County (Metro-Atlanta) or Whitﬁeld County (North Georgia). Most respondents completed High School/GED level, worked full-time or more than 40 hours per week, reported an average income between $10,000 to $29,999, and had an average household size of four individuals.Rural & Non-Rural Counties | Demo-graphics & Analysis Top 3 Counties (Overall & Non-Rural) In Georgia With Highest Hispanic/Latino Population Count (Table 4)Gwinnett County is the second-most populous county in Georgia, with the highest Hispanic/Latino population count in the entire state at 213,869. Hispanics/Latinos encompass 22% of Gwinnett County’s total population.Cobb County is the third-most populous county in Georgia and contains the second-highest Hispanic/Latino population count in the entire state at 104,672. Hispanics/Latinos encompass 14% of Cobb County’s total population.Fulton County contains the third-highest Hispanic/Latino population count at 77,733. Hispanics/Latinos comprise 7% of Fulton County’s total population.Demographic Overview of Participants

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29Top 3 Rural Counties In Georgia With The Highest Hispanic/Latino Population Count (Table 5)· Colquitt County is in South Georgia and is known for its agricultural industry, particularly in the production of cotton, peanuts, and vegetables. As indicated in the table below, Colquitt County contains 9,399 people who are Hispanic/Latino, the highest number of the rural counties in Georgia. Hispanics/Latinos comprise 21% of Colquitt County’s total population.· In northeastern Georgia, Habersham County is known for its scenic beauty and outdoor recreational opportunities. The county ranks second-highest among Georgia’s rural counties in Hispanic/Latino population count (7,785 people). Hispanics/Latinos encompass 17% of Habersham County’s total population.· Situated in the northwestern part of Georgia, Murray County is bordered by the Chattahoochee National Forest. The county ranks third among Georgia’s rural counties in terms of the Hispanic/Latino population count (6,404 people). Hispanics/Latinos make up 16% of Murray County’s total population.Table 5Top Rural Counties in Georgia with the Highest Count of Hispanic/Latino People In 2021Note. Adapted from the Online Analytical Statistical Information System (OASIS), Web Query Tool, Georgia Department of Public Health, Ofﬁce of Health Indicators for Planning (OHIP). https://oasis.state.ga.us

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30During the qualitative portion of the study, forty-four demographic surveys were completed by both key informant and focus group participants, providing valuable insights into the characteristics of the study sample. Table 1.3a (see Appendix) reveals signiﬁcant trends, with most participants identiﬁed as female, Mexican, and aged range of 31-40 years old. A signiﬁcant proportion of participants were married and did not specify their immigration status. Most identiﬁed themselves as heterosexual or straight, preferred Spanish as their primary language, and resided in Cobb County (Metro-Atlanta) or Whitﬁeld County (North Georgia). Most respondents completed High School/GED level, worked full-time or more than 40 hours per week, reported an average income between $10,000 to $29,999, and had an average household size of four individuals.

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32The Social Determinants Of Health (SDoH) section highlights the inﬂuence of various conditions in the environments where Hispanics/Latinos in Georgia are “born, grow, live, work, and age” on their overall health, functionality, and quality of life (World Health Organization, N.d.).In the following sections of this report, the diverse aspects of social determinants of health (SDoH) impacting the Hispanic/Latino population in Georgia are explored:· Education Access, and Quality: Factors like status of school enrollment and educational attainment among the Hispanic/Latino community of Georgia. · Economic Stability: Trends analysis on segments such as employment, income, poverty, and health outcomes. · Neighborhood and Built Environment: Analyses on housing conditions and their health impact on the Hispanic/Latino population in Georgia.· Health Care Access and Quality: The challenges and developments in healthcare access, insurance coverage, and the inﬂuence of policies like The Affordable Care Act and Medicaid expansion.· Social and Community Context: The interplay of language barriers, cultural representation in healthcare, and relationships with the U.S. healthcare system in shaping health outcomes among the Hispanic/Latino Population in Georgia.Georgia’s Hispanic/Latino residents have lower education levels than the overall Georgia average and Hispanic/Latino national population. Of the Hispanic/Latino Georgia residents, 38% did not complete high school, compared to 31% of Hispanic/Latinos nationally (Ahn et al., 2022). Signiﬁcant educational disparities exist subgroups, such as 69% of Guatemalans did not complete high school, versus 11% of Puerto Ricans and 9% of South Americans (Ahn et al., 2022). Based on the provided data from the 2021 American Community Survey (ACS) focusing on the Hispanic/Latino population in Georgia, the following trends and key ﬁndings can be observed below (U.S. Census Bureau., 2022) Social Determinants of Health Education Access and QualityResearch suggests that SDOH can be a more potent inﬂuence on health outcomes than healthcare or lifestyle choices, accounting for between 30-55% of health outcomes, and require strategic cross-sector collaborations (World Health Organization, n.d.)

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33·School Enrollment by Hispanic/Latino Males: Among school-aged Hispanic/Latino males, 80% are enrolled in kindergarten to grade 12 and 16% are enrolled in college or graduate school.School Enrollment by Hispanic/Latina Females: The percentage of school-aged Hispanic/Latina females enrolled in kindergarten to grade 12 is lower at 73%, however, the rate of college or graduate school enrollment is higher at 22%.School Enrollment - Georgia (Acs, 2021)Total School Enrollment: A total of 358,988 individuals of Hispanic/Latino origin aged 3 and over are enrolled in school. Elementary School Enrollment: High School EnrollmentCollege or Graduate School Enrollment47% 24% 19%of this population is enrolled in elementary school (grades 1-8).of this population is enrolled in high school (grades 9-12).of this population is enrolled in college or graduate school.

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34Educational Attainment - Georgia (Acs, 2021)Hispanic/Latino Population with Less Than a High School Diploma: For the population aged 25 years and over (574,391 individuals), the highest percentage (32%) has less than a high school diploma.High School Graduates: High school graduates, including those with equivalency, make up 26% of the population.Some College Education or associate degree: 20% of Hispanics/Latinos have some college education or hold an associate degree.Bachelor’s and Graduate’s or Professional Degree Holders Those with a bachelor’s degree make up 15% and 8% hold a graduate or professional degree.Female Educational Attainment: When considering high school education or higher, females lead with 71%, compared to males with 66%. Similarly, for the attainment of a bachelor’s degree or higher, females again lead with 25%, compared to males with 21%.Summary: Overall, the data indicate that school enrollment is balanced between genders for the Hispanic/Latino population in Georgia. However, females outpace males in both high school and higher education attainment. There is still a signiﬁcant portion of the population (32%) with less than a high school diploma, signaling a potential area for improvement in terms of educational outreach and resources. The data also reﬂect a relatively low percentage of individuals attaining college degrees, which might inﬂuence socioeconomic factors such as income, job opportunities, and overall quality of life for the Hispanic/Latino community in Georgia.Between 2010 and 2022, the Hispanic/Latino 25- to 29-year-old population showed signiﬁcant progress in educational attainment, with a 19% increase in completing at least high school in the United States (National Center for Education Statistics [NCES], 2023).

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35High School Diploma Completion in Georgia Compared to U.S. Average (U.S. Higher): Among the Hispanic/Latino population aged 25 and over in Georgia in 2021, it was found that 32% had not attained a high school diploma. This is higher than the 12% seen among the national Hispanic/Latino population of 25- to 29-year-olds in 2022 (National Center for Education Statistics [NCES], 2023; U.S. Census Bureau, 2022a).High School Graduation Rates in Georgia and Nationwide (U.S. Higher): In 2021, high school graduates, including equivalency, represented 26% of Georgia’s Hispanic/Latino population. This is considerably lower than the national rate of 88% seen among 25- to 29-year-old Hispanics/Latinos (National Center for Education Statistics [NCES], 2023; U.S. Census Bureau, 2022a).Some College or associate degree Attainment (U.S. Higher): Only 20% of Georgia’s Hispanic/Latino population reported having some college education or holding an associate degree in 2021. This rate lags the national average of 34% observed among 25- to 29-year-old Hispanics/Latinos (National Center for Education Statistics [NCES], 2023; U.S. Census Bureau, 2022a).Bachelor’s Degree Completion Rates (U.S. Higher): In 2021, 15% of Georgia’s Hispanic/Latino population held a bachelor’s degree. This ﬁgure is noticeably lower than the national rate of 25% reported among 25- to 29-year-old Hispanics/Latinos (National Center for Education Statistics [NCES], 2023; U.S. Census Bureau, 2022a).Graduate or Professional Degree Attainment (Comparable): The proportion of Hispanics/Latinos in Georgia holding a graduate or professional degree was 8% in 2021, which aligns closely with the national rate of 10% among Hispanics/Latinos aged 25-29.) (National Center for Education Statistics [NCES], 2023; U.S. Census Bureau, 2022a).Education and HealthResearch has established a strong connection between education and health (Zajacova & Lawrence, 2018). Higher levels of educational attainment are associated with several positive outcomes, including better job prospects, increased earnings, improved health literacy, higher self-reported health, and a reduced prevalence of chronic conditions. Conversely, individuals with lower levels of education face a greater risk of experiencing various adverse health outcomes, such as obesity, cardiovascular disease, lung disease, mental health problems, and premature death.Comparative Analysis of Educational Attainment Among Hispanics/Latinos in Georgia vs. National Trends

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36However, while national trends indicate progress in educational attainment among the Hispanic/Latino population, the data from Georgia reveal signiﬁcant disparities at the state level. The Hispanic/Latino community in Georgia consistently trails the national averages across various categories of educational attainment.Economic StabilityEmployment Status & OccupationHispanic/Latino Labor Force Participation In The United StatesHispanics/Latinos represented 18% of the labor force in the United States (U.S. Bureau of Labor Statistics, 2021). Hispanic/Latino males in the United States have a 74% labor participation rate (Ahn et al., 2022). Hispanic/Latino Labor Force Participation In GeorgiaThis following analysis offers valuable insights into the employment and commuting patterns of Georgia’s Hispanic/Latino population, based on the 2021 ACS 1-Year Estimates from the U.S. Census Bureau. By examining data on employment status, commuting behaviors, occupational distribution, industry representation, and class of worker, we can gain a deeper understanding of the Hispanic/Latino workforce in Georgia. Commuting to Work:Most Hispanic/Latino workers in Georgia (64%) commute to work by driving alone in a car, truck, or van, suggesting a reliance on personal transportation.19% carpoolOnly a small percentage (1%) use public transportation, indicating a relatively low usage of public transit among Hispanic/Latino workers.

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37Occupation Analysis by SexAmong male Hispanic/Latino workers, natural resources, construction, and maintenance occupations are the dominant category, comprising nearly 36% of their employment.Management, business, science, and arts occupations account for 19% of male workers.Among female Hispanic/Latina workers, the highest proportion (30%) is in management, business, science, and arts occupations.Service occupations are also signiﬁcant for female workers, representing 28% of their employment.24%Occupation (Table 6)22%21%14%20%The largest occupation category is “management, business, science, and arts occupations” The second-largest occupation category for Hispanics/Latinos in Georgia is “natural resources, construction, and maintenance occupationsService occupations make up 21% of the Hispanic/Latino workforceSales and ofﬁce occupations account for 14% of the employed populationProduction, transportation, and material moving occupations represent 20% of the workforce

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39Income and PovertyThis following analysis offers valuable insights into the income patterns of Georgia’s Hispanic/Latino population, based on the 2021 ACS 1-Year Estimates from the U.S. Census Bureau.Most Hispanic/Latino households in Georgia reported earnings, reﬂecting a high rate of employment within this community: The Hispanic/Latino population in Georgia comprised 297,078 households, with a median income of $59,633 (in 2021 inﬂation-adjusted dollars). It is notable that 91% of these households reported income, with mean earnings of $78,672.Despite the high employment rate, some households still depend on supplemental income: Additional income sources contribute to the overall economic health of the Hispanic/Latino community in Georgia. For instance, 12% of households reported Social Security income, with a mean of $19,289. Supplemental Security Income was reported by a smaller percentage (2%), with an average income of $9,781. Retirement income was reported by 9% of households, with a mean income of $33,144. Another 2% of households reported receiving cash public assistance, with a mean income of $5,735. Lastly, 11% of households reported receiving Food Stamp/SNAP beneﬁts.Family structure impacts the median income among Hispanic/Latino families, with married couples earning more than single-parent households, highlighting the ﬁnancial advantages of dual-income household: In terms of family structure, there were 224,662 Hispanic/Latino families in Georgia. The median family income was $61,473. Married couples accounted for 66% of these families, with a median income of $75,295. Male-headed households without a spouse represented 12% of the total, with a median income of $50,706. Female-headed households without a husband represented 21%, with a median income of $34,844.Distinct wage gap between Hispanic/Latino men and women who are full-time, year-round workers: At the individual level, there were 1,083,524 Hispanic/Latino individuals with a per capita income of $22,462. Full-time, year-round workers comprised 224,063 males and 131,728 females. Males had mean earnings of $54,800, with a median of $40,918. Females had mean earnings of $45,013, with a median of $35,048.Poverty Rates Data from the 2021 American Community Survey 1-Year Estimates detail the poverty rates among the Hispanic/Latino population in Georgia. Below is an analysis of the data presented:All Families: The poverty rate for all Hispanic/Latino families in Georgia stands at 17%, ndicating that approximately one in six families lives in poverty.Married Couples: Among Hispanic/Latino married-couple families, the poverty rate is signiﬁcantly lower at 10.1%, and even among It’s notable that 91% of these households reported earnings.

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40those with children under 18 years, it rises to 14%. This implies that married couples, generally, have a lower risk of poverty, possibly due to dual incomes.Single Mothers: Hispanic/Latino female householders with no spouse present have a signiﬁcantly higher poverty rate at 35%, and those with children under 18 years see this rate rise to a substantial 44%. These ﬁgures reﬂect the ﬁnancial challenges often faced by single-parent households.Individuals: The overall Hispanic/Latino poverty rate among individuals is 19%. There’s a signiﬁcant difference between the rates for those under 18 years (28%) and adults (14% for those 18 years and over), suggesting that young people are at a higher risk of living in poverty. However, it’s important to note that the poverty rate among individuals aged 65 and over is slightly lower at 11%, indicating that senior citizens may have more stable income sources such as social security or retirement savings.Factor contributing to the high level of poverty and low-income rates of Hispanics/Latinos in Georgia are immigration status, low education, and language barriers among other factors. For example, undocumented Hispanics/Latinos in Georgia lack access higher education and higher-paying job opportunities with employment beneﬁts.1 in 6 families live in poverty.

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41Neighborhood and Built EnvironmentGeneral Characteristics of Rural and Non-Rural Counties in GeorgiaRural and non-rural counties in Georgia offer different lifestyles, economies, and environments to residents. Rural counties have smaller populations and lower population densities compared to non-rural (urban and suburban) counties. Urban areas, such as Atlanta in Fulton County, have a much higher concentration of people, leading to more crowded living conditions and increased infrastructure demands. For instance, Georgia DPH lists Fulton County, a non-rural county, with a total population in 2021 of 1,065,334. According to the 2020 U.S Census Bureau, this county had a population density of around 2,025 people per square mile, while Echols County, a rural county, has a total population of 3,699 people and had a population density of approximately 9 people per square mile (U.S. Census Bureau, 2022c). Rural and non-rural counties in Georgia have unique characteristics and challenges. The following section highlights some notable differences:Non-rural counties generally have more diverse economies with a broader range of job opportunities, including those in the technology, ﬁnance, healthcare, and entertainment sectors. Rural counties are typically more reliant on agriculture, forestry, and other natural resource-based industries, leading to fewer employment options and lower average income. For instance, according to the 2017-2021 ACS 5-Year Data Proﬁle, Echols County has signiﬁcantly more land dedicated to agriculture compared to Fulton County (U.S. Department of Agriculture, 2019a, 2019b). Echols County has a total of 103,076 acres of farmland, while Fulton County has 4,323 acres.HousingHome Value And CostsIn 2019, Georgia Hispanics’/Latinos’ median home value was $130,000, $45,000 less than the state median of $175,000. Among Hispanic/Latino origin groups, South Americans own homes with the highest median value of $200,000. At 52%, more than half of Hispanics/Latinos in Georgia have a housing cost burden, meaning that over 30% of their income is spent on housing costs (Ahn et al., 2022)Below are statistics for Georgia Hispanic/Latinos:Home Ownership and Rental Rates: Over half (54.2%) of the 297,078 Hispanic/Latino-occupied housing units in Georgia are owner-occupied, while 45.8% are renter-occupied, The per capita income in urban Fulton County was $52,842 compared to rural Stewart County with a per capita income of $19,763.

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42suggesting a roughly balanced mix of home ownership and renting within this community (U.S. Census Bureau, 2022a).Housing Unit Types: Georgia Hispanics/Latinos occupied housing units (65.2%) that are single, detached, or attached units. A smaller proportion live in multi-unit structures (6.0% in 2–4-unit structures, 18.5% in 5 or more-unit structures) or non-traditional housing types (10.4% in mobile homes, boats, RVs, vans, etc.) (U.S. Census Bureau, 2022a).Housing Costs Relative to Household Income: Housing costs pose a signiﬁcant ﬁnancial burden for some households. Housing costs as a “percentage to household income” helps assess the affordability of housing for different income groups. It is a critical indicator used to gauge the ﬁnancial burden that housing costs impose on households and to study housing affordability trends within a region or across different demographic groups.Among the 104,576 housing units with a mortgage, 33.2% spend 30% or more of their household income on owner costs. Among the 129,661 renter-occupied units, a nearly equal proportion spend less than 30% (50.6%) or 30% or more (49.4%) of their household income on gross rent (U.S. Census Bureau, 2022a).Median Housing Costs and Values: The median housing costs ﬁgures provide information about the monthly costs for households who own their home (those with and without mortgages) and the gross monthly payment for those households paying rent.The median value of owner-occupied housing units is $238,800, with monthly costs averaging $1,462 for those with a mortgage and $451 for those without. The median gross rent for the 134,026 occupied units paying rent is $1,219 (U.S. Census Bureau, 2022a).Crowded HousingOf the total Hispanic/Latino population in Georgia, nearly 10% live in overcrowded dwellings (Ahn et al., 2022).Crowding is a complex issue, deﬁned not merely by the number of occupants but also by the nature of their relationships, age, and gender. The dwelling’s size, layout, and condition, as well as the household members’ needs, contribute to the state of overcrowding (World Health Organization, 2018). In some instances, overcrowding can occur when occupants gather in certain rooms to escape inhospitable sections of the house or to conserve on expenses such as heating.Household crowding can lead to a range of adverse physical and mental health outcomes. For example, overcrowded homes may harbor environmental risks such as mites, roaches, and molds, which thrive in moist conditions often found in such residences (World Health Organization, 2018). These factors, along with the lack of ventilation often seen in overcrowded homes, can promote the spread of diseases such as tuberculosis and other respiratory infections. Further research by WHO on household crowding has indicated a connection between overcrowding and the prevalence of gastrointestinal diseases or parasites, suggesting that such living

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43conditions may contribute to the increased incidence of gastroenteritis and diarrheal diseases. This risk is particularly high for certain populations, including low-income families, renters, racial and ethnic minorities, individuals with physical limitations, children, and older adults (World Health Organization, 2018).Healthcare Access and QualityThe health status of Hispanic/Latino communities is inﬂuenced by their access to quality health care. These include health insurance coverage, linguistic and cultural barriers, and restricted access to healthcare services. The Hispanic/Latino population is 10% of Georgia’s total populace – the majority of which are immigrants. However, a combination of poor health care infrastructure, failure to deliver culturally competent health services, and exclusionary immigration policies result in signiﬁcant and well-documented adverse health consequences for the Hispanic/Latino population. Cost continues to be a signiﬁcant hurdle for many in the Hispanic/Latino communities when it comes to accessing healthcare. This barrier further exacerbates health disparities, illustrating the urgent need for strategies that improve healthcare access and quality for Hispanics/Latinos.According to the focus group and key informant interviews the access to quality care is a large barrier within the Latino community. Many Latinos in Georgia receive health information from people in their community, such as family members, friends, and neighbors. Information about medical experiences with providers and clinics are shared amongst each other. Few participants note that they rely on this source of information because it comes from personal experiences and from people in the Latino community who have been in the country for a longer period. Additionally, many participants report using the internet, speciﬁcally Google, to ﬁgure out what their symptoms mean and to look for resources.Hispanic/Latino populations in Georgia, especially children and adolescents, are most likely to live in over-crowded households (Solari & Mare, 2012).

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44“...with the neighbors. ‘Oh neighbor I need help with this neighbor.’ There we ﬁnd help because that person has been here for a long time and gives us the information [...] I was looking a lot for a clinic for my children, I couldn’t ﬁnd it and I told my neighbors, but they gave me some numbers that did not help me because the clinics were saturated with children. There was no medical assistance for them. […] but on Google I found a children’s clinic near me. That’s how I typed it and that’s where I took my child. But yes, Google and the same neighborhood,” Clayton Focus GroupGeorgia receive health information from people in their community, such as family members, friends, and neighbors. Information about medical experiences with providers and clinics are shared amongst each other. Few participants note that they rely on this source of information because it comes from personal experiences and from people in the Latino community who have been in the country for a longer period. Additionally, many participants report using the internet, speciﬁcally Google, to ﬁgure out what their symptoms mean and to look for resources.Other participants noted that in the past, they would use radio sources for information. Now they are using YouTube videos and general social media platforms such as Facebook. Television and newspaper news outlets were seldom mentioned by participants. Other sources of information in the community include churches, Walgreens pharmacy health clinics, Anthem insurance Sharecare digital platforms, schools, employers, and non-proﬁt organization efforts in the community. Television and newspaper news outlets were seldom mentioned as resources, with a few participants mentioning they did not have a source of information or didn’t know where to look. However, there were some drawbacks to community support when it came to information sharing, such as misinformation.

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45“During COVID, every news site would be like ‘wear your mask’. The employer would then be like ‘you don’t have to wear your mask’, and they were more likely to believe their employer than the news outlet.”“Durante COVID, todos los sitios de noticias decían como ‘usa tu máscara’. El empleador entonces diría ‘no tienes que usar tu máscara’, y era más probable que le creyeran a su empleador que al medio de comunicación”.South Georgia Focus GroupAccurate information is still inaccessible within the Latino community.Many participants describe that improper interpretation services and translated materials are often difﬁcult to understand. Furthermore, responses from the demographic survey show that 11% of participants did not know where to seek medical services in their area. These barriers are one of many reasons that negatively impact the health of Georgia Latinos.Health ServicesHealth services, including policies and programs, are vital in addressing health needs. Key elements include access, coverage, cost, quality, and performance, all of which have signiﬁcant implications for the Hispanic/Latino population in the U.S (Velasco-Mondragon et al., 2016b). The health status of Hispanic/Latino communities is signiﬁcantly inﬂuenced by their ability to access quality healthcare. Many factors contribute to this, including health insurance coverage, linguistic and cultural barriers, and restricted access to healthcare services.

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46The cost continues to be a prominent impediment for many within the Hispanic/Latino communities in terms of accessing healthcare. This factor further intensiﬁes health disparities, illustrating the pressing need for strategies that enhance healthcare access and quality for Hispanics/Latinos.Role Of Health Literacy And Cultural CompetenceThe introduction of the Affordable Care Act (ACA) marked a signiﬁcant step towards increasing health care access for Hispanic/Latinos. Statistics indicate an improvement in coverage, with insurance rates at 87% for U.S-born Hispanic/Latinos and 78% for those born outside the U.S (Velasco-Mondragon et al., 2016). Although there has been an increase in insurance coverage for Hispanic/Latinos, health literacy and culturally competent health care has not improved as much. In Georgia, an increase in the Hispanic/Latino immigrant population has emphasized the gap in culturally and linguistically tailored health and social services (Held et al., 2022).Health InsuranceThe lack of insurance coverage has broad implications on health outcomes and access to preventive care. Research has indicated that those without health insurance tend to delay seeking medical attention, have a lack of a consistent healthcare provider, and express increased worry about medical bills compared to their insured counterparts. Additionally, the uninsured are less likely to receive necessary preventive care and screening services, resulting in poorer health outcomes (Ofﬁce of the Assistant Secretary for Planning and Evaluation (ASPE), 2021).The lack of adequate health insurance coverage is a persistent issue in these communities. The ASPE report (2021) indicates that before the enforcement of the Affordable Care Act (ACA), Hispanics/Latinos were the second-largest uninsured ethnic and racial group, with over 30% uninsured. Although the ACA led to a signiﬁcant drop in uninsured rates among Hispanics/Latinos, they represented a disproportionate percentage of the uninsured population as of 2019 (Ofﬁce of the Assistant Secretary for Planning and Evaluation (ASPE), 2021). Overview Of Insurance Coverage In The United States & GeorgiaNational OverviewIn the United States, insurance coverage for health care services is offered mainly via employer-based health insurance, Medicare, or Medicaid. Employer-based private insurance is usually purchased by the employer and the employee (Artiga & Hill, 2022). Medicare insures people 65 years and older (or younger Barrier to Healthcare AccessHispanic/Latino immigrants in Georgia encounter several barriers to accessing healthcare services. These include language differences, the absence of insurance, and lack of driver's licenses. The fear of deportation also serves as a deterrent for this population in seeking health care services (Held et al., 2022).

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47than 65 with disabilities or individuals with End-Stage Renal Disease). Medicaid and the Children’s Health Insurance Program (CHIP) provide free or low-cost health coverage for some low-income people, families and children, pregnant women, the elderly, and people with disabilities.In 2020, the Census Bureau reported that in the United States, 50% of Hispanics/Latinos had private insurance coverage, as compared to 74% for non-Hispanic whites (U.S. Department of Health and Human Services (HHS) Ofﬁce of Minority Health, 2023). Among Hispanic/Latino heritage groups, examples of private insurance coverage varied: o 20% - Mexicanso 19% - Central Americanso 14% - Cubanso 8% - Puerto RicansThe ﬁndings below by (Tolbert et al., 2022) provides additional demographics of the uninsured population in the U.S.:A substantial portion of the approximately 27.5 million uninsured individuals in the U.S. are nonelderly adults, belong to working families, and come from households with low incomes. This report also reveals that six out of ten uninsured individuals are people of color.Hispanic/Latino and non-Hispanic white populations accounted for the largest percentages of the nonelderly uninsured population in 2021, at 39% and 39% respectively. Lastly, the report provides important insight into the citizenship status of the uninsured, noting that a substantial majority (77%) of uninsured individuals were U.S. citizens in 2021, while 23% were non-citizens. Overview Of Coverage In GeorgiaThe total Hispanic/Latino civilian non-institutionalized population in Georgia is 1,066,835. Below are additional statistics (U.S. Census Bureau, 2022a): Total civilian non-institutionalized Hispanic/Latino population in Georgiao 47% have private health insuranceo 29% have public coverageo 29% have no health insurance coverageMexican o 36% have private health insuranceo 31% have public coverageo 36% have no health insurance coveragePuerto Rican o 69% have private health insuranceo 29% have public coverageo 10% have no health insurance coverageOther Hispanic or Latinoo 66% have private health insuranceo 29% have public coverageo 13% have no health insurance coverage

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48Central Americano 40% have private health insuranceo 24% have public coverageo 40% have no health insurance coverageSouth American o 69% have private health insuranceo 26% have public coverageo 13% have no health insurance coverageAll available other Hispanic or Latino o 65% have private health insuranceo 29% have public coverageo 14% have no health insurance coveragePuerto Rican and South American Populations Have High Private Insurance Rates: The Puerto Rican and South American subgroups have the highest percentage of private health insurance coverage, with 69% and 69% respectively. Mexican Population Has the Highest Uninsured Rate: The Mexican population has the highest rate of no health insurance coverage at 36%. This may indicate barriers to obtaining coverage, such as lower income levels, language barriers, or immigration status.Overall High Uninsured Rate: Despite the available private and public health insurance options, a signiﬁcant percentage of the total Hispanic or Latino population in Georgia remains uninsured (29%). Hispanic/Latino Children: Medicaid & Chip: Medicaid and CHIP provide health insurance coverage to children. More than half of Hispanic/Latino children are insured via Medicaid and CHIP. Although Medicaid and CHIP assist with ﬁlling gaps in coverage for Hispanic/Latino children, they are still twice as likely as non-Hispanic white children (9% vs. 4%) to not have any form of health insurance or coverage. Cost Of Healthcare: The cost of healthcare emerged as a prominent barrier consistently highlighted by both key informants and focus group participants, signiﬁcantly impeding their access to adequate healthcare services. This sentiment was further reinforced by survey responses, wherein participants identiﬁed the main reasons preventing them from seeking care. Lack of health insurance, ﬁnancial barriers, and the high costs associated with prescription drugs emerged as the top three factors cited, underscoring the detrimental impact of healthcare expenses on individuals’ ability to pursue necessary medical attention.A participant in a focus group poignantly expressed that Latinos often refrain from seeking care at hospitals due to the lack of insurance, stemming from ﬁnancial constraints that limit their ability to afford coverage or medications. This sentiment was echoed by the survey ﬁndings, as more than half of participants indicated they did not have health insurance. The inability to afford medical services was consistently associated with high levels of stress, which has a profound impact on mental health.

