This chapter provides an overview of the concept of acculturation and reviews existing evidence about the possible relationships between acculturation and selected health and behavioral outcomes among Latinos. The effect of acculturation on Latino health is complex and not well understood. In certain areas - substance abuse, dietary practices, and birth outcomes - there is evidence that acculturation has a negative effect and that it is associated with worse health outcomes, behaviors, or perceptions. In others - health care use and self-perceptions of health - the effect is mostly in the positive direction. Although the literature, to date, on acculturation lacks some breadth and methodological rigor, the public health significance of findings in areas in which there is enough evidence justifies public health action.We conclude with a set of general recommendations in two areas - public health practice and research - targeted to public health personnel in academia, community-based settings, and government agencies.

/pdf/acculturation-and-latino-health-in-the-united-states-a-1tu2ketzzs.pdf

Acculturation and Latino Health in the United States: A Review of the Literature and its Sociopolitical Context

This study examines the extent to which various ethnic-immigrant and US-born groups differ in their risks of all-cause and cause-specific mortality, morbidity, and health behaviors. Using data from the National Longitudinal Mortality Study, 1979-1989, we estimated, for major US racial and ethnic groups, mortality risks of immigrants relative to those of the US-born. The Cox regression model was used to adjust mortality differentials by age, sex, marital status, rural/urban residence, education, and family income. Logistic regression was fitted to the National Health Interview Survey data to determine whether health status and behaviors vary among ethnic-immigrant groups and by length of US residence. Compared with US-born whites of equivalent socioeconomic and demographic background, foreign-born blacks, Hispanics, and Asians/Pacific Islanders (APIs), US-born APIs, US-born Hispanics, and foreign-born whites had, respectively, 48%, 45%, 43%, 32%, 26%, and 16% lower mortality risks. While American Indians did not differ significantly from US-born whites, US-born blacks had an 8% higher mortality risk. Black and Hispanic immigrants experienced, respectively, 52% and 26% lower mortality risks than their US-born counterparts. Considerable differentials were also found in mortality for cancer, cardiovascular, respiratory, infectious disease, and injury, and in morbidity and health behaviors, with API and Hispanic immigrants generally experiencing the lowest risks. Consistent with the acculturation hypothesis, immigrants' risks of smoking, obesity, hypertension, and chronic condition, although substantially lower than those for the US-born, increased with increasing length of US residence. Given the substantial nativity differences in health status and mortality, future waves of immigrants of diverse ethnic and cultural backgrounds will likely have a sizeable impact on the overall health, disease, and mortality patterns in the United States.

Ethnic-Immigrant Differentials in Health Behaviors, Morbidity, and Cause-Specific Mortality in the United States: An Analysis of Two National Data Bases

The authors used the 1992-1995 National Health Interview Survey to examine the effect of immigrant status (both nativity and duration of residence in the United States) on the health of Asian and Pacific Islander adults by constructing models in which national origin was also specified. In logistic regression models adjusted for age, marital status, living arrangement, family size, and several socioeconomic indicators, immigrants were found to be in better health than their US-born counterparts, but their health advantages consistently decreased with duration of residence. For example, for Asian and Pacific Islander immigrants whose duration of residence was less than 5 years, 5-9 years, and 10 years or more, the odds ratios for activity limitations were 0.45 (95% confidence interval (CI): 0.33, 0.62), 0.65 (95% CI: 0.46, 0.93), and 0.73 (95% CI: 0.60, 0.90), respectively. Similar findings emerged for respondent-reported health and bed days due to illness. These results support the validity and complementarity of the migration selectivity and acculturation hypotheses. However, the picture was not uniformly positive. The health of certain Asian and Pacific Islander groups, notably Pacific Islanders and Vietnamese, was found to be less favorable than average. Finally, after adjustment for health status, immigrants seemed to have less adequate access to formal medical care.

Immigration and the Health of Asian and Pacific Islander Adults in the United States

OBJECTIVES: This study examined whether US-born people and immigrants 25 years or older differ in their risks of all-cause and cause-specific mortality and whether these differentials, if they exist, vary according to age, sex, and race/ethnicity. METHODS: Using data from the National Longitudinal Mortality Study (1979-1989), we derived mortality risks of immigrants relative to those of US-born people by using a Cox regression model after adjusting for age, race/ethnicity, marital status, urban/rural residence, education, occupation, and family income. RESULTS: Immigrant men and women had, respectively, an 18% and 13% lower risk of overall mortality than their US-born counterparts. Reduced mortality risks were especially pronounced for younger and for Black and Hispanic immigrants. Immigrants showed significantly lower risks of mortality from cardiovascular diseases, lung and prostate cancer, chronic obstructive pulmonary diseases, cirrhosis, pneumonia and influenza, unintentional injuries, and suicide but higher risks of mortality from stomach and brain cancer and infectious diseases. CONCLUSIONS: Mortality patterns for immigrants and for US-born people vary considerably, with immigrants experiencing lower mortality from several major causes of death. Future research needs to examine the role of sociocultural and behavioral factors in explaining the mortality advantage of immigrants. Language: en

All-cause and cause-specific mortality of immigrants and native born in the United States

