We found significant variability in demographic characteristics and disease prevalence by country of origin among US Hispanics. This country of origin effect on hypertension and diabetes prevalence was significant among both US and foreign-born Hispanic immigrants. Us born Cubans had lower hypertension and US born Mexicans had lower rates of diabetes compared to US born Mexican-Americans. Among foreign-born Hispanics, Puerto Ricans and Dominicans had higher hypertension prevalence compared to Mexican-Americans, whereas Cubans, Dominicans and Central/South Americans had lower diabetes prevalence. These results indicate that Hispanics cannot be clustered into one group and that disease prevalence is different among US born versus foreign born subgroups.
Differences in hypertension and diabetes prevalence among foreign-born Hispanics may be explained by several factors. At the individual level, there may be mediators such as interaction with the country of origin’s healthcare system, exercise and dietary habits, and societal and family stressors that may have different degrees of importance based on country of origin. In addition, foreign-born Hispanics may have different patterns of migration/immigration back to their native land33,34
. Other examples of social determinants that may influence disease prevalence include demographic and socioeconomic characteristics prior to entering the US and the characteristics of the American community into which an immigrant settles24,34
. We found higher prevalence of hypertension in countries with higher prevalence of Hispanic Blacks. Recent studies have shown that prevalence of hypertension was equally high among both Hispanic Blacks and non-Hispanic Blacks.35–38
. Whether this reflects a true genetic difference among groups or a reflection of unmeasured social determinants needs to be further investigated.
Once foreign-born Hispanics arrive in the US, they undergo a process of acculturation that is likely not uniformly experienced. As people spend more time in the US, they likely adopt American lifestyle habits. Prior research has shown that years in the US is a significant predictor of increasing BMI and poor health outcomes39,40
. Conversely, as a positive part of acculturation, they also gain more access to healthcare. The balance between positive and negative aspects of acculturation and how they play out across subgroups has yet to be explored. Although a standard for measuring acculturation has not been reached34,41
, our findings indicate that country of origin may be an important proxy for social determinants related to migration and acculturation and must be considered when exploring these processes.
In contrast, the relatively uniform prevalence of hypertension and diabetes among US-born Hispanic subgroups indicates that the determinants of disease expression in these participants are similar across different Hispanic sub-groups. While US-born Hispanics may share common cultural values, our study also indicates that they have high rates of high school education, insurance, and routine care. These factors have been shown to be important determinants of health18,24
. We also show that US-born Hispanics lack the language disparity of their foreign-born counterparts.
A strength of this study is the large sample size. Also, this study included Dominicans, and Central/South Americans, which have been excluded in prior Hispanic subgroups analysis. However, our findings must be interpreted in light of certain limitations. First this is a cross-sectional analysis and therefore we cannot attribute causality. Nonetheless it presents a valuable starting point for a future longitudinal analysis of the acculturation process and how it manifests itself in each Hispanic subgroup. Second, the data are self-reported and thus could be biased by under- or over-reporting disease prevalence. However, self-reported hypertension has been shown to be similar to physician-diagnosed hypertension among patients who receive routine care42,43
. Another limitation is the issue of misclassification. For instance, although all Puerto Ricans are US-born, because the interviews were conducted only in mainland US, we found that not all Puerto Ricans born outside mainland US considered themselves as US-born. Furthermore, the self-identified Mexican versus Mexican-American categories did not closely correlate with US nativity or years in US. That is, some respondents describing themselves as Mexican were US born whereas other respondents who identified as Mexican-American were born in Mexico. These discrepancies indicate that birthplace alone does not necessarily determine ethnic identity among Mexican and Mexican-American Hispanics. Lastly, although we would have preferred to analyze Central and South Americans as two separate groups, these respondents were grouped into a single category in the NHIS survey.
We conclude that Hispanics are a heterogeneous group and cannot be represented by one subset of this population. This heterogeneity is particularly evident among foreign-born Hispanics. Further, traditional variables of demographics, socioeconomic status, or acculturation do not fully account for differences in disease prevalence across foreign-born Hispanic subgroups. We hypothesize that nationality might be a proxy for risk factors that accompany various migration experiences and the process of acculturation. This concept would be worth exploring in future studies. We need to cease assuming that Mexican Americans or any other Hispanic subgroup are representative of all Hispanics and to take into account the cultural diversity within this population. Future studies should explore how a migrant’s incorporation into the American healthcare system is influenced by the country of origin.