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49Participants in the LGBTQIA+ Focus Group reiterated the profound impact of healthcare costs as a barrier to accessing necessary services. This group emphasized that ﬁnancial responsibilities, such as bills and other ﬁnancial obligations, have signiﬁcantly hindered their ability to afford crucial healthcare services. Furthermore, the challenges faced by immigrants in affording healthcare were underscored, as many lack the necessary resources to cover expenses due to limited ﬁnancial means. These overlapping barriers further exacerbate the healthcare disparities experienced by the Latino community, highlighting the urgent need for equitable and affordable healthcare solutions that address the speciﬁc challenges faced by diverse populations within the Latino community.Immigration Status & Health: During the community leaders’ focus group, a participant highlighted the signiﬁcant barrier to healthcare access created by the intersection of immigration status and health. They shared how immigrants often arrive in a new country without insurance or documentation, leading to their chronic health issues being inadequately addressed. In the South Georgia focus group, another participant emphasized that the majority of immigrants lack social security, rendering them ineligible for health insurance as they work under alternate names. This participant One participant mentioned that money was an issue when it came to asking for healthcare services. By stating that they, “know how much money they have, and they don’t have enough to pay for the services”, which then resulted in them not informing their family member of the need, and later affected their mental health in the process (Key Informant).further explained that this circumstance creates a dilemma for immigrants, as they struggle to decide whether to provide their legal name or alternate name to healthcare staff, ultimately hindering their access to healthcare services. Additionally, a participant disclosed that many immigrants tend to only seek medical help during emergencies, foregoing routine check-ups due to various factors. They also highlighted the lack of awareness among immigrants regarding their eligibility for healthcare services without documentation, leading them to pay out of pocket rather than utilizing available resources. These testimonies shed light on the complex challenges faced by immigrants in accessing healthcare, emphasizing the critical need for inclusive and culturally sensitive healthcare policies and practices that address the speciﬁc barriers encountered by immigrant communities.

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50Affordable Care Act & Medicaid ExpansionNationwide Overview: The Patient Protection and Affordable Care Act (ACA) was signed into law by President Obama in 2010 to improve health care access and affordability through expanded insurance coverage, Medicaid expansion, reduced healthcare costs, and improved quality of care. Overall, in the United States, uninsured rates rose until 2019; however, from 2019-2021 there were modest coverage gains for most racial/ethnic groups. The primary driver of these gains was increased Medicaid coverage resulting from policies aimed at enhancing access to affordable healthcare during the COVID-19 pandemic. States were mandated to keep Medicaid recipients enrolled throughout the COVID-19 public health emergency (PHE). As a result, the gap between people of color and non-Hispanic white individuals narrowed.However, from 2010 to 2021, the uninsured rate among Hispanic/Latino individuals remained more than 2.5 times higher than that of non-Hispanic white individuals.Medicaid Expansion In Georgia: In 2014, Georgia declined to accept federal Medicaid funds and to expand health coverage to over 676,000 low-income adults. This included over 46,000 Hispanics/Latinos. If Georgia were to A participant in a focus group poignantly expressed that Latinos often refrain from seeking care at hospitals due to the lack of insurance, stemming from ﬁnancial constraints that limit their ability to afford coverage or medications. This sentiment was echoed by the survey ﬁndings“...More than anything, sometimes it’s due to the cost of the medical service. That’s why sometimes people don’t want to go to the doctor. So you prefer to go and pay $50 for a masseuse instead of a hospital bill of a thousand a piece or more. So...the service—medical cost is more expensive here. So sometimes a lot of people prefer a household remedy or a masseuse instead.”“...Más que nada es a veces por el costo del servicio médico. Es por lo que a veces la gente no quiere ir al doctor. Entonces preﬁere ir a pagar $50 sobre una persona que soba a lo que vas a que dices que no va a llegar el bil del hospital de mil y cacho o mas. Entonces ...el servicio-el costo médico cuesta sale aquí muy más caro. Entonces, a veces mucho la gente preﬁere con remedio casero o ir con una persona que soba.”Dalton Focus Group

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51fully expand Medicaid in accordance with the Affordable Care Act (ACA), the state would receive federal funding that could provide health coverage to an estimated 600,000 to 700,000 people in the state (Norris, 2023).Despite not expanding Medicaid, total Medicaid/CHIP enrollment in Georgia increased by 58% as of September 2022, largely due to the COVID pandemic and the suspension of eligibility redeterminations (Norris, 2023). However, starting from April 2023, regular Medicaid eligibility redeterminations are expected to resume, potentially reversing the trend. Research indicates that Medicaid expansion would greatly beneﬁt people of color, as 6 in 10 newly eligible uninsured adults are people of color. Additionally, Medicaid expansion has been linked to a reduction in health coverage disparities and improved health outcomes, especially for Non-Hispanic Black and Hispanic/Latino individuals, speciﬁcally within the areas of maternal and infant health (Norris, 2023).Deferred Action For Childhood Arrivals (DACA): Deferred Action for Childhood Arrivals (DACA) is an immigration policy established by the Obama administration in 2012. The program was created to provide temporary relief from deportation and work authorization for eligible youth without immigration status who came to the United States as children. To qualify for DACA, applicants must meet speciﬁc criteria, including (1) arriving in the United States before turning 16, (2) living in the country continuously since June 15, 2007, (3) under 31 years old as of June 15, 2012, (4) enrolled in school, having a high school diploma or GED, or being an honorably discharged veteran, (5) not having a felony conviction, a signiﬁcant misdemeanor, or three or more misdemeanors, and not posing a threat to national security or public safety (KFF., 2023)Overview of the DACA-Eligible Population in the United States: Demographics of the U.S DACA-Eligible Population & Beneﬁciaries: As of 2022, there were approximately 580,000 DACA recipients in the United States (KFF., 2023). The majority of DACA recipients are from Mexico (81%), followed by El Salvador (4%), Guatemala (3%), and Honduras (2%) (Figure 4) (Migration Policy Institute, 2023).

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53Mental Health Impact: The implications of immigration policies, particularly with respect to DACA, extend beyond immediate legal concerns, permeating deeply into the realms of mental health, education, and access to essential services for children—for U.S.-citizen, documented and undocumented children. As of 2018, a staggering 4.4 million U.S.-citizen children under 18 were residing with at least one undocumented parent, while an even larger number, 6.1 million, were living with an undocumented family member (American Immigration Council, 2021). The looming uncertainty associated with the potential fallout from DACA places these children in a perpetual state of heightened fear, stress, and anxiety. This emotional burden not only affects the children but also casts a pall over their parents and extended family members. Empirical research has elucidated these concerns further. For instance, a 2020 study pinpointed a disturbing correlation in Atlanta, Georgia, where Hispanic/Latino adolescents showcased elevated rates of suicidal thoughts, alcohol consumption, and aggressive behaviors when confronted with the detention or deportation of a close family member (Roche et al., 2020).in light of such ﬁndings, it becomes evident that the negative repercussions on children’s mental health due to immigration enforcement extend well beyond immediate family separations and into long-term health outcomes and developmental trajectories.DACA and Higher Education: DACA has had a positive impact on recipients’ access to higher education. However, policies affecting access to in-state tuition, ﬁnancial aid, and scholarships vary by state (Higher Ed Immigration Portal, 2023). In Georgia, DACA recipients are not eligible for in-state tuition rates or state-funded ﬁnancial aid. Additionally, certain public colleges and universities in Georgia have policies that ban DACA students from enrolling (Higher Ed Immigration Portal, 2023).Overview Of The DACA-Eligible Population In GeorgiaThe following information focuses on Georgia’s DACA population demographic data, educational attainment, workforce participation, and economic impact.

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54Demographics of the U.S DACA-Eligible Population & Beneﬁciaries: According to the American Immigration Council’s data, Georgia is home to an estimated 36,395 individuals who meet the criteria for the Deferred Action for Childhood Arrivals (DACA) program. Out of these, approximately 19,800 are current DACA recipients, while 26,048 have been granted DACA at some point (American Immigration Council, 2020). Educational Attainment: In Georgia, the issue of education accessibility for undocumented students remains a prominent concern. Since 2008, undocumented students have faced the challenge of out-of-state tuition rates, which can be two to four times the in-state rates, putting higher education beyond the reach of many immigrant families (Muñoz & Young, 2023). Legislation, such as HB 131, known as The Opportunity Tuition Act has aimed to provide a solution. However, its scope is limited to only those who are Deferred Action for Childhood Arrivals (DACA) recipients. While this offers a more affordable college route for DACA recipients, it neglects a segment of the undocumented students who don’t qualify for DACA, thereby failing to promote education equity in the state (Muñoz & Young, 2023).Considering that Georgia sees an average annual high school graduation rate of 3,000 undocumented and DACA students and incurs a state expenditure of approximately $6,000 per student, there’s a pressing need to ensure equal opportunity in education. If Georgia expanded opportunity tuition to all undocumented students, it would not only enhance its return on investment in the K-16 education system but would also emphasize the state’s commitment to educational equity (Muñoz & Young, 2023). The existing measures, however, don’t quite achieve this, highlighting a need for comprehensive educational reforms.Workforce Participation: The DACA-eligible population in Georgia is an essential part of the state’s workforce. Approximately 95% of the DACA-eligible individuals in the labor force are employed (American Immigration Council, 2020). Economic Impact: The DACA-eligible population in Georgia has a signiﬁcant impact on the state’s economy. Their total household income amounts to $796 million. They contribute to the state’s tax revenue by paying $171 million in total taxes, which includes $94 million in federal and $78 million in state and local taxes. The total spending power of the DACA-eligible population is estimated at $624 million (American Immigration Council, 2020)Temporary Protected Status (TPS)Another important immigration program that provides temporary immigration status is Temporary Protected Status (TPS). The Department of Homeland Security Secretary can designate countries with TPS if the country is deemed unsafe due to ongoing armed conﬂict or environmental disasters. Once granted TPS, foreign nationals from the designated country are eligible for a work authorization card, social security number, and driver’s license. In 2020, the Trump administration tried to end TPS, a decision

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55that has since been in court litigation. The TPS program was scheduled to end on June 30, 2024, for TPS holders from El Salvador, Haiti, Honduras, and Nicaragua. However, the Biden administration renewed TPS designation for TPS holders from El Salvador, Honduras, and Nicaragua among other countries (Moslimani, 2023). Venezuela was designated TPS on March 9, 2021, and is set to expire on March 10, 2024 (Moslimani, 2023)The following information focuses on Georgia’s TPS population (Center for American Progress, 2017)8,200 TPS holders from El Salvador and Honduras reside in Georgia.6,100 TPS holders work in Georgia.Nearly $296 million would be lost from Georgia’s Gross Domestic Product each year without workers from El Salvador and Honduras who hold TPS status. Both DACA and TPS show the power that protections for immigration status have on the national and state economies.Healthcare challenges and cultural considerationsLanguage & Acculturation BarriersLanguage access is a critical national issue as healthcare systems aim to address disparities in healthcare for patients of diverse racial, ethnic, and linguistic backgrounds. Effective language access services enable individuals with limited English proﬁciency (LEP) to access a broader range of healthcare services safely.For instance, a study of two urban hospitals found that LEP patients with no access to interpreter services during their initial emergency department visit were 1.47 times likelier to be readmitted within 30 days compared to those who received interpreter services (Karliner et al., 2010). Furthermore, LEP patients without professional interpreter services experienced a longer adjusted length of stay, with an increase of 0.75 days compared to English-speaking patients (Karliner et al., 2010).Deﬁning Limited English proﬁciency (LEP): LEP refers to individuals who cannot speak, read, or write English at the level necessary for effective communication with healthcare providers. Language access comprises various services that may be provided to Hispanic/Latino patients’ perception of their healthcare providers’ communication skills varies based on their level of English proﬁciency, underscoring the importance

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56Although often misclassiﬁed under the overarching Hispanic/Latino umbrella, the Maya people, in fact, embody a distinct Indigenous group originating from countries like Guatemala, whose primary languages include a variety of Mayan dialects, with Spanish often being a second or even third language (Kennesaw State University, n.d.). This misclassiﬁcation is largely rooted in the societal misconceptions and lack of in-depth understanding about the rich cultural diversity within the Latino demographic, especially in relation to Indigenous populations from Latin America.This information could be useful for policymakers, educators, and community organizations in Georgia to better understand and serve the linguistic needs of the Hispanic/Latino population, particularly regarding English language learning programs and services.of providing culturally sensitive healthcare. Healthcare organizations can demonstrate their commitment to improving the healthcare experience for Hispanics/Latinos by offering cultural competency training programs to providers and offering interpretation services for patients. Increasing the representation of minorities in clinical education programs is essential to building a diverse medical workforce, which will provide Hispanic/Latino patients with more providers who speak their language, resulting in more satisfactory clinical interactions.LEP individuals to guarantee equitable access to healthcare services. Language access services include oral interpreting, written translations, provision of services in a non-English language, and taglines (Youdelman, 2019).Linguistic Diversity And English Proﬁciency Within The Hispanic/Latino Population In GeorgiaThe U.S Census Bureau (ACS, 2021), reports that most of the Hispanic/Latino population in Georgia, irrespective of country of birth, speaks a language other than English at home. The ability to speak English “very well” is higher among those born in the United States compared to those born outside of the United States. Spanish is the most common language spoken at home among Hispanic/Latino people in Georgia, with a notable proportion of the population also reporting various levels of English proﬁciency.When needed language support is not available, the risk of patient harm increases signiﬁcantly. Research indicates that patients with LEP are at a greater risk of experiencing negative health outcomes resulting from communication errors compared to English-speaking patients.

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57Language Proﬁciency Analysis In GeorgiaAnalysis of both 2021 American Survey data tables: Nativity by Language Spoken at Home by Ability to Speak English for the Population 5 Years and Over (Hispanic or Latino) and Language Spoken at Home by Ability to Speak English for the Population 5 Years and Over (Hispanic or Latino) revealed the following:Nativity By Language Spoken At Home By Ability To Speak English (U.S. Census Bureau, 2022b)·Out of the 950,298 Hispanics/Latinos in Georgia who are 5 years or older, 57% (544,807) were born in the United States and 43% (405,491) were born outside the United States.(Native) Among those born in the United States, 37% (202,231) speak only English, and 63% (342,576) speak another language. Of those speaking another language, 81% (277,361) report speaking English “very well,” and 19% (65,215) report speaking English less than “very well.”(Foreign-born) Among those born outside the United States, only 6% (23,879) speak only English, while 94% (381,612) speak another language. Of those speaking another language, 33% (126,071) report speaking English “very well,” while 67% (255,541) report speaking English less than “very well.” Language Spoken At Home By Ability To Speak English (U.S. Census Bureau, 2022b)Of the total Hispanic/Latino population aged 5 and older in Georgia, 24% (226,110) speak only English, 76% (718,357) speak Spanish, and 1% (5,831) speak another language.Among those who speak Spanish, 56% (399,987) report speaking English “very well,” 20% (143,329) speak English “well,” 17% (120,088) speak English “not well,” and 8% (54,953) do not speak English at all.Language Access In GeorgiaSince 2003, the National Health Law Program has conducted multiple 50-state surveys to assess statutes and regulations pertaining to language access in healthcare; the most recent was conducted in 2018. As of 2019, all states in the United States have passed laws on language access, but there is signiﬁcant variation in the number of provisions between states, highlighting the need to make further progress in ensuring that patients can communicate effectively during healthcare encounters (Youdelman, 2019). While some states have robust laws and regulations in place that ensure the provision of language assistance services, others have limited or no speciﬁc regulations for language access. Georgia has only 3, the lowest of all states (Table 7).

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58Language & Translation Services Language differences emerged in the qualitative study as a signiﬁcant barrier for Latinos seeking adequate healthcare, according to both key informants and focus group participants. Both key informants and focus group participants reported a lack of Spanish-speaking healthcare staff, particularly in mental health, dental, and specialized services, especially in rural areas of Georgia. Participants expressed that language barriers deter them from seeking healthcare as they fear not being understood, taken seriously, or effectively helped. Language differences emerged in the qualitative study as a signiﬁcant barrier for Latinos seeking adequate healthcare, according to both key informants and focus group participants. Both key informants and focus group participants reported a lack of Spanish-speaking healthcare staff, particularly in mental health, dental, and specialized services, especially in rural areas of Georgia. Participants expressed that language barriers deter them from seeking healthcare as they Many mentioned the need to wait for someone to accompany them for translation, leading to delayed carefear not being understood, taken seriously, or effectively helped. “He was born in ‘54, so he is older and I am taking him to his primary doctor, but his doctor does not speak Spanish and he gets frustrated that if I am not available to go, he has to move the appointment or cancel the appointment because [...] there isn’t a Spanish-speaking doctor in the area.”“Él nació en el 54, es mayor edad y lo estoy llevando a su doctor primario, pero su doctor no habla español y se frustra de que si yo no estoy disponible en ir, tiene que mover la cita o cancela la cita porque [...] no hay un doctor que habla español en el área”. South Georgia Focus group Legal obligations: Healthcare providers/systems have legal obligations under federal law, such as Title VI of the Civil Rights Act of 1964, to ensure language access for LEP individuals.

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59Due to language differences patients may not understand their illness or treatment, and seeking healthcare can be difﬁcult without English proﬁciency. Spanish-speaking clinics are often too expensive, and affordable clinics may lack translation services. Participants also reported little to no translation services available to help them understand speaking, reading, or writing regarding their healthcare information and paperwork.Language factors were cited as a barrier when receiving information as well. Language barriers can pose signiﬁcant challenges for Georgia Latinos in understanding health information, leading to reduced access to quality healthcare and potential disparities in health outcomes. Participants indicated factors such as literacy levels, complicated language in information sources and resources, lack of inclusivity of native languages, and lack of resources to facilitate translation.“[...] language. Um, sure we do everything in English and Spanish, but like, if you, if you examine our communities, um, some folks may speak Spanish, but they might not write it or read it. Or some folks they speak Spanish, but really it’s their second language because the ﬁrst language [...]it’s one of the other dialects”“el idioma... seguro que hacemos todo en inglés y español, pero si examinas nuestras comunidades, algunas personas pueden hablar español, pero es posible que no lo escriban o lo lean. O algunas personas hablan español, pero realmente es su segundo idioma porque el primer idioma[...] es uno de los otros dialectos”.Key Informant

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60When discussing translation services, participants consistently highlighted the severe shortage of available services within health clinics, hospitals, and mental health settings. Additionally, participants expressed concerns about the effectiveness of translation due to the linguistic diversity within the Spanish language itself, making accurate translation challenging. While some participants reported positive experiences with translation services, others encountered difﬁculties, such as instances where translators failed to accurately convey their symptoms or misunderstood doctors’ instructions, ultimately hindering their comprehension and ability to receive appropriate care. These experiences underscore the critical need for improved and culturally competent translation services to ensure effective communication and understanding in healthcare settings.Another signiﬁcant challenge raised regarding translation services was the potential impersonal and intimidating nature of relying solely on technological methods for translation. Several participants drew comparisons with translation services in schools, emphasizing their success and superiority compared to those available in medical settings. In addition, one participant emphasized the importance of using simple and commonly understood Spanish language when providing verbal translations and information resources, highlighting the need for accessible and culturally appropriate language in healthcare settings to ensure effective communication and comprehension. These insights shed light on the crucial role of human interaction and tailored language services in promoting meaningful and inclusive healthcare experiences for the Latino community.The lack of translation services leads participants to seek alternative translating methods. A participant recounted that when they reach out to someone in the community to translate, it’s expensive and may lead them to pick between other ﬁnancial responsibilities“[...] when you know a little English, you understand that he is not translating you well.[...] he does not explain your pain well and what he is talking about. [...] sometimes I understand well that the translator is not translating me well [...] that was not what I said.”“[...] cuando tú sabes poquito inglés, tú entiendes que él no te está traduciendo bien.[...] No explica bien tu dolor y lo que está hablando. [...]. A veces yo entiendo bien que el traductor no me está traduciendo bien [...] eso no fue lo que yo dije”. Cobb Focus Group

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61Many participants often reported that their children would be their translators at their appointments. People who have children noted they at least have access to a potential translator and someone to facilitate ﬁlling out forms. More often than not participants reported that their children may not know how to translate correctly because they don’t speak Spanish ﬂuently. Without prompting, participants reported unintended effects of using children as translators. They acknowledged the difﬁculty for a child to translate healthcare language and therefore misunderstanding healthcare instructions, potential for family issues and mental health impacts, school absences, delaying healthcare or parents opting out of seeking healthcare completely. “Even when it comes to going to the doctor’s ofﬁce, I don’t really think people really know how difﬁcult a doctor’s ofﬁce visit can be. [...] thankfully my parents, they had me to translate, but even that was a battle to go to the doctor because it’s like, they had to wait to go on a day that I didn’t have school, or it’s like I would have to skip school to go translate for them... and then it’s like they couldn’t, they couldn’t go alone because they didn’t understand the papers cuz the papers was just like a lot of words and it was really difﬁcult to understand. And it, like, that made them just not wanna go to the doctor […]”“Incluso cuando se trata de ir al consultorio del médico, realmente no creo que la gente sepa lo difícil que puede ser una visita al consultorio del médico. [...] afortunadamente mis padres me hicieron traducir, pero incluso eso fue una batalla para ir al médico porque es como si tuvieran que esperar para ir un día que no tenía escuela, tendría que faltar a la escuela para ir a traducir para ellos... y no podrían ir solos porque no entendían los papeles porque [en] los papeles eran como muchas palabras y era realmente difícil de entender. Y eso hizo que simplemente no quisieran ir al médico [...]”.Key Informant

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63Healthcare Practitioners And Technical OccupationsOut of the 9,808 professionals employed in healthcare practitioners and technical occupations across the country in 2022, Hispanic or Latino representation stood at a mere 9.3% (U.S. Bureau of Labor Statistics, 2023). Given the signiﬁcant population of the Hispanic/Latino community nationwide, this percentage is notably low. Conversely, non-Hispanic white individuals constituted the majority in this sector at 74.4%. Such data exposes a substantial gap in the representation for Hispanic/Latino individuals in the more specialized tiers of the healthcare profession.Nursing Representation in Georgia: The racial composition of the Georgia nursing workforce has not changed much over a decade. According to the Georgia Nurse Workforce report by Nell Hodgson Woodruff School of Nursing (2020), in 2009 1.4% of nurse were Hispanic/Latinas. A decade later in 2018, only 2.4% of Georgia nurses were Hispanic/Latinas. Nursing Workforce:63.1% non-Hispanic white28.9% non-Hispanic Black 3.23% Asian 2.4% Hispanic/Latino nurses (1.44% vs 2.35%)2.4% belong to other racesHealthcare Support OccupationsThe landscape shifts slightly in healthcare support roles. From the 4,930 individuals employed in this sector, 21.3% identiﬁed as Hispanic or Latino (U.S. Bureau of Labor Statistics, 2023). Though an improvement from the technical ﬁelds, the representation remains disproportionate when juxtaposed against the 62.6% of non-Hispanic white individuals.Physician Representation In GeorgiaIn 2022, the Georgia Board of Health Care Workforce released a report on the distribution of Physicians in the state by race and ethnicity (Georgia Board of Health Care Workforce, 2022). Utilizing the 2019-2020 licensure renewal and new licenses data, the following results were observed:2020 Georgia Physician Proﬁle (Georgia Board of Health Care Workforce, 2022):Total of 24,914 physicianso 44.6% non-Hispanic whiteo 11.5% non-Hispanic Blacko 3.6% Asiano 3.6% Hispanic/Latinoo 0.6% belong to other raceso 39.6% had missing race dataThere is a pronounced underrepresentation of Hispanic/Latino nurses across Georgia counties, especially when considered in relation to the size of the Hispanic/Latino population in these areas. This disparity is more pronounced in rural areas, leading to potential healthcare access challenges for Hispanic/Latino residents. Policies aimed at encouraging more Hispanic/Latino nurses to practice in these underserved areas could help to address this disparity and improve healthcare access.

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64Relationship With The U.S. Health Care SystemHispanic/Latino Values & AgingHispanic/Latino cultural values have an impact on the aging experience, particularly “familismo” or “familism.” This value places emphasis on the expectation that elderly Hispanics/Latinos will be cared for by their own family members rather than hired health care providers. Another value, “personalismo,” highlights the signiﬁcance of building relationships founded on mutual trust and respect. Religious beliefs can also have a signiﬁcant inﬂuence on many Hispanics/Latinos and may therefore shape healthcare priorities and decisions (Samper-Ternent et al., 2022).“Hispanic/Latino Paradox” The theory of the Hispanic/Latino paradox suggests that despite having lower socioeconomic status on average, Hispanic/Latino individuals tend to have better health outcomes than their Non-Hispanic White counterparts (Garcia et al., 2017). This phenomenon has also been referred to as the “Healthy Immigrant Effect,” which proposes that those who choose to migrate to the United States are generally healthier and more physically ﬁt. Cultural factors such as healthier lifestyle behaviors and strong family support systems may contribute to the greater better health outcomes for Hispanic/Latino individuals. Pandemic: Health & Sdoh Projections The COVID-19 pandemic spotlighted existing health disparities and inequities among the Hispanic/Latino communities, particularly related to social determinants of health. Data from the Centers for Disease Control and Prevention (CDC) indicate that Hispanic/Latino individuals are nearly three times more likely to be hospitalized due to COVID-19 compared to non-Hispanic white individuals. Additionally, Hispanic/Latino individuals have experienced higher rates of job loss and food insecurity during the pandemic, which negatively impact physical and mental health. Other social determinants of health, such as language barriers and immigration status, have also impacted the Hispanic/Latino community’s access to healthcare and COVID-19 prevention and economic relief resources.Covid-19 Pandemic-Related Health Disparities And Inequities Among The Hispanic/Latino Community In The United States:·Hispanic/Latino individuals are 2.8 times more likely to have a COVID-19 hospitalization compared to non-Hispanic white individuals (Saksa & Macagnone, 2020)·Hispanic/Latino individuals are 2.3 times more likely to die from COVID-19 compared to non-Hispanic white individuals (Paz et al., 2022). The pandemic disproportionately impacted Hispanic/Latino individuals in terms of economic and social consequences. Many Hispanic/Latino individuals in Georgia work in essential industries such as agriculture, food processing, and healthcare, putting them at increased risk of exposure to COVID-19. Widespread job loss and ﬁnancial insecurity has hit the Hispanic/Latino community particularly hard across the United States (Noe-Bustamante et al., 2021).

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65Covid-19 Racial/Ethnic Disparities And Hospitalization In GeorgiaIn a comprehensive study undertaken by (Lobelo et al., 2021), researchers delved into the racial disparities observed in COVID-19 outcomes among 5,712 members of Kaiser Permanente Georgia (KPGA). Spanning from early March to late October 2020, the study aimed to delve into the effects of socio-demographic factors, existing health conditions, and social determinants of health on COVID-19 outcomes. Distinct patient outcomes, such as hospitalization (experienced by 14.4% of patients), ICU admission, and readmission rates, were studied. Despite having insurance and access to high-quality care within an integrated healthcare system, non-Hispanic Black and Hispanic/Latino KGPA members were disproportionately affected by COVID-19, leading to a higher risk of hospitalization. Key ﬁndings from the study for the Hispanic/Latino KPGA patients include:Demographics: Hispanic/Latino patients, who made up 8.5% of the total sample, had 60% higher odds of hospitalization than the reference group (non-Hispanic white). For each additional year of age, the odds of hospitalization for Hispanic/Latino patients increased by 5%. Female Hispanic/Latino patients had about 61% lower odds of hospitalization compared to male patients.Social Determinants: Living in high unemployment zip codes increased the odds of hospitalization by 11%.Comorbidities: Patients with Chronic Obstructive Pulmonary Disease (COPD) had more than 4.0 times the odds of hospitalization. Those with Congestive Heart Failure (CHF) had more than 2.5 times the odds of hospitalization.Quality of Care Metrics: Poor diabetes control, as indicated by an uncontrolled HbA1c>8%, increased the odds of hospitalization for Hispanic/Latino KPGA patients nearly 6.0 times.Lifestyle Behaviors: Physical inactivity, deﬁned as self-reported weekly exercise <10 min, increased the odds of hospitalization for this group by 45%.Findings from this study underscored the increased hospitalization odds faced by non-Hispanic Black and Hispanic/Latino KFGA patients compared to their non-Hispanic white counterparts. Additionally, the research emphasized the signiﬁcance of considering metrics related to quality of care, lifestyle behaviors, and social determinants of health when devising strategies to tackle these racial disparities in COVID-19 outcomes.Overall, the impact of COVID-19 on the Hispanic/Latino community in Georgia underscores the urgent need for targeted interventions and policies to address the underlying health and social inequities that contribute to these disparities.

