To our knowledge, this is the first study to assess the association between adherence to diabetes care guidelines and nativity status in a nationally representative sample of adults. After adjustment for potential confounders, foreign-born individuals were 49 and 36% less likely to have had an influenza vaccination or to be compliant with at least one of the seven recommendations compared with U.S.-born individuals, respectively. Studies conducted in the U.S. compare diabetes care by race and ethnicity, but not by nativity status; thus, it is challenging to compare our study with previous U.S. studies.
Therefore, we turned to studies conducted outside of the U.S. to inform our current findings. One study focused on diabetes care (12
) and the other study was qualitative in nature and shed light on diabetes beliefs (13
). Other researchers examined the influence of patient-physician interactions on diabetes care (14
) or just compared clinical indicators (i.e., BMI and cholesterol) between U.S.- and foreign-born individuals with diabetes (16
). It is important to emphasize that the latter studies did not evaluate whether or not recommended diabetes care guidelines had been achieved; they just provided descriptive characteristics.
More specifically, Kristensen et al. (12
) found that diabetes care did not differ among native Danes compared with Lebanese or Turkish immigrants. However, Thabit et al. (17
) suggested that immigrants in Ireland had significantly worse glycemic control and a higher microalbumin to creatinine ratio compared with Irish patients. Our study contributes to this literature by including U.S. findings in the discourse and by specifically showing in which areas immigrants fall behind in diabetes care recommendations and in which areas they are similar compared with U.S.-born individuals.
In our study, immigrants were less likely to have had an influenza vaccination than U.S.-born individuals. One study suggested that immigrants in general were less likely to obtain vaccinations compared with U.S.-born individuals (18
). This may be due to language barriers in that immigrants may not know they need a vaccination. In addition, various cultures have different beliefs about vaccines, thinking they may cause illness or they are only needed if an individual is concerned about getting influenza (19
). Hence, the foreign-born individuals in our study may have related to some of these beliefs and therefore not obtained an influenza vaccination.
Another reason we may see this difference is that there may be disparities in access to and quality of health care between foreign- and U.S.-born individuals (8
). Dallo et al. (8
) showed that foreign-born individuals had greater odds of reporting that their physician did not involve them in their care as much as they would have liked and that their physician did not spend as much time with them as they would have liked. In our sample, perhaps physicians did not spend as much time with foreign-born individuals to review all of the diabetes care recommendations.
To mitigate the aforementioned barriers, we suggest that clinicians take advantage of the office visit to effectively communicate with the patient about the importance of receiving an influenza vaccination. There are several other reasons why we put forth such a recommendation. First, influenza is a preventable infection; second, having diabetes increases the risk of death from influenza (20
); and third, the influenza vaccination reduces hospital admissions among individuals with diabetes (21
Literature suggests that foreign-born individuals enjoy better health in general that U.S.-born individuals (5
). However, with acculturation, this health advantage tends to decline (22
). In our study, we could not compare various levels of acculturation, because the MEPS did not incorporate a comprehensive acculturation scale. However, we did examine whether language spoken, length of residency in the U.S., and other demographic characteristics account for the differences between foreign- and U.S.-born individuals with respect to diabetes care.
In our study, of the foreign-born, only 12.8% spoke Spanish at home and 79.8% had lived in the U.S. for ≥15 years, which may signify high acculturation levels. Further studies should include an acculturation scale (i.e., Acculturation Rating Scale for Mexican Americans) (23
) to lend validity and reliability to the acculturation measures. Our findings also show that foreign-born individuals had fewer years of education compared with U.S.-born individuals. One study showed that “greater acculturation, higher educational attainment, and higher diabetes prevalence were associated with greater cultural knowledge about diabetes” (24
). Perhaps the foreign-born sample in our study had low acculturation and educational attainment; therefore, they were less likely to comply with diabetes protocol.
Our study is not without strengths and limitations. Its strengths are the large sample size, which allowed us to compare foreign- to U.S.-born individuals, while controlling for many potential confounders. In addition, the findings can be generalized to the U.S. population. Its limitations are that we could not probe reasons that foreign-born individuals were less likely to report having specific tests. In addition, we would have liked to explore subgroup variation by nativity status. However, the small sample size for Asians (U.S.-born = 31 and foreign-born = 165) precluded us from providing any meaningful conclusions for Asians. Among Hispanic subgroups, Mexican Americans would be the only subgroup large enough to detect meaningful differences (U.S.-born = 537 and foreign-born = 558). All other Hispanic subgroups had sample sizes too small to generate reliable estimates in the adjusted analyses (i.e., Cubans: U.S. born, n = 8; foreign born, n = 73).
Furthermore, the goal of this article was to add to the literature by providing overall estimates for diabetes care by nativity status. Our findings call attention to the importance of oversampling minorities in national studies, inquiring about specific subgroup identification, and including place of birth as a questionnaire item in future studies. Another limitation is that the data were self-reported. Patients may not always have recalled if or when they obtained each test. It would have been useful to verify the respondent's information with their medical records.
As suggested earlier, further research is needed to ask additional questions related to acculturation status, such as the language individuals speak or think in when they are at home or with relatives or friends, whether individuals follow the diet of their own or their host society's culture, and whether they choose to view, read, or listen to media in their own or their host society's culture.
These measures will provide more detailed information about acculturation levels. Further, we believe qualitative research would be the next best step, which would provide us with an in-depth analyses of why foreign-born individuals are less likely to follow some of the diabetes care recommendations. Was it because of lack of knowledge, lack of access to care, no recommendation from their physician, or the respondent's beliefs? Such studies also would inform appropriate interventions so that all individuals with diabetes would comply with diabetes care recommendations. One study suggested that, “Communication interventions to educate vulnerable populations need to be strategic and evidence-based. It is important for health educators to adopt culturally sensitive communication practices to reach and influence vulnerable populations” (25
). Foreign-born individuals are a vulnerable population, and their health may worsen with increased length of stay in the U.S (22
). This study suggests that we should track diabetes disparities not only by race and ethnicity but also by nativity status.