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67Mortality & Morbidity of the Hispanic/Latino PopulationMorbidity & Mortality Rates/AnalysisThe mortality and morbidity rates of the Hispanic/Latino population in Georgia vary depending on the health conditions and demographic factors. This section will focus on the mortality and morbidity rates based on available data. It is important to note that these rates can vary depending on subgroups within the Hispanic/Latino population. Additionally, social determinants of health, such as access to healthcare and socioeconomic status, can impact morbidity and mortality rates among Hispanics/Latinos in Georgia.Mortality Rates and Analysis of Hispanics/Latinos in GeorgiaThe data in Figure 5 present a 5-year change (2016-2020) in mortality rates among Hispanics/Latinos in Georgia for various causes of death, provided by the National Institute on Minority Health and Health Disparities (NIMHD) (National Institute on Minority Health and Health Disparities, 2023). The increased death rates in most of the categories indicates that the health of the Hispanic/Latino community in Georgia has generally been declining over the past ﬁve years. The most signiﬁcant increases were seen in Alzheimer’s disease and Homicide & Legal Intervention. Only pneumonia and chronic lower respiratory disease has declined.Figure 5Hispanic/Latino Mortality 5-Year Rate Changes, Georgia, 2016-2020 Note. Pulse: An Ecosystem of Minority Health and Health Disparities Resources. National Institute on Minority Health and Health Disparities Available from https://hdpulse.nimhd.nih.gov. *Note* The data source provides a note that inconsistencies in race identiﬁcation and undercounts in census data can affect statistics for minority groups, which is an important factor to consider when interpreting this data.5- Year Rate Changes - Mortality For GeorgiaHispanic/Latino (Any Race), Both Sexes, All Ages, 2016-2020

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68Between 2016 and 2020, death rates among Hispanic/Latino individuals showed variations across Georgia counties (Figure 6). The statewide average age-adjusted death rate for this demographic in Georgia stood at 415.1 per 100,000. This is approximately 28% lower than the U.S. average of 575.4 for the same group. In comparison to the White non-Hispanic population, the Hispanic/Latino death rate in Georgia was roughly half, representing a 49% lower rate (rate ratio: 0.51), which might suggest better health outcomes or other factors promoting longevity in this group. Tift County trailed closely with a rate of 635.9, marking a 53% increase from the state average. On the other hand, Long County and Glynn Zooming into speciﬁc counties, Tattnall County posted the highest death rate at 701.2 per 100,000. This is about 69% higher than the state average for Hispanic/Latino individuals. Figure 6All Causes of Death Rates for Georgia by CountyNote. HDPulse: An Ecosystem of Minority Health and Health Disparities Resources. National Institute on Minority Health and Health Disparities. Created 5/20/2023. Available from https://hdpulse.nimhd.nih.gov

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69County exhibited signiﬁcantly lower rates at 336.3 and 331.4 per 100,000, respectively. This means they had death rates that were roughly 19% and 20% below the state average. Additionally, certain counties like Newton County and Lowndes County maintained stable death rate trends, while others, such as the entire state of Georgia, the U.S., Tift County, and Columbia County, witnessed upward trends. Mortality Rates And Analysis Of Hispanics/Latinos In The United StatesWhen looking at the mortality rates among Hispanics/Latinos in the United States from 2016 to 2020, a range of trends can be found that provide a complex yet informative picture. These patterns (Figure 7) span across various diseases, each with their unique trajectory, contributing to an overall landscape of health within this population. Delving into these trends enables us to better comprehend the health dynamics of the Hispanic/Latino community in the United States.Figure 7Hispanic/Latino Mortality 5-Year Rate Changes, United States, 2016-2020 Note: The data source provides a note that inconsistencies in race identiﬁcation and undercounts in census data can affect statistics for minority groups.5- Year Rate Changes - Mortality For United StatesHispanic/Latino (Any Race), Both Sexes, All Ages, 2016-2020

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70A Comparative Breakdown & Analysis Of The 5-Year Rate Changes In Mortality For The Hispanic/Latino Population In The United States And Georgia Between 2016-2020When discussing health outcomes, geographical comparisons often reveal critical insights. This data analysis compares the 5-year changes (2016-2020) in mortality rates for diverse causes among the Hispanic/Latino population in the United States as a whole, versus Georgia. Through a comparative analysis using metrics such as Average Annual Percent Change (APC) and conﬁdence intervals, we can identify trends in the unique health challenges faced by the Hispanic/Latino population in Georgia when compared to the wider US Hispanic/Latino population. Key Points (Figures 6 & 7) All Causes of Death: The mortality rate for all causes of death increased in both the U.S. and Georgia. However, the increase was steeper in the U.S. (7.5%) compared to Georgia (4.3%). Pneumonia: The U.S. saw a signiﬁcant decrease in pneumonia-related mortality (-4.1%) which indicates successful management or prevention strategies at a national level. However, in Georgia, the decrease was smaller (-1.7%), suggesting that the strategies or conditions leading to decreased pneumonia mortality in the U.S. overall may not be as effective in Georgia.Chronic Lower Respiratory Disease: The U.S. saw a signiﬁcant decrease in mortality rates (-1.4%), indicating effective disease management or prevention at the national level. However, in Georgia, the decrease was minimal (-0.3%).Cerebrovascular Diseases: Both the U.S. and Georgia saw an increase in mortality rates for cerebrovascular diseases, but the increase was signiﬁcantly larger in the U.S. (1.8% compared to 0.6% in Georgia).

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71Septicemia: Interestingly, while the U.S. saw a signiﬁcant decrease in septicemia mortality (-3.8%), Georgia experienced a slight increase (0.8%), though not statistically signiﬁcant. Diabetes Mellitus: Both the U.S. and Georgia saw an increase in diabetes-related mortality, with the increase being signiﬁcantly higher in the U.S. (4.5% compared to 1.8% in Georgia). This suggests an ongoing struggle in managing diabetes at both state and national levels.Heart Disease: Heart disease mortality rates slightly increased in both the U.S. (0.8%) and Georgia (1.9%). Heart disease mortality rates remained relatively stable over this period in both regions.Upon comparing the 5-year mortality rate changes from 2016 to 2020 for Hispanics/Latinos in both the United States and Georgia, interesting disparities and similarities emerge. For both regions, the mortality rates due to Alzheimer’s Disease, Suicide & Self-Inﬂicted Injury, and Accidents & Adverse Effects have shown an increase, highlighting the growing health issues in these areas. The United States’ data also show an alarming rise in the mortality rate due to Inﬂuenza, at 9.6% APC, which is not reﬂected in Georgia’s data. Furthermore, while the all-cause mortality rate shows increase in both regions, the rise is notably steeper for the United States at 7.5% compared to Georgia’s 4.3% (National Institute on Minority Health and Health Disparities, 2023)Life Expectancy Life expectancy ﬁgures have consistently demonstrated a gap between non-Hispanic white populations and various minority groups, including the Hispanic/Latino community. Throughout the past decade, concerted public health efforts had been slowly reducing these life expectancy disparities, with the gap between Hispanic/Latino and non-Hispanic white populations narrowing over time. However, the years 2020 and 2021 saw a reversal of this trend, attributable in part to the disproportionate impact of the COVID-19 pandemic and related complications on these communities (Arias et al., 2022)Overall Life Expectancy In The United StatesA signiﬁcant revelation of the 2021 data was the decline in overall life expectancy in the US. The estimate dropped from 77.0 years in 2020 to 76.1 years in 2021, which is a notable 0.9 years decrease (Arias et al., 2022). This reduction was pronounced among males, with a decrease of 1.0 years, from 74.2 years in 2020 to 73.2 years in 2021. Females saw a smaller but still signiﬁcant reduction of 0.8 years, from 79.9 years in 2020 to 79.1 years in 2021. COVID-19, along with other causes, contributed to this overall decline, which is the most signiﬁcant life expectancy drop in recent years.Life Expectancy in the United States: Hispanic/Latino vs. Non-Hispanic Groups (Arias et al., 2022): For the Hispanic/Latino population, life expectancy decreased by 0.2 years from 77.9 years in 2020 to 77.7 years in 2021. Despite this reduction, the Hispanic/Latino population had higher life expectancy than

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72non-Hispanic hola (76.4 years) and non-Hispanic Black populations (70.8 years). The primary causes of the decreased life expectancy across all racial and ethnic groups were COVID-19 and unintentional injuries. Cause-Speciﬁc Mortality Impact on Life Expectancy for Hispanics/Latinos in the United States (Arias et al., 2022): The changes in life expectancy are inﬂuenced by cause-speciﬁc mortality rates. In the Hispanic/Latino population, the decrease in life expectancy was primarily due to increases in mortality due to unintentional injuries (31.2%), COVID-19 (25.5%), chronic liver disease and cirrhosis (5.1%), homicide (4.8%), and suicide (2.8%). Decreases in mortality rates for heart disease (36.8%), inﬂuenza and pneumonia (22.8%), diabetes (12.4%), Alzheimer disease (12.2%), and chronic lower respiratory diseases (9.8%) offset some of these declines.Overall Life Expectancy, Life Expectancy By Race/Ethnicity In The United States And GeorgiaTable 8 includes Life Expectancy data from the CDC’s National Center for Health Statistics (NCHS): Provisional Life Expectancy Estimates for 2021 in the United States (Arias et al., 2022) and National Equity Atlas (National Equity Atlas [NEA], n.d.).Table 8Life expectancy in the United States and Georgia, categorized by race/ethnicity and sex, 2020, 2021Note. U.S Life Expectancy data from the CDC’s National Center for Health Statistics (NCHS): Provisional Life Expectancy Estimates for 2021 in the United States (Arias et al., 2022). Georgia data from National Equity Atlas’ (NEA) statistical analysis from CDC Centers for Disease Control and Prevention, CDC WONDER, https://wonder.cdc.gov/. According to NEA, the estimated life expectancy at birth based on abridged life tables constructed from mortality data by race/ethnicity and gender. The “years above average” measure in the ranking and map breakdowns reports the difference in life expectancy between a given racial/ethnic group and the overall population in a given geography. Data for each year represents an average over the previous ﬁve years (e.g., 2020 is a 2016-2020 average) (National Equity Atlas, 2023)

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73As depicted in Table 8, the life expectancy ﬁgures provide a clear overview of different racial and ethnic groups in both Georgia and the broader United States. In Georgia for 2020, the Hispanic/Latino community holds the top spot in life expectancy at 82.6 years. They are followed by non-Hispanic white people at 77.4 years, and Non-Hispanic Black individuals trail at 75.0 years. On the national stage in 2021, distinct variations are evident both within and between different racial and ethnic categories. Hispanic/Latino females lead the life expectancy metrics at 85.3 years, while non-Hispanic Black males record the shortest life expectancy at 69.1 years. These disparities underscore the diverse health realities faced by different communities in both Georgia and the broader United States, which are crucial for informing targeted healthcare strategies and interventions.Cardiometabolic Health In The Hispanic/Latino PopulationCardiometabolic diseases refer to a group of conditions that affect both the heart and metabolic systems, including disorders related to blood sugar, cholesterol, and blood pressure. Cardiometabolic diseases are a major health concern for the Hispanic/Latino population in the United States as well as a signiﬁcant health concern in the Hispanic/Latino community in Georgia. It’s important to note that these cardiometabolic diseases often occur together and share common risk factors such as unhealthy diet, physical inactivity, and obesity. The cardiometabolic diseases that most affect this population at both the national and state level include obesity, diabetes, hypertension, and cardiovascular disease. Below are statistics from the America’s Health Rankings (AHR) analysis of CDC, 2021 Behavioral Risk Factor Surveillance System (United Health Foundation, 2021)Obesity ▪US: The obesity rate among Hispanic/Latino adults in the United States was around 37%, higher than the rate for non-Hispanic white adults, 32%.▪ GA: The obesity rate among Hispanic/Latino adults in Georgia in 2021 was nearly 33%, which was higher than the rate for non-Hispanic white adults in Georgia at over 30%.Diabetes▪ US: Hispanic/Latino adults in the United States are slightly more likely to develop diabetes than non-Hispanic whites. In 2021, the prevalence of diagnosed diabetes among Hispanic/Latino adults in the United States was slightly over 12% compared to over 10% among non-Hispanic white adults.▪ GA: Hispanic/Latino adults in Georgia are less likely to develop diabetes than non-Hispanic whites. In 2021, the prevalence of diagnosed diabetes among Hispanic/Latino adults in Georgia was 6%, compared to 12% among non-Hispanic white individuals.Hypertension ▪U.S.: Hispanic/Latino adults in the United States have a lower prevalence of hypertension than non-Hispanic whites. In 2021, the prevalence of hypertension among Hispanic/Latino adults in the United States was over 24%, compared to approximately 35% among non-Hispanic white adults. ▪GA: Hispanic/Latino adults in Georgia

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74have a lower prevalence of hypertension than non-Hispanic whites. In 2021, the prevalence of hypertension among Hispanic/Latino adults in Georgia was 22%, compared to approximately 38% among non-Hispanic whites.Cardiovascular disease ▪ U.S.: Cardiovascular disease, including coronary artery disease and stroke, is a leading cause of death among Hispanic/Latino adults in the United States. However, in 2021, Hispanic/Latino adults in the United States had a lower prevalence of cardiovascular diseases than non-Hispanic whites at over 5% vs. 9.4%. ▪ GA: In 2021, Hispanic/Latino adults in Georgia had a lower prevalence of cardiovascular diseases than non-Hispanic whites at 5.4% vs. 10%. Obesity: Obesity is deﬁned as a body mass index (BMI) of 30 or more. The risk factors include genetic and biological attributes, poor nutrition, minimal physical activity, medications, sleep deﬁciency, stress, and environmental factors, such as access to healthy food, and safe spaces for physical activity. The prevalence of obesity among Hispanic adults in Georgia increased from 26% in 2011 to 33% in 2020 (Figure 8).Figure 8Prevalence of Obesity by Race/Ethnicity in Georgia, 2011-2021Note From United Health Foundations, America’s Health Rank-ings, 2021 America ’s Health Rankings gets their(obesity) data from CDC, BRFSS, 2020)

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75Type 2 Diabetes: Diabetes mellitus is deﬁned as the inability to maintain healthy blood glucose levels. In the case of type 2 diabetes, the body fails to use insulin well. The risk factors for type 2 diabetes include having prediabetes, being overweight, being 45 years or older, and participating in minimal physical activity. The complications of excess blood sugar in the bloodstream can include heart disease, vision loss, kidney disease, lower-limb amputation, and stroke (Morales et al., 2020). National Diabetes DataGeorgia is not considered one of the states with the highest age-adjusted diabetes death rates (Figure 9) The state of Georgia falls between the range of 21.86 to 26.72 for age-adjusted diabetes death rates, the second-lowest category of mortality rates.Figure 9Diabetes Mortality by State, 2020Note. Diabetes Mortality by State, 2020. Source: CDC, WONDER, 2020.DIABETES MORTALITY BY STATEWashingtonOregonMontanaIdahoWyomingNevadaUtahColoradoNew MexicoArizonaCaliforniaNebraskaIowaKansasNorth DakotaSouth DakotaMinnesotaWisconsinIllinoisMissouriArkansasOklahomaTexasLouisianaMississipiAlabamaGeorgiaSouthCarolinaNorth CarolinaVirginiaTennesseKentuckyWestVirginiaPennsylvania NewJerseyMarylandDelawareConnecticutRhodeIslandMassachussettsNewHamshireMaineVermontNew YorkFloridaMichiganIndianaOhioHawaiiAlaska

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76In 1996, the age-adjusted death rate of diabetes for Hispanics/Latinos in Georgia was 13 per 100,000 individuals. In 2020, the age-adjusted diabetes death rate for Hispanics/Latinos in Georgia was 19 per 100,000 individuals (Figure 10). In 2020, the diabetes death rate for non-Hispanic Black people in Georgia was 40 per 100,000. Non-Hispanic white and Hispanic/Latino in Georgia had similar age-adjusted diabetes death rates (Figure 11)19940.05.010.015.020.019951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020Figure 10Age-Adjusted Deathh rate of diabetes among georgia hispanics/latinos, 1994-2020Figure 11Note. Created from OASIS, 2022Note. Created from OASIS, 2022Diabetes Trends in Georgia

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77HypertensionHypertension, commonly known as high blood pressure, represents a condition characterized by blood pressure consistently above the normal spectrum. Persistent elevations in blood pressure may lead to a clinical diagnosis of hypertension. The severity of one’s blood pressure levels can increase the risk for other health issues like heart disease, heart attack, or stroke (Centers for Disease Control and Prevention, 2021b).A Comparative Breakdown & Analysis of Hypertension by Race/Ethncity United States (Figure 12): While hypertension remains a prominent public health concern nationally, research reveals that Hispanic/Latino adults have a comparatively lower incidence of this condition than their non-Hispanic white counterparts. The prevalence of hypertension among Hispanic/Latino adults in the United States stood at 24%, lower than 35% reported for non-Hispanic whites and the 43% among non-Hispanic Black individuals (United Health Foundation, 2021) GEORGIA (Figure 12): In the state of Georgia, the prevalence of hypertension among Hispanic/Latino adults (22%) was lower than the national average of 24% in Hispanic/Latino adults. This contrasted sharply with the state’s non-Hispanic white population of 38% and the non-Hispanic Black population of 41% (United Health Foundation, 2021). Figure 12Hypertension by race/ethnicity, Georgia, United States, 2013 – 2021Note: Adapted from America’s Health Rankings analysis of CDC, Behavioral Risk Factor Surveillance System, United Health Foundation, AmericasHealthRankings.org

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78Cardiovascular HealthUnderstanding Cardiovascular DiseaseCardiovascular disease is comprised of multiple health conditions that originate from the build-up of plaque within arteries, which lead to ailments like:· Coronary artery disease· Angina (chest pain)· Myocardial infarctions (heart attacks)· Cerebrovascular accidents (strokes)As of 2020, heart disease was recognized as the leading cause of death in the U.S. (Ahmad & Anderson, 2021). Figure 13Percentage of Hispanic/Latino adults medically diagnosed with a cardiovascular diseaseNote: Adapted from America’s Health Rankings analysis of CDC, Behavioral Risk Factor Surveillance System, United Health Foundation, AmericasHealthRankings.org Cardiovascular Diseases By State: HispanicPercentage of the adult Hispanic population (all races) who reported being told by a health professional that they had angina or coronary heart disease; a heart attack or myocardial infarction; or a stroke

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79Prevalence Of Cardiovascular Disease (Race/Ethnicity in the United States & Georgia) United States (Figure 13 & 14): At the national level, the Hispanic/Latino community has a lower prevalence (5%) of cardiovascular diseases compared to non-Hispanic whites (9%) and non-Hispanic Blacks (9%) (United Health Foundation, 2021). This disparity may point to overall better health outcomes compared to other groups, or potentially an underdiagnosis or underreporting in this community due to barriers in healthcare access or language and cultural differences.GEORGIA (Figure 14): The Hispanic/Latino community in Georgia exhibits a similar percentage to the nationwide statistics, with a prevalence rate of 5% (United Health Foundation, 2021). Here, non-Hispanic whites reported a higher percentage, 10%, indicating a slightly greater prevalence of these conditions in Georgia (United Health Foundation, 2021). Figure 14Percentage of adults who received a medical diagnosis of angina or coronary heart disease, experienced a heart attack or myocardial infarction, or suffered a stroke, 2021United States & Georgia, 2021

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80National Trends In Cardiovascular Mortality By Race/Ethncity, 1999-2018Key ﬁndings about cardiovascular disease (CVD) mortality within the Hispanic/Latino community from 1999 to 2018 (Khan et al., 2022):· Lower Age-Adjusted Mortality Rate: Between 1999 and 2018, Hispanic/Latino adults demonstrated a lower age-adjusted mortality rate (186.4 per 100,000 individuals) for total CVD compared to non-Hispanic white adults (254.6 per 100,000 individuals). This suggests that the Hispanic/Latino community may have a lesser burden of these diseases or could indicate potential underdiagnoses or underreporting in this group.·Decrease in Mortality Rate: Between 1999 and 2018, the mortality rate declined more signiﬁcantly for Hispanic/Latino adults compared to non-Hispanic white adults for total CVD and ischemic heart disease (IHD). However, this decline was not seen in the case of stroke.·Mortality Trends in Hypertensive Heart Disease: For hypertensive heart disease, mortality increased less rapidly in Hispanic/Latino patients compared to non-Hispanic white individuals. This could point to better management of hypertension in the Hispanic/Latino community or a lower prevalence of risk factors for hypertensive heart disease.·Recent Trends in Stroke Mortality: Since 2011, stroke-related mortality has seen an increase in Hispanic adults while it has remained relatively stable in non-Hispanic white individuals. This points to an emerging concern regarding stroke within the Hispanic/Latino community.In summary, these results highlight the complex dynamics of CVD mortality in the Hispanic/Latino community. While some positive trends are observed, particularly in relation to IHD and hypertensive heart disease, the recent increase in stroke mortality necessitates targeted attention and further investigation.Respiratory HealthUnderstanding Chronic Respiratory IllnessDiseases of a chronic respiratory nature (i.e., chronic obstructive pulmonary disease (COPD), asthma) predominantly impact the lungs and their associated structures.Among the multiple risk factors that contribute to the development of these diseases are exposure to tobacco smoke, airborne pollutants, occupational chemicals, and dusts, as well as frequent lower respiratory infections in early childhood. AsthmaAdult asthma is a long-term inﬂammatory ailment of the airway. Symptoms of asthma are typiﬁed by periods of shortness of breath, which can range from minor to fatal, resulting from blockage and constriction of the airway. Management of the disease involves medication use and steering clear of triggers, including environmental factors.

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81National Asthma Statistics For Hispanics/Latinos Key Findings (Ofﬁce of Minority Health, 2021a):·Adult Asthma Prevalence: In 2018, the prevalence of asthma among adults aged 18 and over was 6.4% for the overall Hispanic/Latino population, while it was slightly higher at 7.6% for the non-Hispanic white population. Among speciﬁc Hispanic/Latino subgroups, Puerto Ricans had the highest prevalence rate of 14.9%, followed by Mexicans with a prevalence rate of 5.3%. ·Preventive Treatment: Based on data from 2016, the percentage of adults aged 18 and over who currently have asthma and take preventive medicine daily or almost daily was 22.0% for the Hispanic/Latino population and 22.9% for the non-Hispanic white population.·Childhood Asthma Prevalence: Among children under 18, the prevalence of asthma was higher in the Hispanic/Latino population, with a rate of 8.0%, compared to 5.6% in the non-Hispanic white population in 2018. Speciﬁcally, Puerto Rican children had the highest prevalence rate of 17.0%, followed by Mexican children with a rate of 6.9%.·Hospital Admissions Rates for Children: In 2017, the hospital admissions rate for asthma among children aged 2-17 was higher in the Hispanic/Latino population, with a rate of 76.3 per 100,000 population, compared to a rate of 41.9 per 100,000 population among the non-Hispanic white population.Adult Asthma By Racial/Ethnic Group In The United States & GeorgiaFigure 15 demonstrates a comparison of asthma prevalence among adults across various racial and ethnic groups in the United States and Georgia in 2021 (KFF, n.d.).

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82The prevalence of asthma in adults (Figure 15) is slightly lower in Georgia (8.8%) than the national average (9.6%). When examining racial and ethnic statistical disparities, certain groups experience a higher asthma prevalence. Speciﬁcally, the prevalence of asthma in non-Hispanic Black adults is higher than the national average in the U.S. (11.8%) and Georgia (10.6%). Conversely, the asthma prevalence among Hispanic/Latino adults in Georgia (4.4%) is signiﬁcantly lower than the national average (8.4%). Liver & Kidney HealthLiver HealthLiver disease is a signiﬁcant public health concern in the United States, affecting an estimated 4.5 million individuals, equating to approximately 2% of the American adult population (Allencherril et al., 2022). This condition includes chronic liver diseases like fatty liver, steatohepatitis, and cirrhosis, which contribute to the increasing mortality rate associated with liver disease. Liver disease was the sixth-most common cause of death among Hispanic/Latino individuals, which is signiﬁcantly higher compared to its ranking as the 11th-most common cause of death for the general American populace (Velasco-Mondragon et al., 2016b). The mortality rate due to liver disease and cirrhosis in the Hispanic/Latino community is an alarming rate, 48% higher than that observed in non-Hispanic whites (Velasco-Mondragon et al., 2016b). Among Mexicans, the prevalence of liver disease ranges from 2.4% to 8.4%, which is higher than the national average (Velasco-Mondragon et al., 2016b).Given the disproportionate prevalence of liver disease among Mexican Americans nationally and that most of the Hispanic/Latino community in Georgia is of Mexican descent, it is plausible that this disease is a signiﬁcant health concern in the state. Research is needed to establish the prevalence of liver disease among Hispanic/Latinos in Georgia. Furthermore, researched focused on interventions that include overcoming language barriers, enhancing healthcare access, and targeting the speciﬁc risk factors prevalent in this community are needed.Kidney HealthKidney disease is one of the leading causes of mortality worldwide and is more prevalent in ethnic and racial minorities (Kovesdy, 2022). Hispanic/Latino are almost 1.3 times more likely to develop kidney failure compared to non-Hispanics. Traditional risk factors of kidney disease are obesity, diabetes, and hypertension, which are chronic conditions with high prevalence within Hispanic/Latinos (National Institute of Diabetes and Digestive and Kidney Diseases, 2014). A study of dialysis patients at a Georgia safety-net hospital that provides emergency dialysis for uninsured patients reported 96% of 50 patient participants were undocumented Hispanic/Latinos who had work history in agriculture, construction, and landscaping industry (Smith et al., 2022). Cancer Deﬁnition & Basic FactsCancer is deﬁned as the result of abnormal and unregulated proliferation of cells in the body, often leading to the formation of a tumor (National Cancer Institute, 2021). The progression of cancer varies greatly, with

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83some types advancing slowly and others proliferating rapidly and aggressively. The treatment of cancer is multifaceted and can involve a variety of strategies such as surgery, radiation therapy, chemotherapy, and immunotherapy, all contingent upon the speciﬁc type and progression stage of the cancer (National Cancer Institute, n.d.)PreventionCancer prevention is a proactive measure to diminish the probability of developing cancer, a group of related diseases inﬂuenced by our genes, lifestyle, and environment (National Cancer Institute, 2023). With close to 1.9 million new diagnoses in the United States in 2021 alone, the emphasis on cancer prevention is of paramount importance (National Cancer Institute, 2023).·Lifestyle Modiﬁcations: Lifestyle adjustments could have a substantial impact on cancer. Such modiﬁcations include the cessation of tobacco, maintaining a healthy body weight, regular physical activity, and the restriction of alcohol intake. ·Screening For Early Detection: Screening plays a pivotal role in cancer prevention. Early detection often results in less aggressive and generally more successful treatment approach.Cancer Burden In The Hispanic/Latino Population National LevelProjections estimate that 176,600 new cancer cases and 46,500 cancer-related deaths occurred in the Hispanic/Latino population in 2021 (Miller et al., 2021).The subsequent key points and signiﬁcant ﬁndings offer current insight on a national level concerning cancer incidence, mortality, and associated challenges within the Hispanic/Latino population (Miller et al., 2021). Key Points & Signiﬁcant Findings:· Comparison to non-Hispanic white individuals: In comparison to non-Hispanic white people, Hispanic/Latino men and women had 25%-30% lower incidence and mortality rates for all cancers combined between 2014 and 2018. However, the gap is narrowing, with the colorectal cancer incidence rate ratio for Hispanics/Latinos compared to non-Hispanic white people decreasing from 0.75 in 1995 to 0.91 in 2018.·Higher Incidence of Certain Cancers: The Hispanic/Latino population has twice the incidence rate of liver and stomach cancer compared to non-Hispanic white people. Furthermore, cervical cancer incidence is 32% higher among Hispanic/Latino women.·Stage at Diagnosis & Access to Care: There’s a lower prevalence of localized-stage breast cancer at diagnosis among Hispanic/Latino women (59%) compared to NHW women (67%). This disparity suggests a lesser access to care among Hispanic/Latino women, which may be linked to the fact that Hispanic/Latino individuals diagnosed with cancer between 2014 and 2017 were more than twice as likely as non-Hispanic white people to be uninsured.·Cancer Risk Factors: The Hispanic/Latino population exhibits a higher prevalence of

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84potentially modiﬁable cancer risk factors, such as obesity and type 2 diabetes. These health issues, combined with disproportionate poverty and lower insurance coverage, increase their vulnerability to cancer inequalities.The American Cancer Society has identiﬁed a trend where most cancer data for the Hispanic/Latino population in the U.S are grouped together, despite the population’s diverse origins. This lumping of different subgroups makes it difﬁcult to identify signiﬁcant variations based on factors such as country of origin, acculturation level, and nativity status (American Cancer Society, 2021a). Cancer screening, diagnosis, and treatment strategies should consider the heterogeneity of the Hispanic/Latino population, given their varying linguistic capabilities, access to healthcare, and cultural beliefs and values. To reduce cancer rates among Hispanics/Latinos, strategies could include training community health professionals and patient guides, as well as collaborating with community organizations to create culturally sensitive programs to improve rates of screenings and healthcare accessibility.Cancer Trends Analysis: Incidence and Mortality Rates in the Hispanic/Latino Community Versus Other Racial or Ethnic GroupRacial/Ethnic Differences (Miller Et Al., 2021): · Overall, non-Hispanic white individuals have higher probabilities of developing (41.0% in males and 39.9% in females) and dying from cancer (20.8% in males and 18.2% in females) than Hispanic/Latino (36.9% of males and 36.2% of females have a chance of developing, and 18.8% of males and 15.4% of females have a chance of dying from cancer).· In the context of speciﬁc cancers, Hispanics/Latinos are more likely to develop and die from liver and intrahepatic bile duct cancers (Hispanic/Latino males: 2.4% and 1.7%, Hispanic/Latino females: 1.2% and 1.0%) compared to non-Hispanic white males: 1.2% and 0.9%, non-Hispanic white females: 0.5% and 0.5%). The same pattern applies to stomach cancer, where Hispanic/Latino (males: 1.6%, females: 1.1%) have higher probabilities than non-Hispanic white (males: 0.8%, females: 0.5%).Gender Differences: There are noticeable gender-based disparities in both racial/ethnic groups (Miller et al., 2021).·Males, regardless of ethnicity, exhibit higher overall probabilities of developing and dying from cancer. The gender disparity is evident in speciﬁc cancers such as kidney and liver cancer. For instance, the probability of developing kidney & renal pelvis cancer is higher in males (Hispanic/Latino: 2.3%, non-Hispanic white: 2.3%) than females (Hispanic/Latino: 1.5%, non-Hispanic white: 1.3%). Similarly, liver & intrahepatic bile duct cancer is more prevalent among males (Hispanic/Latino: 2.4%, non-Hispanic white: 1.2%) than females (Hispanic/Latino: 1.2%, non-Hispanic white: 0.5%).United States: New Cases & Deaths Among The Hispanic/Latino Population, 2016-2020Between 2016 and 2020, the United States

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85recorded 720,769 new cancer diagnoses among the Hispanic/Latino population (Centers for Disease Control and Prevention, 2023g). During the same period, cancer claimed the lives of 208,897 Hispanic/Latino individuals. This means that for every 100,000 members of the Hispanic/Latino community, there were 340 newly diagnosed cancer cases and 108 cancer-related deaths.Top 5 Cancers By Rates Of New Cancer Cases Among Hispanic/Latino Individuals In The United States From 2016-2020 (Figure 16) (age-adjusted rate per 100,000 people and case count) (Centers for Disease Control and Prevention, 2023g):1. Female Breast – 95.6 rate, 112,037 cases2. Prostate – 83.7 rate, 76,182 cases3. Colon and Rectum – 32.0 rate, 67,085 cases4. Lung and Bronchus – 27.7 rate, 51,104 cases5. Corpus and Uterus, NOS Cancer – 24.8 rate, 29,630 casesTop 5 Cancers By Rates Of Cancer Deaths Among Hispanic/Latino Individuals In The United States From 2016-2020 (age-adjusted rate per 100,000 people and case count | Figure 17) (Centers for Disease Control and Prevention, 2023g):1. Lung and Bronchus – 15.4 rate, 27,857 deaths2. Prostate – 15.3 rate, 10,366 deaths3. Female Breast – 13.7 rate, 15,533 deaths4. Colon and Rectum – 10.7 rate, 21,023 deaths5. Liver and Intrahepatic Bile Duct – 9.2 rate, 18,314 deathsGeorgia: New Cases & Deaths Among The Hispanic/Latino Population, 2016-2020In the period from 2016 to 2020, different types of cancers among Hispanic/Latino individuals in Georgia presented varying incidence rates and numbers of cases.Top 5 Cancers By Rates Of New Cancer Cases Among Hispanic/Latino Individuals In Georgia From 2016-2020 (Figure 18) (Centers for Disease Control and Prevention, 2023g)1. Female Breast Cancer: The highest incidence was noted in Female Breast cancer, with an age-adjusted rate of 113.4 per 100,000 individuals and 1,698 cases recorded.2. Prostate Cancer: The second most prevalent was Prostate cancer, with an age-adjusted rate of 105.7 per 100,000 individuals, resulting in 1,114 cases.3. Colon and Rectum Cancer: Equally signiﬁcant, Colon and Rectum cancer had an age-adjusted rate of 34.6 per 100,000 individuals, leading to 914 cases.4. Lung and Bronchus Cancer: This type of cancer had an age-adjusted rate of 34.6 per 100,000 individuals and registered 697 cases.5. Corpus and Uterys, NOS: The incidence rate stood at 27.1 per 100,000 individuals with 399 cases reported.Top 5 Cancers By Rates Of Cancer Deaths Among Hispanic/Latino Individuals In The United States From 2016-2020 (Figure 19) (Centers for Disease Control and Prevention, 2023g)1. Lung and Bronchus Cancer: At the top of the list, this cancer had the highest age-adjusted mortality rate of 12.7 per 100,000 individuals, accounting for 239 deaths.

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862. Female Breast Cancer: This type of cancer was responsible for the second-highest number of deaths, with an age-adjusted mortality rate of 11.3 per 100,000 individuals, leading to 155 deaths.3. Prostate Cancer: This cancer type had an age-adjusted mortality rate of 11.1 per 100,000 individuals, causing 72 deaths.4. Colon and Rectum Cancer: The age-adjusted mortality rate for this cancer was 7.8 per 100,000 individuals, resulting in 176 deaths.5. Liver and Intrahepatic Bile Duct Cancer: This cancer had an age-adjusted mortality rate of 7.2 per 100,000 individuals, leading to 139 deaths.Georgia: New Cases & Deaths Among The Hispanic/Latina Women, 2016-2020Between the years 2016 and 2020, the United States witnessed 382,638 newly diagnosed cancer cases amongst Hispanic/Latina women. During the same timeframe, cancer claimed the lives of 100,448 Hispanic/Latina women. This translates to 332 new cancer diagnoses and 93 cancer-related deaths for every 100,000 women within the Hispanic/Latina community. In Georgia (2016-2020), among Hispanic/Latina women, 10,186 new cancers were reported – meaning, for 100,000 Hispanic/Latina women, there were 383 newly-diagnosed cancer cases.Top 5 Cancers By Number Of New Cases Among Hispanic/Latina Females In Georgia From 2016-2020 (Figure 20) (Centers for Disease Control and Prevention, 2023g):1.Female Breast Cancer was the most common, with an age-adjusted rate of 113.4 per 100,000, and 1,698 new cases.2. Colon and Rectum Cancer was the second-most common, with an age-adjusted rate of 34.0, and 449 new cases.3. Thyroid Cancer was the third-most common, with an age-adjusted rate of 22.7, and 426 new cases.4. Corpus and Uterus, NOS Cancer was the fourth-most common, with an age-adjusted rate of 27.1, and 399 new cases.5. Lung and Bronchus Cancer was the ﬁfth-most common, with an age-adjusted rate of 32.5, and 358 new cases.Top 5 Cancers By Number Of Deaths Among Hispanic/Latina Females In Georgia From 2016-2020 (Figure 21) (Centers for Disease Control and Prevention, 2023g):1. Female Breast Cancer had the highest number of deaths (155) and the highest age-adjusted death rate (11.3 per 100,000) among Hispanic/Latina females in Georgia from 2016-2020. This suggests that this type of cancer was the most lethal for this demographic during the speciﬁed timeframe.2. Lung and Bronchus Cancer was the second-most lethal type, with an age-adjusted death rate of 10.7 and 106 deaths. While the number of deaths was lower than Breast Cancer, the relatively close death rate suggests that it is almost as prevalent.3. Colon and Rectum Cancer was the third-most lethal type, with a death rate of 6.5 and 78 deaths. This is signiﬁcantly lower than the top two types of cancer.4. Pancreatic Cancer and Liver and Intrahepatic Bile Duct Cancer had the same age-adjusted death rate of 5.0 but differed slightly in the number of deaths (52 and 47, respectively).5. Leukemia had a lower death rate of 3.4, but the number of deaths was identical to Liver and Intrahepatic Bile Duct Cancer (47).

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90Infectious Diseases TuberculosisMycobacterium tuberculosis, commonly known as “tuberculosis,” is a serious bacterial infection which mainly affects the lungs. There are two types of tuberculosis: (1) latent tuberculosis; (2) tuberculosis disease (active). Tuberculosis can result in severe cough, chest pain, and blood in cough. If not treated properly, tuberculosis disease can be fatal. In the United States, there has been a low incidence of tuberculosis since the early 1990s with a slow decrease with time (Deutsch-Feldman et al., 2021). For example, there was a decrease from 9,925 incident cases in 2012 to 7,163 reported cases in 2020 (2.2 cases per 100,000 people).Key Findings from Georgia Department of Public Health [GDPH], 2021 Georgia Tuberculosis Surveillance Report:· TB Cases and Incidence: The total number of TB cases in Georgia increased by 1% from 220 in 2020 to 222 in 2021. The TB case rate remained the same at 2.1 cases per 100,000 persons in both years. This indicates a stable incidence of TB in the state.·TB Incidence by Health District (2021): The TB case rates varied across health districts in Georgia in 2021. District 9-1 (Coastal) had the lowest case rate of 1.1 cases per 100,000 persons, while District 3-5 (DeKalb) had the highest rate of 5.5 cases per 100,000 persons. Five health districts reported TB case rates higher than the overall state incidence in 2021, indicating localized variations in TB burden.· TB Cases by County (2021): Three counties in Georgia, namely Dekalb, Fulton, and Gwinnett, reported more than 25 TB cases each in 2021, accounting for 46% of all reported cases statewide. This highlights the concentration of TB cases in speciﬁc regions within the state.· Non-U.S.-Born TB Cases (2021): Approximately 60% (132 cases) of the total TB cases in Georgia in 2021 were among non-U.S.-born individuals. The top four countries of origin for non-U.S.-born TB cases were India, Mexico, Vietnam, and Guatemala. Cases from these four countries constituted 52% of all non-U.S.-born cases. This emphasizes the inﬂuence of international factors on TB incidence in Georgia.· HIV Status: HIV status was reported for 93% of Georgia’s TB cases in 2021. Among the 207 patients with known HIV status, 7% were HIV-positive. This suggests a potential association between HIV and TB co-infection, which may require targeted interventions.Georgia ranked sixth highest in the United States for the number of new tuberculosis cases and ranked ninth highest for tuberculosis case rate (per 100,000) among the 50 reporting states (Georgia Department of Public Health, 2023a).

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91·High-Risk Populations: A small proportion of Georgia’s TB cases had speciﬁc risk factors. Approximately 3% of total TB cases experienced homelessness in the year before diagnosis, highlighting the vulnerability of this population to TB. Additionally, 4% of cases were diagnosed while residing in a prison, indicating the increased risk of TB transmission within such settings.· Multidrug-Resistant TB (MDR-TB): Five cases of MDR-TB, which refers to TB resistant to at least isoniazid and rifampin, were diagnosed in Georgia in 2021. MDR-TB poses challenges in terms of treatment and control due to limited treatment options and higher transmission potential.The analysis of Georgia’s TB situation in 2021 reveals a slight increase in TB cases and a stable overall incidence. There are variations in TB burden across health districts, with certain counties reporting a higher number of cases. Non-U.S.-born individuals, particularly from India, Mexico, Vietnam, and Guatemala, constitute a signiﬁcant proportion of TB cases. HIV co-infection, high-risk populations, and the presence of MDR-TB cases highlight the complexity of TB control efforts. Strategies targeting early identiﬁcation, treatment completion, contact investigation, and addressing high-risk populations should be implemented to accelerate progress toward TB elimination in Georgia. Tuberculosis incidence was noticeably lower in 2020 compared to previous years, both in Georgia and in the United States. This can be best explained by the increase in social distancing, mask mandates, and decreased global travel coinciding with the onset of the COVID-19 pandemic. Viral HepatitisLiver infection known as viral hepatitis results in inﬂammation and harm to the organ. The infection, affecting a signiﬁcant number of individuals annually in the United States, has a high mortality rate and is a major contributor to liver cancer. Predominantly, Hepatitis A, B, and C are the types seen in the US, with each one impacting the liver in a distinct manner. Despite severe public health implications, Hepatitis A and B can be prevented through vaccination, and Hepatitis C can be successfully treated.Hepatitis AHepatitis A originates from an infected individual’s feces and typically spreads via the consumption of tainted food or water. It can also spread using unsterilized drug-injection apparatus. The years between 2012 and 2015 saw Hepatitis A cases range from 1,200 to 1,800 annually, according to the (Centers for Disease Control and Prevention, 2021c). In 2020, the rate of Hepatitis A decreased slightly among most racial and ethnic groups, possibly due to heightened infection control measures instituted at the onset of the COVID-19 pandemic. A peak in hepatitis A was observed in 2019, with 6.8 cases per 100,000 people among non-Hispanic whites, largely due to severe outbreaks across 31 states, predominantly among drug users and homeless people, as per the CDC’s Viral Hepatitis report.

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92Regarding other racial and ethnic groups in 2020, the report provides the following ﬁgures: 1.6 cases per 100,000 people among non-Hispanic Blacks and 0.6 cases among Hispanics/Latinos. Georgia had a higher rate of acute Hepatitis A infections in 2019 than the national rate, with 5.9 cases per 100,000 people compared to the national average of 5.0.Hepatitis A immunization rates exhibit variance based on race, ethnicity, and whether individuals were born in the U.S. or abroad. A study of 36,872 travelers to a country with endemic Hepatitis A found that 17.4% of U.S.-born travelers and 13.1% of non-U.S. born travelers were vaccinated against Hepatitis A (Narayanan et al., 2019). Vaccination rates across different racial and ethnic groups were as follows: non-Hispanic whites 17.03%, non-Hispanic Blacks 15.51%, Hispanics/Latinos 12.02%, and Others 25.88% (Narayanan et al., 2019).Hepatitis BHepatitis B, a bloodborne pathogen, can be transferred through direct blood exposure or sexual contact. Risk factors include unprotected sexual activity, sharing drug-injection tools, or transmission from an infected mother to her newborn. Although Hepatitis B can be eliminated within 3-6 months, it can evolve into a lifelong infection and raise the risk of cirrhosis or liver cancer. Hepatitis B is the most prevalent strain of viral hepatitis (Bhuiyan et al., 2020)The 2020 data from CDC Viral Hepatitis revealed the following ﬁgures: 0.7 cases acute cases per 100,000 people among non-Hispanic Blacks, 0.3 cases among Hispanics/Latinos, and 0.7 cases among non-Hispanic whites (Bhuiyan et al., 2020). Notably, despite constituting only 6% of the U.S. population, Asian Americans account for roughly 60% of the Hepatitis B cases also accounting for 21.2% of past and present infections, followed by non-Hispanic Blacks (10.8%), Hispanics/Latinos (3.8%), and non-Hispanic whites (2.1%) (Chen & Dang, 2015). It is generally more common among adults born outside of the U.S. versus U.S.-born adults (Kruszon-Moran et al., 2020).Despite the availability of a vaccine, the immunization rates are unsatisfactory, with less than 35% coverage across all racial and ethnic groups as per Bhuiyan et al., 2020. A similar study by Kruszon-Moran et al., 2020 showed that Hepatitis B immunization prevalence in 25.2% among adults with Asians having the highest rate at 31.4%, followed by non-Hispanic whites at 26.6%, non-Hispanic Blacks at 23.2%, and Hispanics/Latinos at 19.9%. The birth location, whether in the U.S. or abroad, did not signiﬁcantly affect these results.The highest concentration of Hepatitis B cases is found within the Atlanta metropolitan area. Hepatitis B disproportionately affects racial and ethnic minorities, particularly non-Hispanic Black, and Asian/Paciﬁc Islander populations. In the year 2016, a total of 1,875 conﬁrmed Hepatitis B infections were recorded. Among these, 34% of the chronic cases were among Asian/Paciﬁc Islanders, another 34% were among non-Hispanic

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93Blacks, 14% among non-Hispanic whites, and 3% among Hispanics/Latinos.Hepatitis CHepatitis C is yet another bloodborne pathogen, transmissible through direct blood-to-blood contact or sexual intercourse. Regular exposure risks include shared drug-injection equipment, unprotected sex, or an infected mother passing it to her baby during childbirth. Over 75% of those infected will progress to chronic infection, potentially leading to severe complications such as liver damage, cirrhosis, or even lung cancer.Approximately 2.4 million people in the United States are grappling with a chronic Hepatitis C infection. It’s the most prevalent bloodborne infection (Bradley et al., 2020; Hofmeister et al., 2019) and the leading instigator of liver disease, imposing a heavy burden on the healthcare system due to the associated mortality and morbidity costs. Since 2013, the rate of incidence has more than doubled, witnessing a 15% surge between 2019 and 2020 (Centers for Disease Control and Prevention, 2022c). Among the three most common strains, only the incidence of Hepatitis C saw an increase in 2020.This signiﬁcant hike was particularly observed among non-Hispanic Blacks, Hispanics/Latinos, and non-Hispanic whites. In 2020, there were 2.1 cases per 100,000 people among American Indian and Alaska Native, 0.4 cases among Asian and Paciﬁc Islander, 1.1 cases among non-Hispanic Black, 0.7 cases among Hispanic/Latino, and 1.6 cases among non-Hispanic white (CDC Viral Hepatitis, 2022).Human Immunedeﬁciency Virus (HIV)The State Of HIV In Georgia: Prevalence, Diagnosis, Impact Of Covid-19, And Criminalization LawsGeorgia’s struggle with HIV continues to persist as a serious public health concern. Based on a 2020 report by the CDC, Georgia ranked high nationally in terms of HIV diagnoses and prevalence. It placed fourth and ﬁfth respectively for new diagnoses and total HIV count, outpaced by Florida, California, Texas, and New York (Georgia Department of Public Health, 2023b). For HIV diagnosis rates, Georgia came second only to the District of Columbia. As of 2021, the state reported 61,518 residents living with HIV, with 2,412 fresh cases diagnosed within the year. This increment in HIV cases is mainly attributed to the effectiveness of modern treatments.The declaration of the COVID-19 pandemic as a national and state emergency in March 2020 disrupted access to HIV-related healthcare services. The consequent reduction in testing availability and changes in healthcare utilization led to a dip in HIV diagnoses in 2020. However, the diagnosis count rebounded to pre-COVID-19 levels in 2021. Georgia’s HIV criminal laws disproportionately impact people of color, particularly non-Hispanic Black people. According to the Williams Institute, 6 out of 10 non-Hispanic Black people were arrested for an HIV offense – with 46% identiﬁed as non-Hispanic male and 16% non-Hispanic female (Sears & Goldberg, 2020).

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94HIV Transmission, Treatment And PreventionAfter three decades of HIV research, the difﬁculty of transmission without preventive measures is understood. Modern treatments have empowered those living with HIV (PWH) to lead healthy lives with minimal transmission risk. Furthermore, tools such as PrEP (pre-exposure prophylaxis) and PEP (post-exposure prophylaxis) have signiﬁcantly decreased HIV contraction risk among HIV-negative individuals (Sears & Goldberg, 2020).TransmissionSince 1988, when Georgia implemented its Reckless Conduct laws, HIV’s nature has drastically changed, transitioning from a generally fatal disease to a controllable chronic condition (Sears & Goldberg, 2020). HIV transmission has proven to be more challenging than originally perceived in the early years of the epidemic. With antiretroviral therapy (ART), PWH who achieve an undetectable viral load can’t sexually transmit the virus (Sears & Goldberg, 2020).Transmission risks differ based on the type of exposure. The most hazardous sexual exposure, receptive anal intercourse, presents an average transmission efﬁciency of 1 per 100 sex acts. Insertive anal intercourse carries a 0.11% risk, vaginal intercourse is even less risky, while needle sharing for drug injection presents a 0.63% risk, and needlestick a 0.23% risk (Sears & Goldberg, 2020).Certain exposures carry such a minimal risk that the CDC cannot provide a precise numerical ﬁgure (Sears & Goldberg, 2020). Condom use can decrease transmission risk by 63%-80%. With ART’s introduction in 1995, viral loads in most PWH have been suppressed to undetectable levels, essentially eliminating transmission risks. As of 2020, 52% of PWH in Georgia have undetectable viral loads (Sears & Goldberg, 2020).Treatment: In the era when Georgia’s HIV criminal laws were passed, HIV was incurable and usually fatal. The landscape of HIV treatment has drastically transformed since then. With the advent of multi-antiretroviral drugs, HIV reproduction and drug resistance have been inhibited (Sears & Goldberg, 2020). According to the Williams Institute, recent studies highlight the beneﬁts of immediate ART initiation post-HIV diagnosis, leading to decreased patient morbidity and mortality (Sears & Goldberg, 2020). Most PWH achieve an “undetectable” viral load soon after starting ART. Today’s ART usually involves single daily pills with minimal side effects, promoting higher adherence levels.Prevention: An undetectable viral load signiﬁcantly reduces transmission risks. Clinical evidence ﬁrmly establishes that PWH with an undetectable viral load have virtually no chance of transmitting HIV to an uninfected partner, even without other prevention methods. As of now, 52% of PWH in Georgia have an undetectable viral load (Sears & Goldberg, 2020).·PrEP: Pre-Exposure Prophylaxis (PrEP) has provided a protective shield against HIV for those at risk, reducing the contraction risk by approximately 99% with daily single-pill medication. The US Preventive Services Task Force awarded PrEP a Grade A rating for its effectiveness in June 2019 (Sears & Goldberg, 2020).

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95· PEP: Post-exposure prophylaxis (PEP) is ART provided to HIV-negative individuals post-exposure to decrease HIV acquisition risk. Studies show PEP to be highly effective, with no HIV infections reported in a study of 100 participants following high-risk exposure (Sears & Goldberg, 2020).The nuanced insights from the state’s public health data underscore the pressing need for tailored approaches that cater to the speciﬁc needs of the Hispanic/Latino community in Georgia. Below are some statistics on HIV/AIDS among Hispanic/Latino populations in Georgia (Georgia Department of Public Health, 2021):Shifts in Diagnosis - A Decade’s Glimpse (2010-2020): While Hispanic/Latino men witnessed their HIV diagnosis rates jump from 46.1 to 52.1 per 100,000 between 2010 and 2019, non-Hispanic Black and white men experienced decreases in their diagnosis rates. Hispanic/Latino women, however, experienced a sharp decrease from 12.4 to 7.1 per 100,000 in the same period.Demographic Context and Birth Origin: In 2020, of all the new HIV diagnoses in Georgia, Hispanic/Latinos made up 9%, translating to 177 individuals. Furthermore, they represented 8% (or 4,508 individuals) of those living with HIV/AIDS in the state. Interestingly, over half (57%) of these patients had their birthplaces documented, with the U.S. and Mexico being the most common origins.Regional & Age-speciﬁc HIV Diagnosis Trends (2014-2020): An analysis of metro Atlanta showed a hike in diagnosis rates, escalating from 32 to 38 per 100,000 from 2014 to 2019. Additionally, a discernible increase in diagnosis was especially evident among Hispanic/Latino adults and adolescents aged between 18-24 and 25-34 years during this timeframe.Care Continuum for Hispanic/Latino Population: Between 2014 and 2019, positive strides were made in the HIV/AIDS care for Hispanic/Latinos, showcasing better access to and utilization of care services. Nevertheless, a noticeable discrepancy was present, with those residing in metro Atlanta having superior care access than those in other parts of the state.Comparative Analysis - Hispanic/Latinos vs. Other Major Racial/Ethnic Groups: Over a span of 10 years (2010-2020), the Hispanic/Latino population in Georgia expanded by 19%, surpassing the growth of the Black (12%) and White (2%) communities. It’s essential to underscore that the ampliﬁcation in HIV diagnoses within the Hispanic/Latino group predominantly involved men. A 2020 snapshot revealed that Hispanic/Latinos living with HIV/AIDS were slightly less engaged in care In Georgia, while the overall HIV/AIDS diagnoses showed a downward trend, a contrasting 13% increase was observed speciﬁcally among Hispanic/Latino men from 2010 to 2019 (Georgia Department of Public Health, 2021).

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96compared to non-Hispanic Blacks and whites. Their viral suppression levels were on par with non-Hispanic Blacks but lagged behind non-Hispanic whites. However, their rates of linkage to care were consistent with both these groups.Barriers To Care For HIV Among Hispanics/Latinos In GeorgiaHIV Criminalization: The term “HIV criminalization” is utilized to denote laws that deem otherwise legal actions as criminal, or enhance penalties for unlawful behavior, based on an individual’s status as HIV-positive (Sears & Goldberg, 2020). Laws in Georgia (Table 9) that criminalize HIV might undermine the public health initiatives of the state by creating disincentives for individuals to pursue HIV screening and therapy, stigmatizing individuals living with HIV, and disproportionately impacting communities most burdened by HIV, which include Hispanic/Latino, non-Hispanic Black populations, women, individuals identifying as LGBTQIA+, and those with a history of incarceration (Sears & Goldberg, 2020). Evidence from certain studies indicate that the legal consequences faced by people living with HIV (PWH) might act as a deterrent for those who are most susceptible to HIV, preventing them from undergoing tests, revealing their HIV status to potential partners and healthcare professionals, and from continuously availing medical assistance.Georgians living with HIV face further stigmatization due to these HIV-speciﬁc laws. Studies have demonstrated that when PWH confront stigma, it results in worsened health outcomes and decreased consistent participation in personal healthcare and wider public health initiatives (Sears & Goldberg, 2020). Georgia implements HIV-speciﬁc criminal laws that categorize seven unique behaviors as unlawful (Table 3.2). The subsequent section will provide a succinct summary of our current understanding of HIV, its treatment and prevention measures, and the implications of HIV criminalization on the Hispanic/Latino community in Georgia (Sears & Goldberg, 2020).

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98COVID-19Over the duration of the COVID-19 pandemic in Georgia, evident disparities have emerged in the distribution of cases across different racial and ethnic groups. The Hispanic/Latino community, constituting 9.5% of Georgia’s population, witnessed a total of 15,627 COVID-19 cases per 100,000 individuals (Health Equity Tracker, n.d.). In contrast, the non-Hispanic Black and non-Hispanic white populations, which form 31.2% and 52.7% of Georgia’s demographic respectively, registered 12,527 and 10,653 cases per 100,000 members of their communities (Health Equity Tracker, n.d.). The contrast in numbers is compelling.The Hispanic/Latino community recorded an approximately 24.7% increase in cases compared to the non-Hispanic Black group and a 46.8% rise in relation to the non-Hispanic White community. These disparities potentially underscore existing health inequities and disparities in access to care, socio-economic factors, or other determinants of health. Furthermore, when observing the broader impact of the virus, the Hispanic/Latino community had a share of 13.1% of the total cases but represented only 5.6% of hospitalizations and 5.3% of deaths. This contrasts with the non-Hispanic white population, which accounted for 49.3% of cases, but a disproportionately high 60% of hospitalizations and 66.1% of deaths. On the other hand, non-Hispanic Blacks made up 34.3% of cases, 32.7% of hospitalizations, and 26.5% of deaths.The observed trends suggest that while the Hispanic/Latino community experienced a higher rate of infections compared to the other two groups, the severity of the disease, indicated by hospitalizations and deaths, was notably higher among non-Hispanic Whites. The data brings to the fore the critical need for targeted interventions to address these disparities and to ensure that all communities receive equitable care and support during health crises.Disparities In Testing, Hospitalization, And Death Rates Among Ethnic Groups·Testing Rates Among Racial/Ethnic Groups: In 2022, data from eight states revealed signiﬁcant disparities in testing rates among different racial and ethnic groups. The testing rates were particularly pronounced between Hispanic/Latino individuals and non-Hispanic white patients. Hispanic/Latino individuals received signiﬁcantly fewer tests per case compared to non-Hispanic Black and non-Hispanic white individuals (Pond et al., 2022). ·Testing, Hospitalization, and Death Rates: An analysis of 2020 data from Epic Health records highlighted the disparities in testing, hospitalization, and death rates among different racial and ethnic groups. People of color, including Hispanic/Latino individuals, had lower testing rates compared to non-Hispanic white patients. Additionally, when people from these communities did receive testing, they were more likely to test positive. Speciﬁcally, Hispanic/Latino individuals were over two and a half times more likely to have a positive result compared to non-Hispanic whites (Rubin-Miller & Alban, 2020).

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99·Hospitalization: Among those who tested positive, Hispanic/Latino patients faced a higher risk of hospitalization compared to non-Hispanic white patients. The hospitalization rates for Hispanic/Latino patients were more than four times higher than those of non-Hispanic whites (Rubin-Miller & Alban, 2020).·Death Rates: The death rate among Hispanic/Latino individuals was found to be twice as high as that of non-Hispanic whites. This suggests a disproportionate impact of COVID-19 on the Hispanic/Latino population in terms of mortality (Rubin-Miller & Alban, 2020).In summary, it is evident that there are signiﬁcant disparities in testing rates, as well as subsequent hospitalization and mortality rates, among different racial and ethnic groups. These disparities highlight the need for targeted interventions and improved access to testing and healthcare services for marginalized communities, particularly Hispanic/Latino individuals.Factors Contributing To Covid-19 Disparities Among Hispanic/Latino Individuals · Increased Risk of Exposure: The higher infection rates among Hispanic/Latino individuals may reﬂect an elevated risk of exposure to COVID-19 through work, living conditions, and transportation situations. Occupations that involve close contact with others, crowded living environments, and reliance on public transportation may contribute to a higher likelihood of exposure (Rubin-Miller & Alban, 2020).·Barriers to Testing: Hispanic/Latino individuals and other marginalized communities face increased barriers to testing, which contribute to delays in care. Limited access to testing facilities, lack of transportation, language barriers, and cultural factors that affect healthcare-seeking behavior can all contribute to lower testing rates among these populations (Rubin-Miller & Alban, 2020).·Underlying Health Conditions and Socioeconomic Inequalities: Hispanic/Latino individuals, non-Hispanic Black people, and non-Hispanic white people from disadvantaged backgrounds are more likely to have underlying health conditions, such as diabetes and obesity, that increase the severity of COVID-19 symptoms. Additionally, socioeconomic inequalities, including limited access to healthcare services, income disparities, and inadequate social support systems, can contribute to poorer health outcomes (Rubin-Miller & Alban, 2020).·Racism and Discrimination: Even after controlling for COVID-19 infection, sociodemographic factors, and underlying health conditions, there is evidence to suggest that racism and discrimination play a signiﬁcant role in negatively affecting the health outcomes of Hispanic/Latino individuals and non-Hispanic Black people. These systemic factors create additional avenues through which health disparities emerge and persist (Rubin-Miller & Alban, 2020).In summary, Hispanic/Latino individuals experience lower testing rates for COVID-19,

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100and this disparity is accompanied by a disproportionate impact of the disease within their communities. Similar disparities are also observed among the non-Hispanic white and non-Hispanic Black groups. Various factors, including increased exposure risks, barriers to testing, underlying health conditions, socioeconomic inequalities, and the negative effects of racism and discrimination, contribute to the observed disparities. Addressing these issues is crucial for reducing health inequities and ensuring better outcomes for all populations affected by COVID-19.Effects of COVID-19 Other prevalent themes that were shown in the qualitative study were due to effects of COVID-19. One major theme was mistrust of public ofﬁcials and health care personnel. Due to an increase in surveillance efforts worldwide, contact tracing expanded exponentially but unfortunately increased the number of identity thefts that also occurred (Sowmiya et al., 2021; U.S. Department of Health and Human Services, 2023). This, as well as fear of immigration enforcement contributed to community members being more closed off about sharing their personal information and hesitant about receiving certain health services such as getting tested for covid and receiving the vaccine (Bergquist et al., 2020; Khubchandani & Macias, 2021).I feel like there was some trauma created after COVID occurred [...]. Places of employment, like farmwork and warehouses, they weren’t really employing the 6-feet apart and wearing a mask mandates. So it was kind of like, the government and the place where I work doesn’t care about my health, and that feeling was reinforced.”“Siento que hay algún trauma creado después de COVID […]. Lugares de empleo como en granjas u otros lugares de trabajo agricola y almacenes, no estaban empleando los mandatos de 6 pies de distancia y usando una mascarilla. Así que si antes yo sentía que el gobierno y el lugar donde trabajo no se preocupan por mi salud, ahora lo pude conﬁrmar”.Key Informant “I think after COVID, there was just a lot of stuff going on and people didn't know how to maneuver it and didn't cared for it. Maybe they had a negative experience or something, you know?”"Creo que después de COVID estaban sucediendo muchas cosas y la gente no sabía cómo maniobrar y no le importaba. Tal vez tuvieron una experiencia negativa o algo así, ¿sabes?"Key Informant

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101Another theme that was prevalent was the increase in immigration policies due to the quarantine mandates (Miller et al., 2020). This also affected employment instability as it became a lot more common, especially among individuals who are undocumented. This was seen in both Latino communities in the North and South Georgia regions.“There were weekend checkpoints in predominantly Latino areas knowing that many were without a license driving.”"Había puntos de control los ﬁnes de semana en áreas predominantemente latinas sabiendo que muchos no tenían licencia de conducir".Dalton Focus Group“They announced that they were going to start using e-verify where I work. During that time, many people without documents left. So now it is impossible to enter the factories without documents” "Anunciaron que iban a comenzar a usar e-verify donde trabajo. Durante ese tiempo, muchas personas sin documentos se fueron. Así que ahora es imposible entrar en las fábricas sin documentos".Dalton Focus Group“In the past, there were a lot more opportunities for Latinos who are un-documented in Georgia. Now, a lot of Latinos that used to live in Georgia had to move away simply because they were no longer able to ﬁnd a job that would allow them to work without having a legal status.”"En el pasado, había muchas más oportunidades para los latinos indocumentados en Georgia. Ahora, muchos latinos que solían vivir en Georgia tuvieron que mudarse simplemente porque ya no podían encon-trar un trabajo que les permitiera trabajar sin tener un estatus legal".South Georgia Focus Group

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102The demographic survey reﬂected these perspectives as a majority of participants who are undocumented said they do not currently have stable jobs. Employment instability was also a barrier expressed amongst Georgia Latinos with documents as well.As the pandemic begins to subside, jobs are beginning to increase nationally for the Latino populations. However, the employment rate is still not the same as before the pandemic and there is still a shortage of employees in every occupation (U.S. Bureau of Labor Statistics, 2022). Now, as a result of inﬂation due to COVID-19, participants have mentioned working longer hours in order to make up for the costs of living. Table 1 shows that participants on average work 40 or more than 40 hours a week and most make an average salary of under $30,000 a year. The long work hours make it difﬁcult for the community members to have time for themselves and their family.“My mom used to have more stable hours. What she kind of does is she helps paint houses, prepare trailers, etc…now that after covid, there has been a de-crease in the amount of hours that she has been given, especially now with like inﬂation and the rising costs.”"Mi mamá tenía horarios más estables. Lo que hace es ayudar a pintar casas, preparar tráilers, etc. Ahora después de COVID, ha habido una disminución en la cantidad de horas que se le han dado, especialmente ahora con una inﬂación y el aumento de los costos".Key Informant“You enter without sun and leave without sun. I mean, you don't see daylight at all. They say that at least I have my job. Ok, ﬁne but I couldn't even go to open a bank account because I was working.” "Entras sin sol y sales sin sol. Quiero decir, no ves la luz del día. Dicen que por lo menos tengo mi trabajo. Ok, está bien, pero ni siquiera podía ir a abrir una cuenta bancaria porque estaba trabajando".Clayton County Focus Group

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103General Health & Health By Life StageThis section explores the general health and life stage-speciﬁc health trends among the Hispanic/Latino population in Georgia and the broader United States. A key area of examination includes immunization trends – encompassing inﬂuenza, pneumococcal vaccines, and Georgia’s unique requirements for children’s vaccinations. Further, the section explores the signiﬁcance of health screenings as well as their role in early detection, prevention, and management of various health conditions and the role of health screenings in health maintenance. Health considerations for children and adolescents are addressed, highlighting the challenges and opportunities in this demographic as well as the multifaceted health considerations in later adulthood, including life expectancy, Alzheimer’s, dementias, participation in clinical trials, Parkinson’s disease, and the impact of neurocognitive disorders on mental health.Overall Health Of Latinos Based on existing research, Latinos have one of the largest health disparities across the board from maternal mortality to physical health like diabetes and obesity, and mental health like depression and suicide (U.S. Department of Health and Human Services, 2023b). According to the Centers for Disease Control and Prevention, the top three main causes of death in the population are COVID-19, heart disease, and cancer (Center for Disease Control and Prevention, 2023). The assessment asked participants in the demographic survey and interviews what they thought about their own health and their community’s health. When it comes to physical health, many participants acknowledge that diabetes, hypertension, and cancer are very common in their community. The cost of health care as mentioned earlier further hinders this population from being able to manage treatment for conditions like diabetes. The mix of inﬂation and bills make healthy eating a low priority for some. Participants noted that students get meals at school, but they aren’t always healthy. Poor diet within the community is linked to limited access to nutritious food, as well as cultural attitudes towards healthier habits and genetics.“Blood glucose strips are $50 so I don’t check my blood sugar everyday in order to make the strips last.” “Las tiras de glucosa en la sangre cuestan $50, así que no reviso mi nivel de azúcar en la sangre todos los días para que las tiras duren”. - Canton Focus Group General Health & Health By Life Stage

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104“I consider the same effort to go to work doesn’t allow me to cook a healthy breakfast, so they go to school to eat. That’s the easiest. I’m tired. I’ll stay in bed an extra 20 minutes instead of preparing a healthy breakfast” “Considero que el mismo esfuerzo para ir a trabajar no me permite cocinar un desayuno saludable, por lo que van a la escuela a comer. Eso es lo más fácil. Estoy cansado. Me quedaré en la cama 20 minutos más en lugar de preparar un desayuno saludable”. Clayton County Focus Group“I’ve gone sometimes when all the children are having breakfast and what they have on their table is a stick of bread or a pizza or a juice. There are always fried things and that’s every day”“He ido a veces cuando todos los niños están desayunando y lo que tienen en su mesa es un pan o una pizza o un jugo. Siempre hay cosas fritas y eso es todos los días”.Clayton County Focus Group

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106Attitudes Participants noted different attitudes inﬂuence healthcare and resource hesitancy in the Latino community. A lot of participants reported that Latinos often think going to see a doctor is not necessary. Some of the reasons that were reported for thinking this is that Latinos don’t believe they will have an illness or that it can become severe. A couple participants mentioned COVID and cancer as an example. Because of this belief they expressed that Latinos will not undergo routine screening or delay healthcare until they have complications, or the disease becomes severe.“Something very important [...] at least from what I have seen is true that with cancer also with mental health, we think that it does not exist or that it is very far from our lives and we do not take the precautions to do exams until it is very advanced. [...] So we realize cases when they already have stage two, three, or four”“Algo muy importante [...] por lo menos lo que he visto, [es] que con el cáncer los latinos también somos con como con la salud mental. Pensamos que no existe o que está muy lejano de nuestra vida y no tomamos las precauciones de hacer exámenes hasta que ya está muy avanzado [...] Entonces nos damos cuenta de casos cuando ya tienen etapa dos, tres o cuatro”.Dalton Focus Group

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107“With COVID, most people did whatever they were supposed to [..] even if you did not agree with covid, like me, people did not believe in COVID. A lot of people stayed at home, and fought with family, if they didn’t agree [...] and people also fought about vaccines.”“Con COVID, la mayoría de las personas hicieron lo que se suponía que debían hacer. E incluso si no estabas de acuerdo con COVID, como yo, la gente no creía en COVID. Mucha gente se quedó en casa y peleó con la familia, si no estaban de acuerdo [...] y la gente también peleó por las vacunas”.Key InformantIn the discussions, the reliance on home remedies sometimes as an alternative to more expensive or inaccessible traditional medicine emerged as a signiﬁcant factor contributing to delayed healthcare seeking. Participants shared that within the Latino community, there exists a strong belief in seeking the assistance of community healers and relying on traditional remedies as the initial approach to addressing health concerns. The cultural belief in the effectiveness of home remedies often leads individuals to prioritize these resources over seeking medical attention or taking prescribed medications. This cultural perspective underscores the importance of understanding and respecting diverse healthcare beliefs and practices within the Latino community, as well as the need for culturally competent healthcare approaches that integrate traditional healing practices with evidence-based medicine.“A child had fractured his ankle and his father took him to get massaged. ‘No. It's okay. Nothing happened to you, you just hurt it, but with a little massage you'll have enough’ and that's how the little boy lasted and the pain didn't go away. They took him to the doctor and it turns out that he broke his bone and now he was on crutches for a long time. And that affected him and that is what happens with Latino people who with a home remedy think they are going to heal” "Un niño se había fracturado el tobillo y su padre lo llevó a recibir un masaje. ‘No. Está bien. No te pasó nada, solo te lastimaste, pero con un pequeño masaje tendrás suﬁciente’ y así duró el niño y el dolor no desapareció. Lo llevaron al médico y resulta que se rompió el hueso y ahora estaba con muletas durante mucho tiempo. Y eso le afectó y eso es lo que pasa con las personas latinas que con un remedio casero piensan que se van a curar".Dalton Focus Group

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108The issue of mistrust emerged as a critical barrier impacting the healthcare-seeking behavior of the Latino community, as expressed by multiple participants. Mistrust towards organizations and larger entities was cited as a signiﬁcant deterrent that prevents individuals from seeking help and support, leading to long-term negative effects on their health. Furthermore, participants highlighted a growing mistrust in information, which further fuels skepticism towards organizational efforts. Negative experiences, especially within healthcare settings, were identiﬁed as particularly detrimental, as they signiﬁcantly discourage Latinos from seeking medical care and foster a deep sense of apprehension.Participants highlighted the pressing issue of prioritizing employment over healthcare within the Latino community. They also emphasized that the need to provide for themselves and their families often takes precedence. “[...] there’s more of a bigger distrust for the information that is presented. [...] we’ll try to talk to them about, you know, like doing a blood work checkup. And it’s like, but how are they gonna do it? Like, Are they trying to steal my information? Like, or even when it comes to getting the Covid vaccine ... there was a lot of rumors spread around... and I would say like the lack of access to information that is accessible has a lot to do with it in regards to the healthcare aspect.”“[...] Hay más de una mayor desconﬁanza por la información que se presenta. [...] Trataremos de hablar con ellos sobre, ya sabes, cómo hacer un chequeo de sangre. Y, pero ‘¿cómo lo van a hacer? ¿Están tratando de robar mi información? [...] o incluso cuando se trata de obtener la vacuna de COVID... hubo muchos rumores difundidos.... y yo diría que la falta de acceso a la información que es accesible tiene mucho que ver con eso en lo que respecta al aspecto de la atención médica”. - Key Informant

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109Many participants shared their experiences of working long hours or in demanding jobs, which ultimately hindered their ability to prioritize personal health and well-being. This challenging dynamic creates difﬁculties in improving overall health outcomes and may have detrimental effects on family dynamics, exacerbating existing health or mental health issues.“A lot of it is part of the culture. I think they come from good. Many come from a country where they have to work and work to be able to support themselves, so they come with this fear that if I don’t work I won’t have a way to support myself without a day’s work.[...] I don’t have money to support myself.”“Mucho es parte de la cultura. Creo que vienen de bueno. Muchos vienen de un país donde tienen que trabajar y trabajar para poder mantener entonces vienen con este miedo de que si no trabajo no voy a tener cómo mantenerme sin un día de trabajar.[...] no tengo dinero para sostenerme”.Dalton Focus Group “[…] if they’ve got to decide between, you know, food for the kids or them going to the doctor, they might go for food for the kids. They might not be able to afford insulin. They might not be able to afford some of the medication, even if they do get prescribed it.“[…] si tienen que decidir entre, ya sabes, comida para los niños o ir al médico, podrían optar por comida para los niños. Es posible que no puedan pagar la insulina. Es posible que no puedan pagar algunos de los medicamentos, incluso si se los recetan”.Key Informant

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110Immunizations & Health ScreeningsA crucial part of maintaining a healthy community is the utilization of preventative healthcare measures, which include routine health screenings and vaccinations. These interventions enable early detection and prevention of disease, leading to improved health outcomes. For the Hispanic/Latino community, health screenings and immunizations play a signiﬁcant role in sustaining health and reducing health disparities. The Hispanic/Latino community, one of the most dynamic and diverse ethnic groups in the United States, has speciﬁc health challenges that require tailored approaches. Socioeconomic, cultural, and linguistic factors inﬂuence the way this community interacts with healthcare services. Understanding these elements is key to developing strategies that increase access and adherence to preventive health measures like screenings and immunizations.Inﬂuenza (Flu) VaccinationThe inﬂuenza vaccination, often referred to as the “ﬂu shot,” is a preventive measure designed to safeguard individuals against inﬂuenza, a contagious respiratory illness that can lead to serious complications, and in some instances, death (Centers for Disease Control and Prevention, 2022b). It is produced annually to combat the ﬂu viruses expected to be most prevalent in the upcoming ﬂu season, based on global surveillance and scientiﬁc predictions made by the World Health Organization. The vaccine works by introducing a weakened or inactivated form of the virus, or a piece of the virus (such as a protein), into the body (Centers for Disease Control and Prevention, 2022b). This triggers the immune system to develop antibodies that “remember” how to ﬁght off the ﬂu virus if they encounter it in the future. By getting the ﬂu vaccination, individuals not only protect themselves but also contribute to the larger community’s health by reducing the overall spread of the virus. It’s particularly crucial for vulnerable populations like the elderly, young children, pregnant women, and individuals with certain chronic health conditions who are at a higher risk of developing serious ﬂu-related complication (Centers for Disease Control and Prevention, 2022b).During the 2021-2022 inﬂuenza season, Hispanics/Latinos in Georgia had a slightly higher rate of receiving a ﬂu vaccination compared to Hispanics/Latinos nationwide (Table 10, Figure 22).

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111Table 10Hispanics/Latinos ages 6 months+ received the ﬂu vaccine during 2021-2022 inﬂuenza seasonTable 10Hispanics/Latinos ages 6 months+ received the ﬂu vaccine during 2021-2022 inﬂuenzaNote. Centers for Disease Control and Prevention, 2021-22 Inﬂuenza Season Vaccination Coverage Dashboard,Cumulat ive monthly inﬂuenza vaccination coverage est imates by state, 2021-22 Inﬂuenza Season.https:/ /www.cdc.gov/ﬂu/f luvaxview/reportshtml/report i1920/reportii/index.htmlNote: Centers for Disease Control and Prevention, 2021-22 Inﬂuenza Season Vaccination Coverage Dashboard, [Cumulative monthly inﬂuenza vaccination coverage estimates by state, 2021-22 Inﬂuenza Season]. (https://www.cdc.gov/ﬂu/ﬂuvaxview/reportshtml/reporti1920/reportii/index.html) 53%45%45%55%43%50%41%50%Ot he r / M ul t ip le R ac e sHispanic/ LatinoNon-Hispanic BlackNon-Hispanic WhiteUnited States Georgia

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112Pneumococcal VaccinationPneumococcal disease is a grave condition that has far-reaching consequences. It’s the catalyst behind approximately 150,000 hospitalizations each year in the United States due to pneumococcal pneumonia. In 2019, pneumococcal meningitis and bacteremia claimed the lives of nearly 3,250 individuals in the U.S. (National Center for Immunization and Respiratory Diseases, Division of Bacterial Diseases, 2023). Pneumococcal disease does not discriminate; it can affect anyone. However, certain demographics, such as young children and older adults, ﬁnd themselves at a heightened risk compared to other age groups. Also, individuals with certain medical conditions or risk factors are at an increased risk of developing pneumococcal disease (Centers for Disease Control and Prevention, 2023b).To combat the effects of this disease, the CDC recommends pneumococcal vaccines for both children and adults. Children under 5, and those between the ages of 5 and 18 with speciﬁc health conditions that elevate their risk, should receive either the PCV13 or PCV15 vaccines. Additionally, children between the ages of 2 and 18 with certain medical conditions should also receive the PPSV23 vaccine (Centers for Disease Control and Prevention, 2023b).Low Pneumonia Vaccination Rate In Hispanic/Latino Adults Aged 65+ In GeorgiaA key ﬁnding from the KFF analysis of the Centers for Disease Control and Prevention (CDC)’s 2013-2021 Behavioral Risk Factor Surveillance System (BRFSS) is the notably low rate of reported pneumonia vaccination among Hispanic/Latino adults aged 65 and over in Georgia. Only 32.6% of individuals within this demographic reported having ever received the pneumonia vaccine (Table 11) (KFF, 2021a)Pronounced Disparities In Pneumonia Vaccination Rates Between Hispanic/Latino Adults And Other Racial/Ethnic GroupsTable 11 further highlights the pronounced disparities when the Hispanic/Latino community’s vaccination rate is compared to that of other racial and ethnic groups in Georgia:

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113Vaccination Requirements For ChildrenOverview Of Child Vaccination Importance And RequirementsPublic health is greatly safeguarded by the implementation of vaccination requirements for children, which are critical in preventing infectious diseases’ spread and protecting the vulnerable. These requirements often stipulate that speciﬁc vaccines be administered before children are admitted into educational or childcare institutions. Standard vaccinations in this regard often include measles, mumps, rubella (MMR), diphtheria, tetanus, pertussis (DTaP), polio, hepatitis B, and varicella (chickenpox).The high vaccination coverage rates resulting from these requirements signiﬁcantly lower the risk of disease outbreaks, safeguarding both children who have been vaccinated and those medically unable to receive vaccines. Table 11 Adults Aged 65+ Who Report Ever Having a Pneumonia Vaccine by Race/Ethnicity in Georgia, 2021Note: KFF analysis of the Centers for Disease Control and Prevention ( CDC)’s 2013 - 2021 Behavior Risk Factor Surveillance System (BRFSS)

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115Child Immunization Rates Across Different Racial And Ethnic GroupsComparing the immunization rates across racial and ethnic groups in the United States and Georgia highlights an interesting trend (Table 13). Nationally, the vaccination rate for Hispanic/Latino children averages at 68%. However, in Georgia, the vaccination rate for this group stands at 72%, which indicates a 4% higher vaccination rate than the national average for Hispanic/Latino children (Centers for Disease Control and Prevention, 2017).In the United States, non-Hispanic white children have a vaccination rate of 71%, which is 3% lower than the 72% for Hispanic/Latino children in Georgia. Similarly, the rate for non-Hispanic Black children nationwide is 64%, a substantial 8% lower than the rate for Hispanic/Latino children in Georgia. When examining the rates within Georgia itself, Hispanic/Latino children have a 2% higher vaccination rate than non-Hispanic white children and a signiﬁcant 7% higher rate than non-Hispanic Black children (Centers for Disease Control and Prevention, 2017).Table 13Percent of Children Aged 0-35 Months Who Are Immunized by Race/Ethnicity, 2014-2017Note: Data presented are for children born f rom 2014 to 2017 who received the combined (4 :3:1:3:3:1:4) vaccine series by 2020. The combined 7-series vaccination includes ≥4 doses of DTaP, ≥3 doses of poliovirus vaccine, ≥1 dose of measles-containing vaccine, full series of Hib vaccine (≥3 or ≥4 doses, depending on product type), ≥3 doses of HepB, ≥1 dose of varicella vaccine, and ≥4 doses of PCV Children identif ied as non-Hispanic white, non-Hispanic Black, or Other were non-Hispanic/Latino. Sources: Adapted f rom U.S. Department of Health and Human Services (DHHS) . Nat ional Center for Immunizat ion and Respiratory Diseases. The Nat ional Immunizat ion Survey-Child, Atlanta, GA: Centers for Disease Control and Prevention, 2020. Data can be accessed through[ChildVaxView Interactive. https://www.cdc.gov/vaccines/imz-managers/coverage/childvaxview/datareports/index.html

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116Childhood | Adolescent HealthAcross the United States, disparities in health amongst Hispanic/Latino individuals often begin in their formative years. Due to a variety of factors such as socioeconomic class, skin color, gender, and origin, Hispanic/Latino youth are placed in vulnerable positions (Perreira & Allen, 2021). This accumulation of hardships can harm the health of Hispanic/Latino children and adolescents during key stages of their growth and can result in health inequities persisting into adulthood. Key stages of development are periods when experiences, behaviors, and health concerns can leave lasting impacts on an individual’s health. This section will delve into various issues, including health insurance, access to medical care, oral health, obesity, substance use, asthma, mental health, and physical activity among children and adolescents.Key Points· Children in the United States with two undocumented parents typically have poorer health compared to those with only one undocumented parent. Furthermore, a mother’s place of birth and legal status can have a more profound impact on a child’s health than the father’s (Perreira & Allen, 2021).· Individuals without health insurance often delay seeking healthcare or decide against it entirely, which can lead to worse health outcomes compared to those who are insured (Garﬁeld et al., 2019)· Despite the fact that most Hispanic/Latino children are born in the United States, around 55% have at least one immigrant parent, with an estimated 25 to 28% having a parent who is an undocumented immigrant (Perreira & Allen, 2021).· In Georgia, 20% of parents of children within the age groups 0 to 4 and 5 to 10 are immigrants. Among these immigrant parents, 47% of those with children aged 0 to 4 are Hispanic/Latino, and for those with children aged 5 to 10, 49% are Hispanic/Latino. In contrast, most U.S.-born parents of children in these same age groups identify as either non-Hispanic white or non-Hispanic Black, with Hispanic/Latino and AAPI parents forming a signiﬁcantly smaller percentage (Hofstetter & McHugh, 2021)· Hispanic/Latino children in Georgia are nearly three times less likely to have health insurance compared to their non-Hispanic/Latino (Whitener & Corcoran, 2021) In Georgia, the disparities in health coverage among Hispanic/Latino subgroups reveal pressing inequities. In 2019, a particularly alarming statistic is that nearly one out of every two Honduran children (46.7%) in the state remains uninsured (Whitener & Corcoran, 2021). In contrast, the uninsured rate for Mexican children in Georgia stands at 15.5% (Whitener & Corcoran, 2021). Meanwhile, Guatemalan children face a signiﬁcant coverage gap, with 32.2% lacking insurance. These numbers starkly contrast with the uninsured rate for non-Hispanic/Latino children, which is a mere 5.9%. Such disparities

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117not only highlight the distinct challenges faced by each subgroup but also underline the urgent need for targeted state and local policies to ensure equitable health coverage for all children, irrespective of their ethnicity or background (Whitener & Corcoran, 2021) Late-To-Older Adulthood Health & The Aging Experience The aging population has experienced signiﬁcant growth over the past century due to multiple factors. The primary reason is the decrease in mortality rates from the leading causes of death, including heart disease, cancer, stroke, chronic lower respiratory tract disease, and Alzheimer’s disease, which collectively account for 69.5% of all deaths (Ferrucci et al., 2008). As a result of increased longevity, there is a rising demand for healthcare and social services. The Hispanic/Latino demographic represents the fastest-growing segment within the older population (Garcia et al., 2017).Key Points· In 2010, the Hispanic/Latino demographic aged 65 or older in the U.S. numbered 2.9 million, representing 7.1% of the population within this age bracket. This number is projected to rise to over 17.5 million, equating to 19.8% of the 65+ population, by 2050 (Garcia et al., 2017).· According to research involving epigenetic clocks, it has been observed that Hispanics/Latinos age at a slower pace compared to other ethnic groups (Horvath et al., 2016; Schmidt, 2016).· Cultural values, such as “familismo” or “familism,” greatly impact the Hispanic/Latino aging experience. This value indicates a preference, and sometimes an expectation, that elderly Hispanics/Latinos will receive care from their family members rather than professional healthcare providers (Samper-Ternent et al., 2022).· The “Hispanic/Latino Paradox” refers to the observation that Hispanics/Latinos, despite having a lower average socioeconomic status, often exhibit better health outcomes compared to their non-Hispanic white counterparts (Garcia et al., 2017).· The “Healthy Immigrant Effect” suggests that individuals who opt to immigrate to the United States are generally healthier and more robust (Garcia et al., 2017).· Hispanic/Latino older adults are frequently underrepresented in clinical trials and research, which can complicate efforts to comprehend their healthcare needs fully (Jimenez et al., 2020)Life Expectancy Trends in the United States by Race/EthnicityHistorically, a notable disparity existed in life expectancy between Hispanics/Latinos and non-Hispanic whites, but this gap substantially diminished in 2020 (Arias et al., 2022). Hispanics/Latinos experienced the most signiﬁcant drop in life expectancy of all groups, declining by 3 years from 81.8 years in 2019 to 78.8 years in 2020, with COVID-19 accounting for 90% of this reduction. Despite this, Hispanics/Latinos continue to have the

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118highest life expectancy at birth among all racial/ethnic groups (2020 data below). The average American life expectancy at birth was 77.8 years in 2020, with Hispanics/Latinos at 79.9 years, non-Hispanic whites at 78.0 years, and non-Hispanic Blacks at 72.0 years. Within all racial/ethnic groups, females consistently outlive males, with Hispanic/Latino women having the highest life expectancy at birth, 83.3 years (Arias et al., 2022).· General American population: 77.8 years· Hispanics/Latinos: 79.9 years· Non-Hispanic whites: 78.0 years· Non-Hispanic Blacks: 72.0 yearsThe Aging Process for Hispanics/LatinosStudies using epigenetic clocks have shown that Hispanics/Latinos age more slowly compared to other ethnic groups (Horvath et al., 2016; Schmidt, 2016). The metric Intrinsic Epigenetic Age Acceleration (IEAA) was used to assess aging, unconfounded by extracellular differences in blood cell counts. Hispanics/Latinos consistently exhibited lower IEAA, indicating slower aging compared to non-Hispanic whites. Interestingly, the study found that Hispanics/Latinos born outside but living in the U.S. have a higher IEAA (age faster) than Hispanics/Latinos born and raised in the U.S. The longer life expectancy of Hispanics/Latinos in the U.S., despite higher burdens of traditional cardio-metabolic risk factors, is referred to as the “Hispanic/Latino Paradox” (Horvath et al., 2016; Schmidt, 2016).Older Hispanics/Latinos: Mortality vs. Morbidity of Disabilities The life expectancy advantage Hispanics/Latinos enjoy may not translate to better health outcomes (Garcia et al., 2017). Despite lower mortality rates, high morbidity rates persist. If health status doesn’t improve over the long term, it could lead to a general decline in population health. The advantage of increased lifespan may be diminished if the additional years are spent coping with physical disabilities. Research suggests that older Hispanics/Latinos are more prone to disability or at a higher risk of developing a disability compared to non-Hispanic whites (Garcia et al., 2017). Type 2 diabetes, associated with depression, stroke, and physical limitations, is a signiﬁcant risk factor for disability.Alzheimer’s Disease And Related Dementias Dementia is a general term for various cognitive changes and disabilities resulting from multiple causes, not a speciﬁc disease. The prevalence of dementia doubles every ﬁve years among individuals aged 65 to 85 (Lopez & Kuller, 2019). Nearly 13% of Hispanics/Latinos age 65 or older have Alzheimer’s or a related dementia (Association, 2021). As part of their mission to better understand the experiences and perceptions surrounding Alzheimer’s and dementia care in the United States, the Alzheimer’s Association commissioned a research study that is particularly noteworthy as it incorporates the perspectives of diverse racial and ethnic groups, including Hispanic/Latino Americans.The data collected highlight signiﬁcant disparities in access to care, experiences of discrimination, and attitudes towards clinical research. Hispanic/Latino Americans are reported to be 1.5 times more likely to

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119develop dementia than non-Hispanic whites, underscoring the pressing need to understand and address their speciﬁc experiences and challenges in relation to Alzheimer’s and dementia care. The key ﬁndings from these surveys highlight signiﬁcant disparities for Hispanic/Latino Americans in areas such as access to care, experiences of discrimination, trust in clinical trials, and perceptions of Alzheimer’s disease.Key Findings:· Discrimination as a Barrier to Care: Discrimination is perceived as a barrier to receiving Alzheimer’s care by more than one-third of non-Hispanic Black Americans (36%), and nearly one-ﬁfth of Hispanic/Latino Americans (18%) and Asian Americans (19%). Notably, Hispanic/Latino Americans, who are 1.5 times more likely than non-Hispanic whites to have dementia, report that a third (33%) have experienced discrimination when seeking health care.·Demand for Culturally Competent Providers: The importance of Alzheimer’s and dementia care providers understanding their ethnic or racial backgrounds is emphasized by most non-Hispanic white respondents. Almost 9 out of 10 Hispanic/Latino respondents (85%) reported this as important. · Diverse Perceptions and Stigma About Alzheimer’s: Levels of concern about developing Alzheimer’s showed signiﬁcant variation across racial and ethnic groups. Nearly 6 in 10 Hispanic/Latino respondents (57%) believe that a signiﬁcant loss of memory or cognitive abilities is a normal part of aging. Non-Hispanic white respondents expressed the highest level of concern (48%), compared to non- Hispanic Black (35%), Hispanic/Latino (41%), and Native American respondents (25%) (Alzheimer’s Association, 2021).Underrepresentation in Clinical Trials for ADRDDespite the rapidly expanding Hispanic/Latino demographic in the United States, which currently accounts for 18% of the total population, there is a notable underrepresentation in Alzheimer’s and related dementias (ADRD) clinical trials. Hispanics/Latinos constitute a mere 2% of participants in ADRD clinical trials (Marquez et al., 2022). This disparity is particularly troubling when juxtaposed with predictions forecasting a staggering 832% surge in the number of Hispanics/Latinos afﬂicted with Alzheimer’s disease by the year 2060. Moreover, studies have identiﬁed Hispanics/Latinos as being 1.5 times more likely to develop ADRD compared to their non-Hispanic white counterparts (Marquez et al., 2022).Mitigating the underrepresentation of Hispanics/Latinos in clinical trials necessitates an understanding of the obstacles discouraging their participation. Marquez et al. (2022) sheds light on this issue by identifying ﬁve main themes from participant responses: remaining in limbo due to uncertainty or lack of information, wanting information about ADRD and its associated research, the need for vetting researchers through trusted local organizations, and practicing altruism through research participation. Accordingly, strategies to boost Hispanic/Latino representation should

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120focus on heightening awareness about ADRD, its elevated prevalence in the Hispanic/Latino community, the value of clinical trials, and the potential beneﬁts to future generations and the wider community. Additionally, creating opportunities for participation through trusted local organizations can alleviate the uncertainty and hesitation often associated with research participation (Marquez et al., 2022).Key Findings of Table 14 Trends by Race/Ethnicity:· Hispanic/Latino: Notably, no data were available from 1994 to 1998. However, in 1999, the death rate was documented at 11.0 per 100,000 individuals. This ﬁgure escalated to 27.4 per 100,000 individuals by 2020, showcasing a signiﬁcant rise in the mortality rate due to Alzheimer’s over two decades (Figure 23).· Non-Hispanic white: The data demonstrate a dramatic increase in the death rate from Alzheimer’s. From 1994 to 1999, the death rate from Alzheimer’s had nearly doubled to 21.2 per 100,000 individuals, and it further jumped to 48.6 per 100,000 individuals in 2020 (Figure 24).· Non-Hispanic Black: In 1994, the death rate was 6.2 per 100,000 individuals, which doubled to 12.6 per 100,000 in 1999. By 2020, the rate had surged to 44.1 per 100,000 individuals, slightly behind the non-Hispanic white population but signiﬁcantly higher than the Hispanic/Latino population (Figure 25).All three demographic groups have seen a rise in Alzheimer’s-related mortality from 1994 (or 1999 for Hispanics/Latinos) to 2020. The data suggest that non-Hispanic whites have the highest age-adjusted death rate due to Alzheimer’s. The data also underscore the considerable overall increase in Alzheimer’s-related deaths in Georgia over the period studied, indicating a growing public health concern that may necessitate increased healthcare resources and preventative measures for Alzheimer’s disease.Table 14Age-Adjusted Death Rate, Alzheimer’s Disease, Georgia, 1999, 2020Rate Trends For Alzheimer’s Disease And Related Dementias By Race/EthncityIn Georgia (1994-2020)Source: OASIS, 2022

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121Impact on Hispanic/Latino Community: The upward trend in Alzheimer’s-related deaths among the Hispanic/Latino population in Georgia from 1999 to 2020 underscores a growing public health issue within this community. The age-adjusted death rate has more than doubled, rising from 11.0 to 27.4 per 100,000 individuals. Although the 2020 death rate for the Hispanic/Latino population was lower than that of non-Hispanic whites and non-Hispanic Blacks, the signiﬁcant increase over two decades signals a considerable health concern. The growing impact of Alzheimer’s on the Hispanic/Latino community in Georgia highlights an urgent need for targeted healthcare strategies, improved access to preventative measures, and more resources dedicated to managing and treating Alzheimer’s within this population group.19940.05.010.015.020.025.030.01995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202019940.010.020.030.040.050.019951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020Figure 23Note: Created on OASIS, 2022Note: Created on OASIS, 2022Figure 24

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122Parkinson’s Disease (PD)Parkinson’s Disease is a neurodegenerative disorder that affects mainly the dopamine-producing neurons in the brain. Symptoms develop gradually over the years and differ from person to person. Some of the symptoms include tremors, bradykinesia (the slowness of movement), limb rigidity, as well as gait and balance problems. The cause of Parkinson’s remains unknown. There is no cure, however, treatment options include medications and surgery.A study reveals a 63% increase in the death rate from Parkinson’s Disease in the United States over the past two decades (Rong et al., 2021). The study utilized data from a national death registry, including 479,059 Parkinson’s-related deaths between 1999 and 2019.19940.010.020.030.040.050.019951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020Figure 25Note: Created on OASIS, 2022

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123PD mortality rates varied by age group over the two-decade period, with individuals aged 85 and above experiencing the most signiﬁcant rise in Parkinson’s-related deaths.PD mortality rates increased for both males and females over the two decades. The rate for males was more than double that of females, suggesting that males had a signiﬁcantly higher risk of dying from Parkinson’s Disease compared to females. Table 15Total and Age-Adjusted PD Mortality RateTable 16PD Mortality Rates by Age GroupTable 17PD Mortality Rates by SexPD mortality rates in the United States increased from 1999 to 2019 by approximately63% - suggesting a concerning upward trend in Parkinson’s-related deaths over the twodecadeperiod.

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124Non-Hispanic white individuals had the highest death rate from PD among the three racial and ethnic groups followed by Hispanic/Latino individuals, and then non-Hispanic Black individuals. Notably, Hispanic/Latino individuals had a lower PD mortality rate initially but experienced a faster increase of approximately 86%, while non-Hispanic Black individuals had the highest percentage increase of approximately 96%. Small metropolitan areas trended a higher overall PD mortality rate compared to rural regions (noncore areas), albeit with a smaller difference in 2019 compared to 1999 (11% versus 36% mortality rate). Notably, rural regions (noncore areas) experienced the highest percentage increase of approximately 89% in PD mortality rates from 1999 to 2019.The data provided in Figures 26, 27, and 28 indicate a concerning increase in the age-adjusted death rate related to the complications of Parkinson’s among different racial/ethnic groups in Georgia from 1994 to 2020. (Figure 26) There is no data on the age-adjusted death rate of Parkinson’s for Georgia Hispanic/Latino from 1994 through 2004. In 2005, the age-adjusted mortality rate of Parkinson’s for Georgia Hispanic/Latino was 7.0 per 100,000 individuals. In 2020, it had only increased to 7.9 per 100,000 individuals.Table 19PD Mortality Rates by Urban-Rural ClassiﬁcationTable 20Age-Adjusted Death Rate, Parkinson’s Disease, Georgia, 2005-2020

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125(Figure 27) The age-adjusted death rate of Parkinson’s for non-Hispanic white Georgians in 1994 was 4.2 per 100,000 individuals. In 2005, it had increased to 6.4 per 100,000. By 2020, it had essentially doubled to 12.7 per 100,000 individuals(Figure 28) The age-adjusted death rate of Parkinson’s for non-Hispanic Black Georgians in 1994 was 2.0 per 100,000 individuals. In 1999, the death rate had slightly dipped to 1.9 per 100,000. In 2020, it tripled to 6.0 per 100,000 individuals, but still behind the mortality rate for Georgia non-Hispanic whites and Hispanics/Latinos. Figure 26Figure 26Note: Created on OASIS, 2022Note: Created on OASIS, 202219940.02.04.06.08.010.012.014.01995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202019940.02.04.06.08.010.019951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020

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126Sexual & Reproductive HealthSexually Transmitted Infections (Sti/Stds)Note on the Potential Impact of COVID-19 on STD Surveillance by the CDC: During the initial phases of the pandemic, decreased screening efforts and a shift in focus from STD-related services to COVID-19-related efforts might have led to a lower number of reported infections, a circumstance particularly relevant for asymptomatic STDs like chlamydia, syphilis, and gonorrhea (Centers for Disease Control and Prevention, 2023c). In the later stages of 2020 and into 2021, the CDC noticed an upward trend in reported cases of gonorrhea and syphilis. These increases may not solely reﬂect higher disease transmission rates. They could also be inﬂuenced by various factors including the reopening of health clinics, changes in sexual behavior during the pandemic, and the potential for longer periods of infection due to delayed access to care. While there was a small increase in the number of diagnosed chlamydia cases from 2020 to 2021, the overall reported cases were still fewer than in 2019 (Centers for Disease Control and Prevention, 2023c). This decline is unlikely to suggest a decrease in actual infections but instead mirrors the changes in STD screening and diagnosis priorities amidst the pandemic. To summarize, due to these various inﬂuences on STD surveillance Figure 27Note: Created on OASIS, 202219940.01.02.03.04.05.06.07.019951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020

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127during the pandemic, readers are advised to interpret the data from these years with caution, as they may not fully represent the actual infection rates during this period.According to the CDC, reported cases of sexually transmitted infections (STIs) have increased dramatically in recent years. Chlamydia, gonorrhea, and syphilis cases have been increasing for years. In 2021, there were 2.5 million new cases of STIs across the United States (Centers for Disease Control and Prevention, 2023f).· Chlamydia: From 2012 to 2021 in the United States, the rate of Chlamydia infections increased by approximately 37.2% for men but slightly decreased by around 1.5% for women. The total rate increased by about 9.3% over the period. In Georgia, The total rate of Chlamydia infections increased by approximately 19.1% from 2012 to 2021.· Gonorrhea: From 2012 to 2021, the rate of Gonorrhea infections nearly doubled in the United States, with a signiﬁcant increase of approximately 137.8% in men, 64.9% in women, and a total increase of around 100.5%. The rate of Gonorrhea infections in Georgia increased by approximately 92.2% from 2012 to 2021, with a shift in the rate category indicating more severe outbreaks in later years.· Congenital Syphilis: While Congenital syphilis rates in the US have decreased by approximately 88% since 1941, there has been a concerning rise of about 827.4% in the last decade, from 2012 to 2021. The rate of Congenital syphilis in Georgia has risen sharply by 525% from 2012 to 2021, with the rate signiﬁcantly increasing from 12 to 75 cases per 100,000 birth.People most affected by STIs include (CDC, 2023):· Adolescents and people aged 15-24 years· Gay, bisexual, and other men who have sex with men· Pregnant people· People from some racial and ethnic minority groupsImpact of STIs on HIV: STIs like chlamydia, gonorrhea, and syphilis increase the chance of getting HIV. STIs also increase the chance of transmitting HIV to others. Notably, 6% of sexually acquired HIV infections are attributed to chlamydia, gonorrhea, and syphilis.ChlamydiaUnderstanding ChlamydiaChlamydia, a bacterial infection, stands as the most reported sexually transmitted infection (STI) in the U.S., impacting both genders (Centers for Disease Control and Prevention, 2023f; United Health Foundation, 2021). Recorded cases in 2020 approached nearly 1.6 million. However, the actual ﬁgure may be signiﬁcantly higher as many individuals remain untested due to the absence of symptoms. Despite not displaying noticeable symptoms, Chlamydia infections can inﬂict irreversible harm to reproductive organs.Populations Most Affected by Chlamydia: Certain demographics report higher rates of chlamydia, including:· Women: more likely to receive a chlamydia

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128diagnosis than men due to routine screening and higher symptom frequency.· Young adults: higher incidence rates than other age groups.· Certain racial and ethnic groups: speciﬁcally non-Hispanic Black, American Indian/Alaska Native (AIAN), and Native Hawaiian Paciﬁc Islander adults (NHPI), have higher prevalence rates compared to multiracial, non-Hispanic white, and Asian adults.United StatesOverview Of Chlamydia Incidence In The United States (2021)The key ﬁndings on the 2020-2021 trends and challenges in Chlamydia trachomatis infections in the United States according to the CDC’s Sexually Transmitted Disease Surveillance 2021:· Dominance of Chlamydia trachomatis Infection in 2021: In 2021, there were a total of 1,644,416 reported cases of Chlamydia trachomatis infection, making it the most common notiﬁable sexually transmitted infection in the United States.· Increase in Chlamydia trachomatis Infection Rates in 2021: The case count in 2021 reﬂects a rate of 495.5 cases per 100,000 population, marking a 3.9% increase from the previous year (CDC, 2023d).Burden Of Chlamydia Among Racial/Ethnic Groups: An Examination Of The Hispanic/Latino PopulationIn 2021, Chlamydia rates varied substantially across different racial and ethnic groups in the United States (Figure 3.31). When looking at the Hispanic/Latino population, the rate of chlamydia stood at 228 per 100,000 for males and 473 per 100,000 for females (Centers for Disease Control and Prevention, 2023f). 0 6 25 1250 1875 2500Non-Hispanic BlackNon-Hispanic whiteHispanic/ Latinorate per 100,000Figure 29Chlamydia — Rates of Reported Cases by Race/Hispanic Ethnicity and Sex, United States, 2021Note. Adapted from Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2021. Atlanta: U.S. Department of Health and Human Services; 2023.

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129These rates indicate a signiﬁcant burden of chlamydia infections among the Hispanic/Latino population. GeorgiaChlamydia Incdience Among Hispanic/Latino Population In Georgia, By Race/Ethnicity, (2019-2021)Between 2019 and 2021, the Hispanic/Latino population in Georgia exhibited a substantial increase in Chlamydia cases and rates. In 2019, this demographic reported 3,149 cases with a rate of 300 per 100,000 population. By 2021, these ﬁgures escalated to 4,233 cases and a rate of 383, a 35% rise in case numbers and a 28% increase in rate over the two years (CDC, 2023c).Comparison By Race/Ethnicity During the same period, non-Hispanic Black and non-Hispanic white populations experienced different trends. While the non-Hispanic Black population continually reported higher case counts and rates than the Hispanic/Latino group, their growth rate was not as considerable, with a 14% increase in cases and an 11% increase in rates. The non-Hispanic white population, however, saw a reduction in cases and rates in 2020, (7.7%) and (7.7%), but rebounded in 2021. Despite this rebound, their overall rate remained the lowest among the three groups (Centers for Disease Control and Prevention, 2023d).SummaryOver the three-year period, the Hispanic/Latino population in Georgia experienced the most substantial growth in both Chlamydia cases and rates. This increase was more pronounced compared to both the non-Hispanic Black and non-Hispanic white populations. Such ﬁndings highlight the necessity for further research and targeted public health interventions to address this growing concern within the Hispanic/Latino community.Chlamydia Incidence Among Males And Females In The Hispanic/Latino Population In Georgia (2021)Disparity in Chlamydia Cases and Rates Among Hispanic/Latino Males vs. Females: In the year 2021, both the number of cases and the rate of Chlamydia infection were signiﬁcantly higher among Hispanic/Latino females in Georgia compared to their male counterparts.· In 2021, a clear disparity in Chlamydia cases and rates was observed between male and female Hispanic/Latino individuals in Georgia. Female cases were signiﬁcantly higher, with 2,941 cases reported (69% of total), as opposed to 1,291 (31% of total) cases in males (Figure 30). This represents over twice the number of cases in females compared to males (Centers for Disease Control and Prevention, 2023d).· The infection rate per 100,000 population also followed the same pattern. Females had a much higher rate of 555, while males had a rate of 224. This means that, in 2021, Over the three-year period, the Hispanic/Latino population in Georgia experienced the most substantial growth in both Chlamydia cases and rates.

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130the Chlamydia infection rate was over twice as high in females as in males within the Hispanic/Latino population in Georgia (Centers for Disease Control and Prevention, 2023d).GonorrheaUnderstanding GonorrheaGonorrhea, an extremely common sexually transmitted disease (STD), can cause infections in the genitals, rectum, and throat. It is especially prevalent among young adults, particularly those aged between 15 and 24 years, making it the second-most frequently reported bacterial infection in the country (Centers for Disease Control and Prevention, 2022a).United StatesStats & Trends For Gonorrhea In The United StatesIn 2021, the Centers for Disease Control and Prevention (CDC) recorded a total of 710,151 cases of gonorrhea, marking it as the second-most reported sexually transmitted infection in the United States for that year (Centers for Disease Control and Prevention, 2023e). A comparison to 2009’s historically low rates reveals a noteworthy 118% increase in reported cases of the disease.Trends By RegionPer CDC’s Sexually Transmitted Disease Surveillance 2021 Report, the South had the highest rate of reported gonorrhea, followed by the Midwest, the West, and the Northeast (CDC, 2023, “Sexually Transmitted Disease Surveillance 2021”) (see Table 21).· South: In 2021, the South reported the highest rate of gonorrhea with 243 cases per 100,000 people, marking a 5.2% increase from the previous year.Figure 30Chlamydia cases, Males and Females, Hispanic/Latino, Georgia 2021Note. Adapted from Centers for Disease Control and Preven-tion. (2023). National Center for HIV, Viral Hepatitis, STD, and TB Prevention [NCHHSTP] AtlasPlus. https://gis.cdc.gov/grasp/nchhstpatlas/charts.html?c=386&d=303&i=206&g=5011&yr=543&a=651&r=555&s=601&tc=801&roc=1101

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131GeorgiaGonorrhea Prevalence Among Speciﬁc Racial/Ethnic Groups Georgia (2021)Incidence Rates In The Hispanic/Latino Population: Despite representing a substantial demographic in Georgia with a population of 1,104,836, the Hispanic/Latino community exhibited a signiﬁcantly lower burden of Gonorrhea compared to other racial and ethnic groups. The number of Hispanic/Latino cases represents approximately 4.7% of 24,143 cases. The data indicated 1,154 recorded cases of Gonorrhea among this group, corresponding to an incidence rate of about 104 cases per 100,000 individuals (1,154 cases out of a population of 1,104,836 Hispanic/Latino individuals) (Centers for Disease Control and Prevention, 2023e).Comparison with Other Racial/Ethnic Groups: Compared to non-Hispanic Black and non-Hispanic white populations, the Hispanic/Latino community experiences signiﬁcantly lower rates of Gonorrhea (660 per 100,000 and 94.6 per 100,000, respectively).The Hispanic/Latino community experiences signiﬁcantly lower rates of gonorrhea compared to other racial and ethnic groups.Note. From the CDC’s Sexually Transmitted Disease Surveillance 2021 Report. Data from this surveillance report is based on case notiﬁcation data provided to the Centers for Disease Control and Prevention (CDC) through the National Notiﬁable Diseases Surveillance System (NNDSS) and data collected through projects and programs that monitor STDs in various settings, including the STD Surveillance Network (SSuN) and the Gonococcal Isolate Surveillance Project (GISP).Table 21Reported Gonorrhea Rates in Different US Regions, 2021

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132Women’s HealthChronic Health Issues Affecting Hispanic/Latina Women In The United States & GeorgiaThis section explores the pronounced disparities in chronic health conditions impacting Hispanic/Latina women in the United States and Georgia. Chronic health conditions are enduring and long-term, signiﬁcantly inﬂuencing the quality of life and often necessitating sustained management or intervention. Among Hispanic/Latina women, these conditions range from obesity to mental health disorders. The high prevalence of these conditions, alongside barriers such as limited access to health insurance, underscores critical health challenges faced by this population. Further complexities arise when considering the impact of immigration status on these health disparities exacerbating these chronic health issues among Hispanic/Latina women.There are several chronic issues in women’s health that disproportionately affect Hispanic/Latina women in the United States and Georgia:· Higher rates of overweight/obesity: 79% of Hispanic/Latina women are overweight or obese compared to 64% of non-Hispanic white women. Excess weight may increase the risk of developing high blood pressure, diabetes, elevated low-density lipoprotein (LDL) cholesterol, heart disease, and stroke (Ofﬁce of Minority Health, 2020).· Higher rates of no health insurance: 46% of Hispanic/Latina women of reproductive age (18-44) are uninsured in Georgia, almost double the national average for Latinas. Nineteen percent of women in Georgia lack health insurance (Georgetown University Center for Children and Families (CCF), 2022)· Cancer risk: Approximately one-third of Hispanic/Latina females are likely to be diagnosed with cancer and the odds of dying of cancer are 1 in 6 for Hispanic/Latina females. Speciﬁcally, Breast cancer mortality accounts for 16% of cancer-related deaths among Hispanic/Latinas, followed by lung cancer (13%) and colorectal cancer (9%) (American Cancer Society, 2021a).· Mental Health: Anxiety and depression are identiﬁed as the most common mental health issues among Hispanic/Latina women. Undocumented Hispanic/Latina women are also more likely to lack ﬁnancial security, and under-reporting of violent and sexual crimes is common. These circumstances lead to chronic stress that signiﬁcantly impacts

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133long-term mental health. Forced family separation worsens the situation further; Hispanic/Latina women who were separated from their children were found to exhibit a 1.52 higher times rate of depression than those who were not (Ramos-Sanchez, 2020).Access & Utilization Of Healthcare Services For Hispanic/Latina Women In The United States & GeorgiaWith the growing presence of the Hispanic/Latina population in the country, it is crucial to understand the speciﬁc challenges and opportunities faced by Hispanic/Latina women in terms of healthcare access and utilization. By using disparity indicators, researchers aim to identify the factors that contribute to disparities among Hispanic/Latina women and other demographic groups.According to the 2021 Behavioral Risk Factor Surveillance System (BRFSS) data, analyzed by KFF, women across racial and ethnic groups in both Georgia and the United States face disparities in their access to quality healthcare (KFF, 2021b). Indicators such as whether women have established a patient relationship with a provider and have had health screenings such as mammograms or pap smears, help elucidate the Hispanic/Latina experience. As seen in Figure 3.13, a larger proportion of women of every race in Georgia reported not seeing a doctor due to cost compared to their national counterparts. Most notably, Hispanic/Latina women in Georgia experienced the most signiﬁcant disparity, with 29% reporting they did not see a doctor due to cost, compared to 18% of Hispanic/Latina women in the United States overall (Table 22) (KFF, 2021b).Table 22Women Who Report Not Seeing a Doctor in The Past 12 Months Due To Cost, By Race/Ethnicity, for Goergia And The United States, 2021Note: Percentages are weighted to reﬂect population characteristics. Adapted from KK’S State Health Facts by Centers for Disease Control and Prevention (CDC)’s 2021 Behavioral Risk Factor Surveillance System (BRFSS)

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134In both the United States and Georgia, Hispanic/Latina women are more likely to not have a health care provider compared to their non-Hispanic white and Black counterparts. The disparity is more pronounced for Hispanic/Latina women (Table 23).Mammogram screening rates in Georgia are lower than the national average in the United States across different racial and ethnic groups (Table 24). Non-Hispanic white women and Non-Hispanic Black women in Georgia have mammogram rates that are 2% lower than the national average. The discrepancy is most noticeable among Hispanic/Latina women. In Georgia, this group’s mammogram rate stands at 55%, which is signiﬁcantly lower than the national average of 68%. Table 24Table 23Women who reported having no personal doctor or health care provider in the UnitedStates and Georgia by race/ethnicity in 2021DISPARITIES INDICATOR: WOMEN AGED 40 AND OLDER WHO REPORT HAVING HAD A MAMMOGRAM WITHIN THE PAST TWO YEARS BY RACE/ETHNICITY, FOR GEORGIA AND THE UNITED STATES IN 2020 (KFF, 2021b)Note: KFF, State Health Facts, Women Age 40 and Older Who Report Having Had a Mammogram Within the Past Two Years by Race/Ethnicity, based on analysis of the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System 2020 survey results

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135In both the United States and Georgia, Hispanic/Latina women are more likely to not have a health care provider compared to their non-Hispanic white and Black counterparts. The disparity is more pronounced for Hispanic/Latina women (Table 23).Non-Hispanic Black women and Hispanic/Latina women in Georgia show slightly higher rates of Pap smears at 80% and 73%, respectively, against national averages of 79% and 72% (Table 25). These results suggest that Georgia performs comparably to the national average when it comes to Pap smear rates among women aged 18-64 across these racial/ethnic groups.Contraceptive KnowledgeA study found disparities in contraceptive knowledge among Hispanic/Latina women in the United States (“Teenagers and Hispanic Women Know Less About Contraception Than Young Adults and Whites,” 2014). The study suggests that clinicians should be aware of the lower contraceptive knowledge among Hispanic/Latina women, particularly among teenagers and foreign-born Hispanic/Latina women and should be prepared to provide necessary education.·Hispanic/Latina women had lower odds of knowing about contraceptive options, such as the intrauterine device (IUD), the ring, the patch, natural family planning, and male sterilization (odds ratios ranged from 0.1 to 0.5).Table 25Disparities indicator: women ages 18-64 who report having a pap smear in the past three years by race/ethnicity, for georgia and the united states, 2018-2020 (kff, 2021b)

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136Maternal, Perinatal & Infant Outcomes In The United States & GeorgiaA National Vital Statistics Report provides an in-depth analysis of maternal characteristics and infant outcomes of Hispanic/Latina women in the United States, based on data from the 2021 birth ﬁle (Driscoll, 2021). The report investigates these characteristics and outcomes based on nativity, (i.e., whether the Hispanic/Latina women were born in the United States or elsewhere) and further breaks them down into the six largest Hispanic/Latino subgroups: Mexican, Puerto Rican, Cuban, Dominican, Central American, and South American.The report provides valuable insights into the signiﬁcant variation in maternal characteristics and infant outcomes among the population of Hispanic/Latina women in the United States, depending on nativity and speciﬁc ethnic subgroup. These differences may reﬂect a range of factors, including access to healthcare, socioeconomic status, cultural and lifestyle factors, and the effects of immigration and acculturation.· Childbirth is associated with a variety of potential health risks and outcomes for both the mother and the baby. In the United States, there is considerable variation in the health outcomes of infants born to different racial and ethnic groups. For example, Hispanic/Latina women experience distinct health outcomes for their infants based on various factors including their country of origin, educational background, and socioeconomic status. · Infant mortality rates, for instance, differ among Hispanic/Latina subgroups, with a generally lower rate among Hispanic/Latina women as compared to non-Hispanic white and Black women. However, within the Hispanic/Latina population, the infant mortality rate can vary. For example, Mexican and Puerto Rican women have different infant mortality rates.· The health and well-being of mothers also differ signiﬁcantly among Hispanic/Latina subgroups. Factors such as access to prenatal care, nutrition, and maternal age at the time of childbirth can inﬂuence these outcomes. For example, Cuban and Puerto Rican women have different rates of access to prenatal care, which can in turn inﬂuence infant outcomes.· Socioeconomic factors, such as education and income level, also play a critical role in maternal and infant health outcomes among Hispanic/Latina women. Women with higher levels of education and income generally have better health outcomes for themselves and their infants, regardless of their ethnic or racial background.· Infant Outcomes: Infants of non-U.S.-born Hispanic/Latina women were less likely to be preterm, to be low birthweight, and to be admitted to the NICU than infants of U.S.-born women. Infant mortality rates differ among Hispanic/Latina subgroups, with a generally lower rate among Hispanic/Latina women as compared to non-Hispanic white and Black women. However, within the Hispanic/Latina population, the infant mortality rate varies.

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137For example, Mexican and Puerto Rican women have different infant mortality rates.· The preterm birth rate was highest among Puerto Rican women at 11.3%, followed by Mexican women at 9.2%, while Cuban women had the lowest rate at 8.1%.· The rate of low-birth-weight infants was highest among Cuban women at 8.6%, followed by Puerto Rican women at 7.9%, with Mexican women having the lowest rate at 7.1%.Summary Of Birth Metrics In The United States And Georgia For 2020-2021 And Provisional Data For 2022 (As Of June 2023) Findings from the 2020-2021 and provisional 2022 data on U.S. births by the CDC’s National Center for Health Statistics suggest that Georgia has higher rates of cesarean deliveries, low-risk cesarean deliveries, late preterm births, and preterm births compared to the U.S. average (Hamilton et al., 2023). These ﬁgures might reﬂect differences in medical practices, healthcare access, population health, and other socioeconomic factors between Georgia and the United States as a whole.· Total Number of Births: The total number of births in Georgia was 125,827 in 2022 and 123,939 in 2021, which is a small fraction of the total births in the United States as a whole, being 3,661,220 in 2022 and 3,659,289 in 2021.· Cesarean Delivery Rates: Both the United States and Georgia saw an increase in the percentage of births delivered by cesarean section (C-section) from 2020 to 2022. However, the cesarean rates in Georgia were consistently higher than the U.S. average. In 2022, the U.S. had a cesarean delivery rate of 32.3%, while Georgia had a higher rate of 35.3%.· Low-Risk Cesarean Rates: Similarly, the percentage of low-risk births delivered by C-section was consistently higher in Georgia compared to the U.S. average. In 2022, the rate in the U.S. was 26.3% while in Georgia, it was 28.9%.· Late Preterm Birth Rates: The percentage of total births that were late preterm was also higher in Georgia in comparison to the U.S. average. In 2022, the U.S. had a late preterm birth rate of 7.6%, while Georgia’s rate was 8.5%.· Preterm Birth Rates: The rates of preterm births in Georgia were also consistently higher than the U.S. average. In 2022, the preterm birth rate in the U.S. was 10.4% while Georgia’s rate was 11.9%.The Disproportionate Burden Of Maternal Mortality In GeorgiaAccording to the Georgia Maternal Mortality Review Committee (MMRC) - in a national context, Georgia remains one of the states with a notably high maternal mortality rate, occupying the second-highest spot with a rate of 46.2 deaths per 100,000 live births (Georgia Department of Public Health, 2019). During the period from 2012 to 2014, the distribution of pregnancy-related deaths in Georgia saw non-Hispanic Black women bearing the brunt, accounting for 60% of these fatalities. Meanwhile, non-Hispanic white women and Hispanic/Latina women

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138represented 24% and 10% of the deaths, respectively (Georgia Department of Public Health, 2019).The top contributing factors to pregnancy-related deaths in Georgia from 2018 to 2020 included hemorrhage, mental health issues, cardiomyopathy, cardiovascular and coronary conditions, and preeclampsia/eclampsia. Interestingly, these causes were deemed preventable by the Maternal Mortality Review Committee (MMRC). Speciﬁcally, for deaths tied to embolism, a striking 83% were identiﬁed as avoidable (Georgia Department of Public Health, 2022) Broadly, an array of social determinants signiﬁcantly inﬂuences maternal mortality outcomes. These encompass factors such as socioeconomic standing, maternal health conditions, healthcare accessibility, and the quality of communication between healthcare providers and patients (Shahin et al., 2020).Maternal MorbidityMaternal Health Concerns In Hispanic/Latina PopulationsThe ﬁeld of maternal health is confronted with signiﬁcant challenges, among which maternal morbidity - health complications arising from pregnancy and childbirth - stands out prominently. These health issues can have both short-term and long-term impacts on women’s health.An alarming concern within this scope is hypertensive disorders of pregnancy (HDP), which include preeclampsia, eclampsia, chronic hypertension, and gestational hypertension. These disorders strike around 6-8% of pregnancies in the United States, making them the most widespread cause of maternal morbidity (Boulet et al., 2020). Particularly worrisome is that these hypertensive disorders, despite being preventable, contributed to 7% of all pregnancy-related deaths between 2013-2017. A striking 60% of these deaths occurred within a week of childbirth (Boulet et al., 2020).While severe maternal morbidity is more common than maternal mortality, with around 50,000 women affected each year (0.5-1.3% pregnancies) (Hirshberg & Srinivas, 2017), speciﬁc communities experience these issues at a higher rate, such as the Hispanic/Latina population. A more comprehensive study conducted between 2009 and 2020, focusing on women in Georgia aged 15-55, found a similar rate of severe maternal morbidity, inclusive of blood transfusions, among Hispanic/Latina women. Maternal health complications are not distributed equally across different ethnic and socioeconomic groups, underlining the urgent need to address these disparities and ensure equitable healthcare for all women (Kramer et al., 2023).

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139Infant MortalityChildbirth carries a wide berth of potential health implications and results that impact both the mother and the infant. There is a signiﬁcant disparity in infant health outcomes across racial and ethnic groups in the United States. Hispanic/Latina women encounter unique infant health outcomes inﬂuenced by a multitude of factors, including country of origin, level of education, and ﬁnancial status (Driscoll, 2021).The rate of infant mortality – particularly among Hispanic/Latina heritage groups – are known to vary. Despite a generally lower rate among Hispanic/Latina women in comparison to non-Hispanic white and Black women, infant mortality rates are not uniform throughout the Hispanic/Latina subgroups. For example, the infant mortality rates between Mexican women and Puerto Rican women are noticeably different (Driscoll, 2021).The infant mortality rate in Georgia is slightly above the national average in the United States, with 6.1 infant deaths per 1,000 live births – compared to the U.S average of 5.2 (Georgetown University Center for Children and Families (CCF), 2022).Latina Birth Outcomes ParadoxThe birth rate among Hispanics/Latinos in the United States is the highest when compared to other racial and ethnic groups. Despite facing vulnerabilities due to their socioeconomic status and limited access to healthcare, babies born to Hispanic/Latina women, especially those who are foreign-born, experience lower rates of low birth weight and mortality compared to the national average. This phenomenon is known as the Latina Birth Outcomes Paradox, and various reasons have been suggested to explain it (Velasco-Mondragon et al., 2016b).One theory is that social support from extended family members, community health workers, and lay midwives may lead to perceived cultural and protective factors. Some protective factors include a cultural emphasis on motherhood, traditional healthy eating habits, and a dedication to maternal responsibilities (Velasco-Mondragon et al., 2016b). However, the foreign-born Hispanic pregnant population faces challenges due to their undocumented or inadequate legal status and lack of healthcare coverage. Although effective prenatal care is crucial, the Latina Paradox suggests that other essential factors need to be considered when addressing maternal health in this population (Velasco-Mondragon et al., 2016b).TEEN PREGNANCYTeen pregnancy and childrearing have substantial implications for the health, social, and economic aspects of society. These include the heightened propensity for teen mothers to drop out of high school and face unemployment, the increased risk for their children to discontinue schooling, experience hospitalization, mortality during infancy or childhood, and the possibility of becoming teen parents themselves. The annual cost to taxpayers in the U.S. for teen pregnancy and childbirth is approximately $9.4 billion (United Health Foundation, 2021)

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140Affected Populations: Despite a steady decline in teenage births over recent decades, disparities remain. The incidence of teenage pregnancy is notably higher among:· Teens in foster care· American Indian/Alaska Native, Hispanic/Latina, non-Hispanic Black, and Native Hawaiian/Paciﬁc Islander females· Teens from low-income counties· Teens from counties with lower educational attainment· Teens living in rural counties compared to their counterparts (United Health Foundation, 2021).Birth Rates by Maternal Age (Ages 10-19): Since 1991, the teen birth rate in the United States has been decreasing (births per 1,000 females aged 15-19) (Centers for Disease Control and Prevention, 2021a). In June 2023, the National Center for Health Statistics released the latest provisional 2022 data on births in the United States. From the data reported in 2021 and 2022, a comparative analysis shows a slight decrease in the birth rates among teenagers in the United States (Hamilton et al., 2023). Table 26 presents the birth rates per 1,000 women for the respective age groups in 2021 and 2022, and the approximate percentage decrease from 2021 to 2022 (Hamilton et al., 2023).Table 26U.S Teenage birth rates per 1,000 women for the speciﬁc age groups in 2021 and 2022, and the approximate rate change from 2021 to 2022Note: From NCHS, National Vital Statistics System. Estimates for 2022 are based on provisional data. Estimates for 2020 and 2021 are based on ﬁnal data (ﬁnal data are available from: http://wonder.cdc.gov/ ) Driscoll AK, Osterman MJK, Hamilton BE, Valenzuela CP, Martin JA. Quarterly provisional estimates for selected birth indicators, Quarter 1, 2020-Quarter 4, 2022. National Center for Health Statistics. National Vital Statistics System, Vital Statistics Rapid Release Program. 2023.

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141Teen Pregnancy In Georgia By Hispanic/Latino Heritage Origin Group (2016-2021)The data clearly demonstrate differences in teen pregnancy rates across Hispanic/Latino heritage origin groups, with variations becoming more pronounced as the age of the mother increases (Centers for Disease Control and Prevention, 2023a). While all groups showed increases in birth rates with age, the Mexican origin group consistently had the highest numbers of teen pregnancies across all age groups (Table 27).Prevention StrategiesEffective Prevention Strategies: In its efforts to eliminate disparities in teen pregnancy, the CDC has highlighted effective teenage pregnancy prevention strategies, which include delaying sexual intercourse, promoting dual contraception use, and promoting the use of long-acting reversible contraceptives (LARCs). It is noted that while over 86% of sexually active teens used birth control the last time they had sex, only a few used the most effective forms of birth controlThe American College of Obstetricians and Gynecologists (ACOG) recommends that physicians should routinely address the contraceptive needs, expectations, and concerns of adolescents.Note. Adapted f rom Centers for Disease Control and Prevention, Nat ional Center for Health Stat ist ics. Nat ional Vital Statistics System, Natality on CDC WONDER Online Database. Data are f rom the Natality Records 2016-2021. Accessed at http://wonder.cdc.gov/natality-expanded-current.html. Caveat. Beginning in 2018, the category “Dominican” was added to both “Mother’s Expanded Hispanic Origin” and “Father’s Expanded Hispanic Origin” and records were coded to this category. Before 2018, there are no reported case counts for the “Dominican” category. Before 2018, case counts for “Dominican” were coded to the “Other and Unknown Hispanic” category, thus there is a discont inuity between 2017 and 2018 for the “Other and UnknownHispanic” category.Table 27Teen Births in Georgia, 2016-2021, Hispanic/Latina Heritage Origin Groups

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142Federal and state policies can play an instrumental role in reducing teen pregnancies. Policies that facilitate access to family planning services have been associated with lower teen birth rates, and comprehensive risk-reduction sex education in schools has proven effective at increasing the use of contraception and decreasing sexual activity, sexually transmitted infections prevalence, and teen pregnancies (United Health Foundation, 2021)Mental & Behavioral HealthMental and behavioral health are crucial elements in the spectrum of holistic wellness, directly impacting the quality of life, productivity, and lifespan of a population. This section seeks to examine these aspects within the context of the rapidly expanding Hispanic/Latino demographic in Georgia. As Hispanic/Latino residents progressively constitute a larger fraction of Georgia’s populace, they contribute signiﬁcantly to the cultural heterogeneity of the state. Despite this, they also encounter distinct mental and behavioral health hurdles. These challenges are largely driven by systemic disparities, culturally speciﬁc nuances, and the stresses associated with acculturation. This section focuses on providing comprehensive view of the mental and behavioral health landscape for Hispanics/Latinos in Georgia - including the prevalence of speciﬁc conditions, rates of treatment and healthcare utilization, healthcare disparities, and social determinants of health.The Acculturation Process & Health Implications For Hispanic/Latino ImmigrantsThis section focuses on the complexities of acculturative stress, including the inﬂuence of acculturation processes on immigrant mental health. Research conducted on the mental health status of Hispanic/Latino immigrants living in the Southeast region can provide context that can offer insight on the Hispanic/Latino immigrant community residing in Georgia (Vazquez et al., 2022).Key Points:· The research indicates that before migrating to the U.S., Hispanic/Latino immigrants often face stressors and trauma in their countries of origin that predispose them to mental distress, notably depressive symptoms. These stressors include exposure to high poverty levels, violence, and political instability, leading to forced migration, which in turn heightens perceived stress. Trauma-related symptoms from pre-migration experiences can also be reactivated by ongoing post-immigration stress. This increased stress perception can be especially pronounced among Hispanic/Latino immigrants due to their often-turbulent migration history (Vazquez et al., 2022).· Post immigration stressors: Highly reported stressors related to post-immigration include immigration-related stress, stress related to health care access, and stress related to discrimination. Stressors include concerns related to documentation status, fear of deportation, social isolation, and perceived racial discrimination (Vazquez et al., 2022).

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143Selective AcculutrationResearch by Bulut & Gayman (2016) ﬁnd that full assimilation into the American culture can negatively impact the mental health of Hispanic/Latino immigrants. The study presents the idea of “selective acculturation” as a healthier alternative (Bulut & Gayman, 2016). This is a process wherein immigrants adapt to the new culture without giving up their original ethnic identities. The mental health beneﬁts observed could be linked to the bicultural immigrants’ capacity to navigate between both their original and adopted cultures, leveraging resources and opportunities from both worlds. · Beneﬁts of co-ethnic communities: Bulut & Gayman (2016) posits that ethnic neighborhoods can offer a wealth of beneﬁts for immigrants and might play a signiﬁcant role in amplifying the beneﬁts of maintaining a bicultural identity. These beneﬁts include access to concentrated resources like churches, voluntary programs, ethnic foods, and native language facilities; the creation of ethnic employment positions; a reduction in exposure to racial and ethnic discrimination; and a sense of belonging that allows for selective acculturation to life in the United States. These communities, through their concentration of familiar resources, and by providing a sense of belonging and identity, facilitate a selective adaptation process for immigrants.Mental health is another health issue that participants noted were common among their community. When participants were asked in the survey how stressed they were on a scale of 1-5, where 1 is not at all and 5 is very much, a majority of participants answered 4. Stress can be linked to a variety of factors based on participants’ responses. The ﬁrst is environmental and social support because when participants were asked how often they would see or talk to people they care about, most answered less than once a week. This is synonymous with the lack of translation services in the mental health ﬁeld. The second factor is the ability to pay bills. Again, due to inﬂation and the increased cost of living, Latinos are working more in order to get by. The lack of time they have for themselves, and their family contributes to why their mental health is suffering. The last factor is stigma and taboos towards mental health.When participants were asked in the survey how stressed they were on a scale of 1-5, where 1 is not at all and 5 is very much, a majority of participants answered 4.

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144“Its not all about the money , we need to tend to our family so we don’t neglect family [...] Also the stress. Not just work but the stress of trying to pay bills to manage life. I think it’s why Hispanics don’t really go to the hospital especially if you don’t have insurance [...] and it’s based on we don’t have money to pay for the medications.”“No todo es dinero, necesitamos atender a nuestra familia para no descuidar a la familia [...] También el estrés. No solo el trabajo, sino el estrés de tratar de pagar las facturas para administrar la vida. Creo que es por eso que los hispanos realmente no van al hospital, especialmente si no tienes seguro [...] y se basa en que no tenemos dinero para pagar los medicamentos”.Clayton Focus Group“Most Hispanics don’t think they can see mental health. They think that it’s just for being on the phone and so they think that it’s just for the phone or something like that.”“La mayoría de los hispanos no creen que puedan ver la salud mental. Piensan que es solo por estar en el teléfono y por eso piensan que es solo por el teléfono o algo así”.Dalton Focus Group“It’s just one of those things that it’s not getting treated and there’s stigma behind it. Overall, folks are just afraid to get it [help] because they’re afraid that, oh, they’re gonna ﬁnd out. My family’s gonna ﬁnd out what they’re gonna say about me. In our community, you also hear this narrative that, oh no, a psychiatrist a psychologist, a counselor, no that’s a white person thing. Or how do you go tell a stranger about your problems?”“Es solo una de esas cosas que no se trata y hay un estigma detrás. En general, la gente tiene miedo de obtener [ayuda] porque tienen miedo de que, ‘oh, van a averiguarlo. Mi familia va a averiguar, que van a decir de mí.’ En nuestra comunidad, también escuchas esta narrativa de que, ‘oh no, un psiquiatra, un psicólogo, un consejero, no, eso es cosa de personas blancas. ¿O cómo le cuentas a un extraño sobre tus problemas?”Key Informant

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145“ [...] many people say my house is ﬁne, my family is ﬁne, and they don’t know that their children are in torment and they are quiet and the father says “My son is ﬁne, the mother is happy”. They don’t know what their children are experiencing. [...] I feel that they try to point ﬁngers to blame so-and-so. But they only point their ﬁngers because they don’t have the information about what depression or anxiety really is, they don’t know.”“ [...] mucha gente dicen que ‘mi casa está bien, mi familia está bien,’ y no saben que sus hijos están atormentados y están callados y el padre dice ‘Mi hijo está bien, la madre es feliz’. No saben lo que sus hijos están pasando. [...] Siento que tratan de señalar con el dedo para culpar a fulano de tal. Pero solo señalan con el dedo porque no tienen la información sobre lo que realmente es la depresión o la ansiedad, no lo saben”.Clayton County Focus Group “The way they were raised and because they never had the resources for that [...] I’m pretty sure they’ve been through 10 times worse than what we have. And they dealt with that by their self. So it’s just something that, that’s how they grew up. Like, oh, I’m going through this. I can’t say it, or I just have to live with it. It just becomes them.”“La forma en que fueron criados y porque nunca tuvieron los recursos para eso [...] Estoy bastante seguro de que han pasado por 10 veces peor que lo que hemos pasado nosotros. Y se ocuparon de eso por sí mismos. Así que es algo que, así es como crecieron. Como, ‘oh, estoy pasando por esto. No puedo decirlo, o simplemente tengo que vivir con eso.’ Simplemente se convierte en ellos”.South Georgia Focus GroupGenerational barriers was another theme that came up when talking about mental health. According to participants, there is a divide between the older and younger generations where in the older generation, mental health discussions are still a taboo. However, in the younger generations, it is talked about more often. This disconnect can help explain why the community has been seeing an increase in mental health problems among Latinos such as depression and anxiety, as well as suicide (Stone, 2023; U.S. Department of Health and Human Services, 2021).

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146Mental Health Services AccessibilityA signiﬁcant factor that contributes to the rising incidence of mental illnesses among the Hispanic/Latino population is the accessibility to mental health care. It’s evident that a noticeable disparity exists in the delivery of mental health services to Hispanics/Latinos in the United States (Katiria Perez & Cruess, 2014) This gap in treatment is notably evident in Georgia, a state that is 49th in the ranking of mental health care accessibility, provision of resources, and insurance coverage out of all 50 states and D.C. (Mental Health America, 2023). (Table 28). Mental Health America’s (MHA) State of Mental Health in America report provides a comprehensive ranking of each state’s mental health status and resources. In the 2023 report, Georgia’s mental health was evaluated across several categories including adult mental health, youth mental health, prevalence of mental illness, and access to care. Each of these categories and Georgia’s ranking in them are presented in Table 28 below.Table 28Mental Health Rankings in Georgia, 2023Note: Adapted from Mental Health America [MHA] (n.d.). The state of mental health in America 2023.Mental Health America (MHA). https://mhanational.org/issues/2023/ranking-states

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147From the table, we see that while Georgia ranks very well in terms of prevalence of mental illness, it performs poorly in access to care. This highlights the critical need to improve mental health infrastructure and resources in the state.The Substance Abuse and Mental Health Services Administration (SAMHSA) highlighted this issue in its 2019 report, which showed that a mere 4% of patients utilizing Georgia’s state mental health authority were Hispanic/Latino. This ﬁgure is dwarfed by the national rate of 15.6%, underlining the marked inequality in mental health service accessibility in Georgia compared to the wider United States (Substance Abuse and Mental Health Services Administration, 2019).As of 2018, Hispanics/Latinos in the United States were 50% less likely to have accessed mental health treatment than non-Hispanic whites. Also, in 2019, the proportion of Hispanic/Latino adults who utilized mental health services or received prescription medications for mental health issues was only half or even less than that of non-Hispanic whites. However, when examining adults who experienced a major depressive episode in the previous year, the proportion of Hispanics (58%) who received treatment was lower than the non-Hispanic white group (70.2%) (Ofﬁce of Minority Health, 2021b).Geographical Disparities In Mental Health FacilitiesFurther, understanding the geographical disparities in mental health facilities across urban and rural areas within the state is key. A signiﬁcant number of these facilities are concentrated in the metropolitan area of Atlanta, leaving many counties devoid of a single mental health center (Figure 31). This geographical disadvantage can pose a signiﬁcant structural hindrance to the acquisition of mental health services (National Mental Health Services Survey (N-MHSS), 2021). The issue becomes stark when one realizes that rural dwellers, compared to their urban and suburban counterparts, need to cover double the distance to reach a hospital. Moreover, they are twice as likely to face limited internet access, which could hinder telehealth services (National Alliance on Mental Illness [NAMI], 2023). This could potentially be a signiﬁcant impediment, particularly for Hispanic farmworker communities in the state. As per the National Alliance on Mental Illness, 66% of farmworkers have reported that the COVID-19 pandemic has impacted their mental well-being (NAMI, 2022). The ongoing inﬂuence of the COVID-19 pandemic on mental health and access to care remains an important area of study (National Mental Health Services Survey (N-MHSS), 2021).

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148Mental Health ConditionsA signiﬁcant portion of the Hispanic/Latino community reported experiencing severe psychological distress in the previous year (12.2%) and in the past 30 days (6.8% for those under the poverty line). Also, the rates at which Hispanics reported feelings of sadness, hopelessness, worthlessness, or constant effort were higher than those reported by non-Hispanic whites. It’s noteworthy that severe psychological distress was more prevalent among Hispanic/Latina women compared to men (Ofﬁce of Minority Health, 2021b).Impact Of Socioeconomic StatusThe data point to a signiﬁcant link between socioeconomic status and mental health condition. Hispanics/Latinos living under the poverty line are twice as likely to report severe psychological distress as compared to those living at twice the poverty level (Ofﬁce of Minority Health, 2021b).Suicide Rates & AttemptsAlthough the rate of suicide among Hispanics/Latinos is less than half that of the non-Hispanic white populace, in 2019, suicide was the second most common cause of death for Hispanics/Latinos aged 15 to 34. Particularly striking is the fact that the suicide rate for Hispanic/Latino males was quadruple the rate for Hispanic females in 2018. In relation to young people, the pattern of suicidal ideation and attempts is also differentiated by gender. Notably, the incidence of attempted suicide was 30% higher among Hispanic/Latina girls in grades 9-12 than their non-Hispanic white counterparts (Ofﬁce of Minority Health, 2021b).Policy AnalysisThe health of Hispanic/Latino immigrants, both documented and undocumented, is inﬂuenced by immigration policies. Hispanic/Latinos are less inclined to se ek services such as those for mental/behavioral health and express signiﬁcant apprehension when it comes to accessing and utilizing the services they are entitled to (Rhodes et al., 2015). The article titled “Immigration Policy Changes and the Mental Health of Mexican American Immigrants” by Gearing et al. (2021) examined Location Of Treatment FacilitiesNote: From Substance Abuse and Mental Health Services Administration, National Mental Health ServicesSurvey (N-MHSS): 2020. Data on Mental Health Treatment Facilities. Rockville, MD: Substance Abuse andMental Health Services Administration, 2021Figure 31Location of Mental Health Facilities in Georgia

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149how immigration policies since 2015 have affected the mental health of Mexican American immigrants. The ﬁndings reveal that 26.5% of participants experienced signiﬁcant psychological distress, while 20% met the clinical cutoff for depression. The length of time since immigrating was associated with these health outcomes. They suggest that stricter and “anti-immigrant” immigration policies may have a detrimental impact on the psychological well-being of Mexican American immigrants, particularly those who have recently arrived. The authors propose that community-based social service providers and faith-based organizations are well-positioned to provide preventive and early intervention services, as well as facilitate access to specialized care when necessary (Gearing et al., 2021). The choice to spotlight these speciﬁc communities is rooted in the recognition that their health outcomes and access to healthcare are shaped not only by their Hispanic/Latino identity but also by other intersecting factors. These include sexual orientation and gender identity, occupational hazards, and cultural factors, respectively. In mainstream discourse and research, these factors and their impacts are frequently understudied or misunderstood.Furthermore, understanding the health status of these overlooked groups is crucial for creating more equitable health policies and interventions. It is only by acknowledging and addressing the unique health needs of every subgroup within the Hispanic/Latino community that we can word to reduce health disparities and promote wellbeing for all.Spotlighting these communities aims to contribute to a more nuanced understanding of the diversity within the Hispanic/Latinx population in Georgia, underscoring the need for tailored health strategies that consider these communities’ experiences and challenges.It is importance to address the mental health needs of immigrants and recognize the broader implications of anti-immigrant policies and rhetoric on both documented and undocumented immigrants.

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150In recent years, growing attention has been focused on the diverse experiences within the Hispanic/Latino community, particularly within the realms of health and identity. As one of the largest minority groups in Georgia, Hispanics/Latinos contribute signiﬁcantly to the cultural, social, and economic fabric of the state. However, they also face unique challenges, as exempliﬁed in numerous health disparities. This section will take an intersectional lens, considering the experiences not just of the broader Hispanic/Latino community in Georgia, but particularly those identifying as part of the LGBTQIA+ spectrum within that community. The LGBTQIA+ community within the Latino community face additional barriers to accessible healthcare services The combination of being Latino and LGBTQIA+ in Georgia affects the lives of the community due to the government policies in place, such as the ban on gender afﬁrming care (Georgia SB140, 2023). The repercussions of anti-LGBTQIA+ laws may increase barriers to healthcare access and use (Moran, 2021). The policies Terminology Note for “Latinx” - The LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, questioning, intersex, and/or asexual section of this report uses the term "Latinx" to refer to individuals who hold Latin American and/or Hispanic cultural or racial identities, including Latinos and Latinas, but also individuals who do not identify strictly as male or female, including non-binary and gender-expansive identities. The term "Latinx" is a gender-neutral and inclusive alternative to "Latino" or "Latina." This choice is particularly relevant to our exploration of the LGBTQIA+ community, as "Latinx" encompasses all gender identities, including those who do not conform to the gender binary. However, we recognize that terminology preferences can be deeply personal and vary among individuals and regional/cultural context. The use of "Latinx" is not intended to overwrite or invalidate other terms individuals may prefer to use to describe their own identities. We understand that individuals and communities may identify more with one term over another. “Latinx” is used in this report for its inclusivity and alignment with the discussions and ﬁndings around health, intersectionality, and identity for this group.LGBTQIA+ COMMUNITY

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151in place can also further perpetuate the stigmatization of the LGBTQIA+ community.The LGBTQIA+ Hispanic/Latinx individuals represent a unique intersection of identities, facing challenges and health disparities that arise from both their ethnic background and their gender or sexual identities. Examining the overview of their health status, health outcomes, access to healthcare, and potential disparities provides insight on the current health landscape for this community in Georgia, including the impact of identity on health outcomes.Thoughts on the LGBTQIA+ CommunityWhen participants were asked about their thoughts on the LGBTQIA+ community, some responded that they respect the community. One participant recalled their elders would speak negatively about the LGBTQIA+ community and discouraged the participant from getting too close with those who identiﬁed as LGBTQIA+. Another participant noted that the mentality is changing a little bit, but even then, they still do not wish to be associated with them. Although thoughts on the LGBTQIA+ community varied between the participants, this stigma can be damaging to mental health and in turn create more barriers to accessing quality health services and support needed to navigate the healthcare system as an LGBTQIA+ identifying person.ResourcesParticipants in the LGBTQIA+ focus group advised the interviewer of the organization’s efforts that helped them get access to legal services and housing. Another participant in the focus group added that an organization called Outreach “provided food and clothing for the homeless, but other than these two [organizations]” had not gotten help from anyone else. “There’s the population that’s very accepting of them [...] But the idea is that “I accept them, but keep them away from me”. And then there’s an-other population that is not fond of the [LGBTQIA+] community, and they’re very open about it.”"Hay una población que los acepta mucho [...] Pero la idea de que “los acepto, pero los manten-go alejados de mí”. Y luego hay otra población a la que no le gusta la comunidad [LGBTQIA+], y son muy abiertos al respecto".Key informant “Many hispanics tell me things; they tell me, ‘Oh you’re sick in the head’. And it’s just because I love who I love.”“Muchos hispanos me dicen cosas; me dicen: 'Oh, estás enfermo de la cabeza'. Y es solo porque amo a quien amo".Clayton County Focus Group

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152Health Status of the Hispanic/Latinx LGBTQIA+ CommunityThe Hispanic/Latinx LGBTQIA+ community, like other intersecting identity communities, faces unique health challenges that often stem from systemic barriers and social disparities. Health disparities and outcomes can vary greatly within the Hispanic/Latinx LGBTQIA+ community based on factors such as immigration status, socioeconomic status, age, and geographic location. Such health challenges often include, but are not limited to, higher rates of HIV/AIDS, mental health disorders, substance abuse, and limited access to healthcare due to a variety of socioeconomic and systemic barriers. Mental Health ChallengesMental Health Disparities· Discrimination-Induced Mental Health Challenges in the LGBTQIA+ Community: Members of the LGBTQIA+ community often grapple with health inequalities, which are closely tied to societal bias, prejudice, and violations of basic human rights. The resulting impacts on mental well-being are considerable, with higher incidences of mental disorders, drug misuse, and suicide linked to the discrimination they encounter (Saldana et al., 2023)· Increased Mental Health Disorders in Hispanic/Latinx LGBTQIA+ Community: The Hispanic/Latinx LGBTQIA+ community reports higher rates of depression, anxiety, and suicide attempts compared to their heterosexual counterparts (Medina-Martínez et al., 2021; Saldana et al., 2023). These health disparities can often be attributed to societal stigma, discrimination, and the stress of managing multiple marginalized identities. Such discrimination often results in aggression and victimization, impacting individuals and the broader LGBTQIA+ community at large (Saldana et al., 2022)DemographicsTable 29Population estimates and proportions of Latinx LGBTQIA+ adults by region, SouthNote: From Wilson, B.D.M., Mallory, C., Bouton, L., & Choi, S.K. (2021). Latinx LGBT Adults in the U.S. Los Angeles, CA: The Williams Institute, UCLA School of Law.

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153· Chronic Stress and Health Complications: The chronic stress arising from enduring prejudice, discrimination, and violence can signiﬁcantly contribute to a variety of health complications. These include, but are not limited to, heart disease, hypertension, and other stress-related conditions (Caceres et al., 2020).HIV Barriers to Care Among Hispanic/Latino MSMHIV and STI · Elevated Rates of HIV and STIs in Hispanic/Latino MSM: Men who have sex with men (MSM) within the Hispanic/Latinx community display notably elevated rates of HIV infection compared to their non-Hispanic/Latino white counterparts, with areas such as Georgia being particularly affected (Saldana et al., 2022). In addition, this group also reports higher incidences of other sexually transmitted infections (STIs). Factors contributing to these elevated rates encompass lower health literacy, prevalent cultural stigma associated with being gay or bisexual and HIV, as well as hurdles in accessing preventive healthcare services (Saldana et al., 2022).· Barriers to HIV Services for Hispanic/Latino MSM: Signiﬁcant hurdles faced by Hispanic/Latino MSM in obtaining HIV services may have contributed to the rapid proliferation of HIV within these groups. Issues such as language barriers, worries related to immigration and deportation, societal stigma towards MSM and HIV-positive individuals, and the scarcity of HIV prevention services in primary and urgent care settings were prevalent. These barriers align with previous research which identiﬁes the obstacles to HIV prevention among Hispanic MSM as being related to access to HIV prevention and care, language proﬁciency, traditional masculinity notions, and medical distrust.Cancer Health Risks Increased Cancer Risk Behaviors· Disproportionate Impact of Anal Cancer on MSM: Men who have sex with men (MSM) face an elevated risk of anal cancer, primarily triggered by the human papillomavirus (HPV), a sexually transmitted infection (STI). This heightened vulnerability largely stems from their involvement in anal sex practices, signiﬁcantly elevating the risk of HPV transmission (Tamargo et al., 2017).· Increased Breast Cancer Risks for Lesbian and Bisexual Women: The risk of breast cancer may be notably higher in lesbian and bisexual women when compared to heterosexual women. This concern arises from a combination of factors such as lower pregnancy rates, elevated levels of smoking, and a higher incidence of obesity. Additional challenges such as barriers to healthcare access and adverse experiences with healthcare providers might lead to less frequent mammogram screenings in these women (American Cancer Society, 2021b; Tamargo et al., 2017).· Cervical Cancer Risks among WSW: Cervical cancer is predominantly caused by the Human Papillomavirus (HPV). Women who have sex with women (WSW) are susceptible to contracting HPV through

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154various means like heterosexual women. These methods include genital-to-genital contact, touching one’s own genitals after contact with a partner, or sharing sex toys without adequate cleaning (National LGBT Cancer Network, n.d.). It is important to note that many lesbian women may also have a history of heterosexual intercourse, which further elevates their risk of HPV infection. Unfortunately, misconceptions surrounding HPV transmission in WSW can lead to the underutilization of essential preventive measures, such as Papanicolaou (Pap) tests, necessary for cervical cancer screening (American Cancer Society, 2021b)Cancer Screening & Preventive Measures· Patient-Provider Communication and its Impact on Cancer Screenings: Regardless of their sexual orientation, people are more likely to be recommended for cancer screenings if their healthcare providers are informed about their sexual orientation. Improved communication and understanding of patients’ sexual orientation by healthcare providers could help to reduce missed opportunities for cancer screenings and other preventive measures (American Cancer Society, n.d.)· Distinctive Preventive Care Trends Among WSW: The disproportionate representation in preventive care and outcomes is especially prominent among women who identify as lesbian. Research shows that they are less likely than their heterosexual counterparts to seek preventive healthcare measures like mammographs, HPV vaccinations, and Pap tests. These disparities are attributed to a variety of factors, from obstacles in obtaining healthcare coverage to highly negative encounters with healthcare professionals (Tamargo et al., 2017).Interestingly, when they do undertake Pap tests, lesbian women, and particularly those from the Hispanic/Latino community, have a higher likelihood of receiving abnormal results (Charlton, n.d.).· Mammogram Prevalence in Non-Hispanic Black and Latina Women: Non-Hispanic Black bisexual women were reported to have the highest prevalence of mammograms compared to their non-Hispanic Black heterosexual peers. Notably, they also showed the highest rates of mammogram usage among fellow LGBTQIA+ non-Hispanic Black lesbian women and Hispanic/Latina lesbian women (Charlton, n.d.).Barriers To Healthcare Accessibility & Employment· Language Proﬁciency Barriers: The deﬁciency of healthcare providers who are ﬂuent in Spanish, along with insufﬁcient Spanish-translated resources, may pose difﬁculties for individuals more adept or ﬂuent in Spanish in understanding and accessing HIV-related services and information.

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155· Immigration-Related Concerns: Apprehensions related to immigration status, including deportation fears, may dissuade individuals from utilizing medical services.· Health Insurance, Unemployment, and Healthcare Accessibility Issues: LGBTQIA+ individuals are more prone to unemployment and are often without health insurance, leading to a lack of adequate healthcare access. Consequently, necessary care, such as preventive cancer services and early screenings, is delayed. Particularly among Hispanic/Latino individuals, this results in substantial barriers to healthcare access and can increase their risk for cancer (Charlton, n.d.).GEORGIA’S POLICY LANDSCAPE, LGBQTIA+ RIGHTS IN GEORGIAKey points about the policy landscape regarding LGBTQIA+ rights in Georgia:· Anti-Discrimination Protections: Georgia does not have a statewide law that prohibits discrimination based on sexual orientation and gender identity in employment, housing, and public accommodations.· Hate Crime Law: In June 2020, Georgia passed a hate crime law that includes protections based on sexual orientation, but it does not explicitly include protections for gender identity.· Same-sex Marriage: As a result of the Supreme Court’s decision in Obergefell v. Hodges in 2015, same-sex marriage is legal across the United States, including in Georgia.· Conversion Therapy: There is no statewide ban on conversion therapy in Georgia. Conversion therapy refers to the pseudoscientiﬁc practice of trying to change an individual’s sexual orientation from homosexual or bisexual to heterosexual using psychological or spiritual interventions.· Transgender Rights: Transgender individuals can change their gender marker on their state IDs and driver’s licenses in Georgia, but the process is more cumbersome than in some other states. It involves submitting an afﬁdavit from a healthcare provider.· Adoption Laws: Georgia law does not prohibit LGBTQIA+ individuals or couples from adopting children. However, in 2018, Georgia passed a law allowing adoption agencies to refuse to place children with same-sex couples based on religious beliefs.The current policy landscape concerning LGBTQIA+ rights in Georgia poses signiﬁcant implications for the state’s Hispanic/Latinx community.The absence of statewide anti-discrimination protections based on sexual orientation and gender identity can leave Hispanic/Latinx

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156members of the LGBTQIA+ community vulnerable to discrimination in areas of employment, housing, and public accommodations. Despite the passage of a hate crime law in 2020, it offers protections based on sexual orientation but does not explicitly protect against offenses targeting gender identity, which could particularly impact transgender or non-binary individuals. While the legality of same-sex marriage, a result of the 2015 Supreme Court’s decision in Obergefell v. Hodges, beneﬁts LGBTQIA+ Hispanic/Latinx people, the lack of a statewide ban on conversion therapy may subject individuals, particularly younger members of the community, to harmful practices aimed at changing their sexual orientation.Transgender rights are recognized to some extent in Georgia, as transgender individuals can change their gender marker on state IDs and driver’s licenses. However, the process, which requires an afﬁdavit from a healthcare provider, can be daunting and may be an obstacle for some, particularly if they lack access to supportive healthcare services.Finally, while Georgia law does not prohibit LGBTQIA+ people from adopting children, the law passed in 2018 allowing adoption agencies to refuse to place children with same-sex couples based on religious beliefs can potentially limit the opportunities for LGBTQIA+ Hispanic/Latinx couples to adopt, contributing to further inequities in the community.FarmworkersThe foreign-born migrant and temporary workers who constitute a signiﬁcant portion of the U.S. Hispanic/Latino population include a group known as migrant seasonal farmworkers (MSFW) (Velasco-Mondragon et al., 2016b). Migrant farmworkers remain one of the most vulnerable and marginalized groups in the US. About 68% of farmworkers were born in Mexico, and they are predominantly male (78%), married (59%), and 36 years old on average (Velasco-Mondragon et al., 2016b). Farmworkers face multiple health risks associated with their work in agriculture, including exposure to pesticides and heat, as well as musculoskeletal, respiratory, skin, and eye injuries. They are also at risk of food insecurity and depression. However, assessing these health hazards and outcomes is challenging due to workers’ highly mobile lifestyle, limited English proﬁciency, varying citizenship status, and cultural barriers. This section aims to shed light on the health status of Hispanic/Latino migrant farmworker families in Georgia. It addresses the unique vulnerabilities and health disparities faced by this population, considering factors such as occupational hazards, environmental exposures, socioeconomic conditions, and other pertinent determinants of health. Additionally, it emphasizes the signiﬁcance of understanding the health proﬁle of the children in these families due to Georgia’s reliance on a migrant farmworker workforce.

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157The Georgia agricultural industry relies heavily on H2A Temporary Agricultural Program to employ agricultural workers due to the shortage of domestic agricultural workers. Georgia’s agriculture industry relies heavily on the H2A Seasonal Agricultural Program to employ farmworkers, due to a domestic farmworker shortage. In 2022, the U.S. Department of Labor certiﬁed 370,000 jobs available for the H2A visa program. Georgia ranked third in the number of H2A workers (9%), behind Florida (14%) and California (12%) (Economic Research Services, 2023). The majority of H2A workers come from Mexico.Working Conditions and Occupational HazardsApproximately 75% of farmworkers in the United States are Hispanic/Latino migrants, and about 50% of hired farmworkers do not have authorization to work in the United States. Farmworkers face numerous chemical, physical, and biological threats to their health (Castillo et al., 2021). Occupational conditions and hazards were a primary cause of physical illness and injury in rural Latinos, particularly those employed on farms or in manufacturing plants (Stone et al., 2022).Heat-related illness and heat stroke are a major problem for agricultural workers. A study of 405 agricultural workers in Georgia found that a third of the workers reported three or more heat-related illness (HRI) symptoms (sudden muscle cramps; nausea or vomiting; hot, dry skin; confusion; dizziness; fainting; headache) (Fleischer et al., 2013). Farmworkers had 35 times the risk of heat-related death, the highest rate amongst occupation groups (Gubernot et al., 2015). A study of 60 Hispanic/Latino farmworkers in Georgia found that over 50% of the workers did not know ﬁrst aid for heat stroke (Smith et al., 2021). In 2018, a 24 year old farmworker in Moultrie, Georgia died from heat stroke (Mauldin, 2018). As of the writing of this report, there are no federal heat protection standards. Georgia does not have state heat protection standards either. Prevalence Of Speciﬁc Health Conditions Amomg Farmworkers In GeorgiaA study of 427 H2A male farmworkers in Georgia (>99%) were from Mexico and a mean age of was 29.7 years (Chicas et al., 2022). When it comes to weight categorization, 35% of the Georgia workers were classiﬁed as having normal weight. Meanwhile, a signiﬁcant proportion were either overweight (41%) or obese (23%), with none being classiﬁed as underweight. The study also reported that only 27% of workers under 40 years of age had normal blood pressure levels. This percentage rose slightly to 28% for those 40 years and older. The data reveal an alarming rate of elevated blood pressure and hypertensive levels amongst these workers, with 19% and 34% having elevated blood pressure and stage 1 hypertension respectively for those under 40. Meanwhile, 20% were found to have stage 2 hypertension, with no workers

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158identiﬁed in a hypertensive crisis. Among those 40 years and older, 4% had elevated blood pressure, 43% had stage 1 hypertension, 25% had stage 2 hypertension, and again, none were in hypertensive crisis.The health status of Hispanic agricultural workers in Georgia, as indicated by this study, reveals concerning levels of overweight and obesity, as well as high rates of elevated blood pressure and hypertension (Chicas et.al, 2022). This signiﬁes a potential need for health interventions and occupational reforms within this community, as well as additional studies exploring occupational, environmental, and lifestyle factors that may contribute to these health disparities.Health Status Of Hispanic/Latino Children Of Migrant Farmworkers In GeorgiaThis section summarizes the health status of Hispanic/Latino children from migrant farmworker families in Georgia. It addresses the unique vulnerabilities and health disparities faced by this population, considering factors such as geographical mobility, socioeconomic conditions, and legislative constraints. Additionally, it emphasizes the signiﬁcance of understanding the health proﬁle of these children due to Georgia’s reliance on a migrant farmworker workforce (Nichols et al., 2014). Common Health Challenges Faced by Migrant Children: Health issues prevalent among migrant children include intestinal parasites, nutritional deﬁciencies, dental problems, diarrheal diseases, exposure to pesticides, and recurrent otitis media leading to hearing loss (Nichols et al., 2014). Key Trends in Overweight, Blood Pressure, Anemia, and Stunting Rates: In a study conducted by the Farm Worker Family Health Program (FWFHP) between 2003 and 2011, concerning health disparities among children of migrant farmworkers in Moultrie, Georgia were identiﬁed (Nichols et al., 2014). · Overweight and Obesity: The prevalence of overweight among these children varied between 13.5% and 21.8% across the study years. However, the prevalence of obesity was particularly alarming, ranging from 24.0% to 37.4%. The children of farmworkers in the FWFHP demonstrated a higher prevalence of obesity than their counterparts in other parts of the U.S. and Mexico.· Elevated Blood Pressure: FWFHP children had a higher prevalence of elevated blood pressure compared to comparison groups.· Stunting: The children in the FWFHP showed a higher prevalence of stunting (5.4%) than U.S. (3.4%) and Mexican American children (2.4).Health Disparities Among Mexican American Migrant Children: Research indicates Mexican American migrant children are 2 to 3x more likely to be rated as having poor or fair health compared to non-migrant children (Nichols et al., 2014).

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159BARRIERS TO HEALTHCARE ACCESSFarmworker families face numerous challenges to accessing healthcare. Nichols et al. (2014) highlights the following signiﬁcant socioeconomic and legislative barriers contributing to health disparities among these children.· Poverty and Limited Resources: Economic challenges and limited access to resources, including nutritious food, safe housing, and healthcare services.· Lack Health Insurance Coverage: Difﬁculties affording necessary medical care and preventive service.· Labor Laws and Working Conditions: The nature of farm work (i.e., long hours, physical demands, exposure to hazardous environments, and limited breaks), can contribute to health issues among both parents and their children.· Immigration Policies and Fear of Deportation: Fear of deportation or concerns about immigration status can deter migrant farmworker families from seeking necessary healthcare services, resulting in delayed or inadequate medical attention.· Limited Education and Health Literacy: Limited educational opportunities and low health literacy levels can hinder migrant farmworker families’ understanding of health information, preventive measures, and available healthcare resources.· Enhancing Health Outcomes for Children of Migrant Farmworkers in Georgia: The health proﬁle of Moultrie, with its signiﬁcant contribution to Georgia’s agricultural sector and large population of farmworkers, offers valuable insights into the health status of farmworker children statewide. Local initiatives like Emory University’s Nell Hodgson Woodruff School of Nursing’s Farm Worker Family Health Program (FWFHP) play a vital role in enhancing healthcare access for migrant populations in speciﬁc Georgia counties. To address health disparities among these children, it is essential to target underlying socioeconomic and legislative factors. These interventions will have a signiﬁcant impact on improving health outcomes and overall quality of life for children of migrant farmworkers in Georgia.CLIMATE CHANGEBackground Climate change has brought long-term shifts in temperatures and weather patterns across the world including the United States (Frankson, 2022). Speciﬁcally in Georgia, rising sea levels along Georgia’s coastline and increased heavy rainfalls statewide could cause more frequent and severe coastal ﬂooding threatening existing development and infrastructure. Areas such as Savannah where there is a sizable Latino community are vulnerable to these potential threats from

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160ﬂooding (Velasco-Mondragon et al., 2016a). Georgia’s temperatures have risen in the past decade and is predicted to continuously rise in temperatures which could lead to more droughts and strain Georgia’s municipal water resources. In turn, heat and ﬂooding poses a threat to agriculture yield and livestock, increase the number of unusually hot days, and cause a risk of heat stroke and related illnesses. Georgia has also had a history of environmental hazards including water contamination, ash pollution from coal plants, and lead poisoning (Basye, 2021; Frankson, 2022; Georgia Department of Public Health; Russ, 2018). One in seven people in Georgia work in agriculture, possibly exposing them to harmful chemicals such as pesticides and other toxins (Georgia Farm Bureau, 2023). Heat and particle pollution can increase smog and aggravate respiratory diseases such as heart or lung disease and asthma, - diseases that are disproportionately prevalent in the Latino community as per the data presented.Climate change and environmental hazards disproportionately affect communities that suffer socioeconomic inequalities (DemoLabSouth, 2023; Frankson, 2022; Patnaik, 2020; U.S. Environmental Protection Agency, 2016). Certain individuals are especially vulnerable to the effects of climate change on health such as children, the elderly, the sick, the poor, and outdoor laborers. There is a large Latino population who are migrant workers and in 2019, about half of Latinos in Georgia lived in poverty (Ahn et al., 2022).The BIPOC Environmental Justice Study, a recent qualitative research report, sheds light on the perceptions of the BIPOC community in South Georgia regarding environmental issues. Through the analysis of 150 surveys, the study reveals that a signiﬁcant majority (70%) of participants experienced the impact of environmental justice concerns (DemoLabSouth, 2023). Notably, 68.3% of respondents expressed dissatisfaction with the level of government efforts to safeguard the rights of BIPOC communities in relation to environmental justice. Moreover, a substantial 81% identiﬁed climate change as one of the top three priorities that Georgia ofﬁcials should prioritize. The study also highlights the limited availability and accessibility of public transportation, posing a challenge for many participants in accessing essential services within their communities that impact air pollution. These ﬁndings underscore the urgent need for targeted policies and interventions to address environmental justice disparities and prioritize climate action among minority communities. Knowledge of climate change/ thoughts about effects on healthVarying responses on climate change emerged from the discussions among focus group participants and key informants. While one participant in the South Georgia focus group acknowledged the unusual change in climate and its impact on the local economy, they did not perceive a direct connection between climate change and health. However, another key informant interview revealed a contrasting viewpoint, emphasizing the signiﬁcant impact of climate change on the Latino community. This perspective centered around the rising rent costs, which forced families to seek affordable housing options that often-lacked adequate safety

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161measures due to outdated construction and the presence of harmful environmental chemicals that remain unaddressed. As a result, families ﬁnd themselves residing in homes with poor air quality, leading to detrimental effects on their health.Work environmentsParticipants noted that most Latinos who work in automotive, agricultural industries, or in factories are negatively affected by climate change as well. With rising temperatures and possible lack of safety regulations or breaks, employees are more prone to dehydration working in the heat. “Someone who does landscaping for a living, [...] Let’s say, you know, climate change for example. There’s an increase in the heat if you are used to 80 degree heat and now the summers are hotter. And now you’re working the same amount of hours. There’s more exhaustion on your body from all the heat. So that automatically has a direct impact on your health..” "Alguien que se gana la vida con jardineria, [...] Digamos, ya sabes, el cambio climático, por ejemplo. Hay un aumento en el calor si estás acostumbrado al calor de 80 grados y ahora los veranos son más calurosos. Y ahora estás trabajando la misma cantidad de horas. Hay más agotamiento en tu cuerpo por todo el calor. Entonces eso automáticamente tiene un impacto directo en su salud". Key informantThere is limited research on the effects and efforts to mitigate potential health issues of climate change and environmental hazards directly affecting Latinos in Georgia.

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162“The occupational safety recommendations like taking water breaks or taking breaks to cool down. It’s easier said than done because then you have workers that might do it, take those 10, 15-minute breaks [...] But then it’s also 10, 15 minutes that you’re not working. It’s 10, 15 minutes you’re not getting more boxes/ packages of produce. So that also is less pay”"Las recomendaciones de seguridad ocupacional, como tomar descansos para tomar agua o tomar descansos para refrescarse. Es más fácil decirlo que hacerlo porque tienes trabajadores que podrían hacerlo, tomar esos descansos de 10, 15 minutos [...] Pero también son 10, 15 minutos que no estás trabajando. Son 10, 15 minutos que no estás recibiendo más cajas/paquetes de productos. Así que eso también es menos paga".Key informant

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163MAYA COMMUNITYConsiderations and Limitations in the Quantitative Analysis of the Guatemalan Maya Community’s Health Status - In framing of an analysis on the health status of the Guatemalan Maya community in Georgia, it is crucial to acknowledge the paucity of speciﬁc, detailed quantitative research dedicated to this community. The healthcare needs, outcomes, and challenges of the Maya community are frequently obscured within the broader analyses of Hispanic/Latino health studies, often due to the presumption of a homogenous ethnicity among Spanish-speaking populations. Consequently, this section draws upon a mosaic of sources across various disciplines to construct a more nuanced understanding of the Maya community’s unique historical, sociocultural, and geographical contexts within the United States, and speciﬁcally Georgia. This multi-disciplinary approach provides insight on the interplay between these factors and their impact on the Maya community’s relationship with healthcare, both within the broader United States and speciﬁcally in Georgia. However, the section contains several statistical data that are an approximation and highlight the need for more detailed, speciﬁc research on the Guatemalan Maya population’s health needs and outcomes.The Guatemalan Maya community in Georgia: an examination of health status within the context of migration and cultural complexityGuatemalan Maya: Basic DemographicsThe health landscape of Georgia’s Hispanic/Latino population is shaped by a myriad of distinct cultural identities (LeBaron, 2018). While common categorizations tend to merge the Maya community within the Hispanic/Latino demographic, the Maya – in this case, the Guatemalan Maya community, is a culturally distinct Indigenous group originating from the Guatemalan nation-state. Therefore, it is important to recognize that “Maya” does not denote a single uniﬁed group with one language; rather, it signiﬁes a linguistic family that dates back almost 5,000 years. The linguistic complexity of this community is reﬂected in the 30 surviving languages and nearly 60 dialects spoken by the Mayan populations of Mexico, Belize and Guatemala.

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164This community’s linguistic complexity is reﬂected in the 30 surviving languages and around 60 dialects spoken by Maya populations across Mexico, Belize, and Guatemala. In fact, within Guatemala alone, 22 languages are ofﬁcially recognized (LeBaron, 2018).In fact, 22 languages are ofﬁcially recognized in Guatemala alone (LeBaron, 2018).The migratory journey of the Guatemalan Maya people to the United States, particularly to the Southeast and Georgia, is marked by historical upheaval, economic aspirations, and the search for security and opportunity (Brown & Odem, 2011). It is essential to note that these migration patterns are often shaped by complex socio-political conditions and have profound implications on the health and wellbeing of this community. Health outcomes, healthcare needs, and access among the Maya are intricately tied to their unique cultural contexts and experiences as immigrants. These elements, coupled with the challenges of acculturation and language barriers in the United States, contribute to a unique health proﬁle that requires nuanced understanding and targeted interventions.Guatemalan Maya In The United States & GeorgiaThe American landscape is dotted with numerous migrant communities, including Mexican and Central American Maya, each sharing common traits and experiences. However, the Guatemalan Maya bear a unique distinction: they comprise nearly half the population of their homeland. For many of them, the migration to the United States was fueled by the harsh conditions in Guatemala’s most impoverished and violence-ridden regions, such as Huehuetenango, San Marcos, and Quetzaltenango (LeBaron, 2012).Despite their emigration, Guatemalan Maya in the United States continue to face challenges reminiscent of those they encountered in Guatemala, including political and social disadvantages and language barriers (LeBaron, 2012).. Additionally, the U.S. immigration system presents a labyrinth of complexities, intensifying the likelihood of detention and deportation. Georgia has emerged as a new home to a signiﬁcant population of this indigenous group, with an estimated 20-25,000 Maya individuals settling within its bounds. From the late 1990s, Maya Guatemalans began settling in Canton, Georgia, where they found employment opportunities amidst the city’s rapid growth (Brown & Odem, 2011).The Guatemalan Maya of north Georgia are part of a substantial wave of Latin American immigration that has reshaped the social, cultural, and economic fabric of the U.S. South since the late 1980s (Brown & Odem, 2011). Although Mexicans comprise about 60% of the region’s Latino population, followed by Central and South Americans, the Maya hold a unique position. Representing one of the largest indigenous groups in the Americas with over four million people in Guatemala and Mexico, it is estimated that as many as 500,000 Maya have migrated to the United States (Brown & Odem, 2011).

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165Georgia Mayan Community – Canton Focus Groups Background The majority of Maya families come from the Western highlands of Guatemala, Mexico, and other countries in Central America The Maya, the largest indigenous group in the Americas, speak more than 20 different Maya languages (Brown, 2011). Historically, they have been subjected to years of oppression, discrimination, and exploitation, by Spanish colonizers and Ladino rulers through major events such as 36-year civil war and the Guatemalan genocide in 1960. Armed conﬂict and inadequate post-war efforts for reparations-initiated migration to the United States in the late 1980s. Since then, economic globalization and neo-liberal policies and practices have marginalized the Maya and now approximately 500,000 Maya people have immigrated to the United States. where they supported themselves mainly through farm work, rural labor, and selling goods. Today, there are 25,000 Maya from Guatemala living in Georgia (Lebaron, 2022). Despite having gone through much turmoil, their labor efforts in Georgia have contributed to its economy, corporate competition, and construction trades (Brown, 2011). Contributions have been successful in developing Georgia’s infrastructure, but the fact remains that the Guatemalan Maya in Georgia are still facing political, social, linguistic, and cultural challenges that are complicated by immigration laws and policies (Lebaron, 2022). Oftentimes, the Mayan population is not differentiated from the Latino population and as a result, their linguistic, cultural needs, and health needs are rarely known and unaddressed.Nine people were interviewed among the Mayan community in the city of Canton. The following perceptions and inputs are limited and does not reﬂect thoughts from the overall Mayan population in Georgia. To optimize conﬁdentiality participants were not audio recorded and all results were derived from the focus group notes. Health Concerns Among the Mayan participants, gastritis, cancer, and diabetes were consistently mentioned as the top health concerns. Additionally, participants expressed concern about the prevalence of leukemia among young people, attributing it to factors related to maternal and child health, such as inadequate transfer of nutrients from mother to baby or advanced maternal age. Moreover, cholesterol and hypertension were identiﬁed as signiﬁcant health issues that warranted attention.Mental healthMental health emerged as a signiﬁcant concern, as expressed by the majority of Mayan participants, although one participant held the belief that mental health issues were uncommon. Among the acknowledged mental health problems were depression, stress, and feelings of hopelessness. Participants

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166observed that depression often arose in response to challenging life situations experienced by themselves or their families. Lack of personal ﬁnancial independence was speciﬁcally highlighted as a signiﬁcant source of depression for mothers.Furthermore, depression was identiﬁed as a contributing factor to alcoholism among Latinos, particularly among women from Guatemala. Stress was attributed to the demanding responsibilities of caring for husbands and family members after a long day of attending to their own duties. Participants described a sense of hopelessness stemming from the inability to work and the repetitive nature of their daily routines in caring for their children.Other mental health issues mentioned included nervousness and anxiety, along with instances of domestic violence affecting both women and men within the community. Although participants expressed their intention to address mental health with their children and recognize mental health concerns, they indicated that adults were generally reluctant to seek help for themselves. Community Strengths & Resources Similar to the ﬁndings amongst other focus groups, participants reported that the desire to work, social connectedness, and unity especially in times of hardship were common values within their community. They described that they have seen community connectedness through support given to newly immigrated pregnant women and collecting money for the sick or to send a family member’s body back to their country of origin. Various participants emphasized that their faith and religion were highly important. A few expressed food and culture were something to be valued because of the differences between Latino subgroups originating from different countries. Unlike the other Latino focus groups, varying participants mentioned the value of herbal medicines such as “mora” to improve health and nutrition however they too are considered expensive.Some services that have had a negative effect on their community is the lack of transparency of healthcare costs. Many participants reported having been told services are free or covered by insurance (i.e; mammograms) but are billed after service. Social workers at hospitals helping to ﬁll out insurance applications, Children’s Health Insurance Program (CHIP) and Medicaid helping labor costs and sliding scale health clinics such as Georgia Highland were all recognized as useful health-related resources to the community. Participants with diabetes reported that their church partners with clinics to provide free insulin and low costs pills. Other serviceable resources mentioned that have been successful in the community

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167were humanitarian services, notaries, and churches.Like other focus groups, the Canton participants mentioned that their sources of information were family, friends, community members, and YouTube. These participants further reported that “Newly immigrated mothers use (our) community to help” and that their friends and the community will refer them to try a medication. Climate change & environmental factors Participants recognized that climate change does affect health among the Latino community in Georgia. The most recognized issue is that pollen affects health because it causes allergies. Participants also reported changes in daily weather cause respiratory illnesses and coughs. Some participants stated that they did not think heat affects the health of Latinos in Georgia. Environmental factors such as atmospheric and water pollution or chemical substances were reported to not affect health by a group of participants, but others believe that hazardous environments and contaminated water affects health. There was mention about cases of mold in homes among their community. When discussing immigration status, participants stated that this was closely related to substandard housing. The community lives in overcrowded homes that aren’t maintained well and that may not have air conditioning or heating. They attribute this to their immigration status and the cost of expensive rent. A participant expressed that if a complaint is made the repairs will cause the rent to go up. People are unable to move to different housing because they don’t have documentation such as a driver’s license and live with multiple families to be able to afford rent.Barriers to Health The barriers mentioned by the participants in this subgroup are similar to those mentioned by other focus groups; cost of healthcare, insufﬁcient translators, lack of health insurance. When asked about managing diabetes, participants who know they have diabetes reported that blood glucose strips are expensive and so they don’t monitor their blood sugar daily. Eating healthy or maintaining a diet is another challenge to managing diabetes reported by participants. Immigration status was also mentioned as an indirect barrier to optimizing their health because without documentation they explained people were limited in job options or were unable to work, and unable to obtain health insurance. It also posed a transportation barrier as they were unable to obtain a driver’s license. Fear of deportation was also explained as a barrier to health when participants mentioned their fear of the police and being “scared of the people reporting people without documentation”.Recommendations from Mayan Focus GroupParticipants in the Canton focus group recommended more support and information about resources, increased educational opportunities, and easier access to government aid. They also suggested specialized education and college scholarships for Mayan children facing language barriers. Some participants needed help obtaining government documents and suggested more

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168representation of the Mayan community among healthcare and agencies in the community. The group also expressed the need for help obtaining government documents and prioritized a free clinic option over more Spanish-speaking healthcare providers. Lastly, more representation of the Mayan community was recommended in healthcare and community agencies.Data-informed Recommendations for Decision MakersPreviously, health disparities were primarily addressed through the promotion of health choices; however, this approach does not address the social and structural barrier that may impede individuals from having access to health choices. Social Determinants of Health (SDOH) have been recognized as factors that affect health outcomes and contribute to health inequities, particularly for racialized/minoritized and medically underserved communities. The World Health Organization deﬁnes SDOH as the conditions in which people are born, grow, live, work and age. Healthy People 2030 categorizes SDOH into 5 domains: economic stability; neighborhood and built environment; education access and quality; social and community context; and health care access and quality. Nonetheless, it is important to recognize that underpinning SDOH are policies or lack of policies that drive the social conditions that affect communities in positive and negative ways– in other words, political determinants of health must also be addressed to advance health equity. Reducing health disparities will require sound policies that improve living and working conditions, provide opportunities for health promotion, and remove barriers that make it challenging for Hispanics/Latinos to attain the full potential for health and well-being. Below are policy and programmatic recommendations based on the ﬁndings of this report that will reduce the health disparities among Hispanic/Latino communities, and that will also have a positive effect on the overall health of Georgia.

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171AppendixTable 1. Key Informant Interview Guide Questions Sample Questions- How healthy are Latinos in your community and Georgia as a whole? - Who do you think is responsible for community health in Georgia?- What changes have you seen in your community over the past 3-5 years regarding employment, health, crime, socioeconomic status, attitudes, and demographics? - What do you think are the main concerns of your community? Which of these do you think is the most important? - How would you characterize the health needs of the Latinx population in Georgia? How are they different than for the general population? - What are your thoughts on mental health? - What are your thoughts on how Georgia Latinos view and treat LGBTQ Latinos?- Are there any environmental health issues that affect communities and health of Georgia Latinos?- What do you see as the major resource gaps/barriers with respect to health and wellness for this population? - What barriers do you see that are not health related but impact health outcomes? - What recommendations do you have that can improve the health of Georgia Latinos? - Are there any assets or resources available to address the needs of this population that can be leveraged?

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172Table 2. Focus Group Interview Guide Questions Sample Questions - What are the strengths of the Latino Community? - What do you see as the top or most pressing health issues in the Georgia Latino communities? - What are top non-health issues facing Georgia Latinos? - There are health issues that affect Latinos more than other groups (e.g. diabetes, obesity, heart diseases, cancer). Why do you think this is happening? - Do you think mental health issues affects the Latino Communities?- The acronym LGBTQ stands for lesbian, gay, bisexual, transgender, and queer. What are your thoughts about the Latino LGBTQ community?- Do you think that climate change (e.g. heat, hurricanes) affects the health of Georgia Latinos?- Are there environmental issues (e.g. air pollution, water contamination, chemicals) that affect the health and communities of Georgia Latinos?- What are the greatest barriers/challenges facing Georgia Latinos in seeking health care? - What services have you received that have been the most helpful? - Are there services that you believe had a negative effect on Georgia Latinos? - Where do you get health-related information? - What is the best way to reach out to the Georgia Latino community?

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