The US immigrant population has grown considerably in the last three decades, from 9.6 million in 1970 to 32.5 million in 2002. However, this unprecedented population rise has not been accompanied by increased immigrant health monitoring. In this study, we examined the extent to which US- and foreign-born blacks, whites, Asians, and Hispanics differ in their health, life expectancy, and mortality patterns across the life course. We used National Vital Statistics System (1986-2000) and National Health Interview Survey (1992–1995) data to examine nativity differentials in health outcomes. Logistic regression and age-adjusted death rates were used to examine differentials. Male and female immigrants had, respectively, 3.4 and 2.5 years longer life expectancy than the US-born. Compared to their US-born counterparts, black immigrant men and women had, respectively, 9.4 and 7.8 years longer life expectancy, but Chinese, Japanese, and Filipino immigrants had lower life expectancy. Most immigrant groups had lower risks of infant mortality and low birthweight than the US-born. Consistent with the acculturation hypothesis, immigrants’ risks of disability and chronic disease morbidity increased with increasing length of residence. Cancer and other chronic disease mortality patterns for immigrants and natives varied considerably, with Asian Immigrants experiencing substantially higher stomach, liver and cervical cancer mortality than the US-born. Immigrants, however, had significantly lower mortality from lung, colorectal, breast, prostate and esophageal cancer, cardiovascular disease, cirrhosis, diabetes, respiratory diseases, HIV/AIDS, and suicide. Migration selectivity, social support, socio-economic, and behavioural characteristics may account for health differentials between immigrants and the US-born.

Health, life expectancy, and mortality patterns among immigrant populations in the United States

OBJECTIVES: This study examined the health insurance status of the US foreign-born population and the influence of race, ethnicity, and length of residence on health insurance status. METHODS: Data were obtained from the 1989 and 1990 National Health Interview Surveys, including the Insurance and Family Resource Supplements. RESULTS: In 1989 and 1990, the foreign-born population was twice as likely as the US-born population to be uninsured (26.2% vs 13.0%). The highest rate of uninsured status, 40.8%, was found among foreign-born Hispanics. Persons who had lived in the United States for less than 15 years were 1.5 to 4.7 times more likely to be uninsured than were US-born Whites. CONCLUSIONS: Foreign-born US residents-especially Hispanics and persons residing in the United States for less than 15 years-are vulnerable to not having health insurance, which may limit their access to medical services. The administrative criteria for public programs may explain the high rates of uninsured status among recent i...

Health insurance coverage among foreign-born US residents: the impact of race, ethnicity, and length of residence.

Key Points Question Do rates of health care utilization for beneficiaries with complex care needs differ between traditional Medicare and Medicare Advantage (MA)? Findings In this cross-sectional study of 1 844 326 Medicare beneficiaries, those enrolled in MA had lower rates of hospital stays, emergency department visits, and 30-day readmissions. The largest relative differences were observed for hospital stays, which ranged from −9.3% to −11.9% across different cohorts of beneficiaries with complex care needs. Meaning Among Medicare beneficiaries with complex care needs, those enrolled in MA had lower rates of acute care utilization, suggesting that managed care activities in MA may influence the nature and quality of care provided to these beneficiaries.

/pdf/comparison-of-health-care-utilization-by-medicare-advantage-n76dys82.pdf

Comparison of Health Care Utilization by Medicare Advantage and Traditional Medicare Beneficiaries With Complex Care Needs

Background: Diabetes and hypertension are prevalent in CKD. The association of coordinated care with outcomes in the setting of these coexisting comorbidities is not well understood. This study evaluated the association between well-managed care and healthcare resource utilization (HCRU) and costs. Methods: Using the Humana Research Database, this retrospective cohort study identified 241,628 patients with CKD Stage ≥ 3a (3% diabetes, 40% hypertension, 50% diabetes and hypertension, 7% neither diabetes nor hypertension) in 2017. Eligible patients were indexed on first evidence of CKD and required to be enrolled in a Medicare Advantage Prescription Drug plan for ≥ 12 months pre-and post-index date. Patients who had kidney transplant or hospice election pre-index were excluded. Well-managed care measures included hemoglobin A1c (HbA1c) monitoring, adherence to glucose medications, cardiovascular (CV) therapy, angiotensin-converting enzyme inhibitors/ angiotensin receptor blockers (ACEi/ARBs), and routine primary care provider (PCP)/ nephrologist visits. HCRU and costs were evaluated within 12-months post-index. Results: The cohort was 55% female, 77% White, average age of 75 years, and comprised of 67%, 23%, 10%, and 1% patients with Stages 3a, 3b, 4 and 5 CKD, respectively. Patients with diabetes and hypertension who were adherent to well-managed care were significantly less likely to experience an inpatient (IP) admission or emergency department (ED) visit (Table 1) and incurred lower mean monthly costs compared with patients who were not adherent to well-managed care. Similar results were observed for patients with diabetes only, hypertension only, or neither condition. Conclusions: Well-managed diabetes and/or hypertension in patients with CKD was associated with lower HCRU and costs. Findings may inform innovative models of CKD care coordination.

Well-Managed CKD and Its Association with Healthcare Resource Utilization and Costs

Effective management of comorbid diabetes and hypertension in patients with chronic kidney disease (CKD) is important for optimal outcomes. However, little is known about this relationship from a health plan perspective. The objective of this study was to evaluate the association of effective management of comorbid diabetes and/or hypertension with healthcare resource utilization (HCRU) in patients with chronic kidney disease (CKD).This retrospective cohort study used the Humana Research Database to identify patients with CKD Stage ≥ 3a in 2017. Eligible patients were enrolled in a Medicare Advantage Prescription Drug plan for ≥ 12 months before and after the index date (first observed evidence of CKD). Patients with end-stage renal disease, kidney transplant, or hospice election preindex were excluded. Recommended comorbid disease management included hemoglobin A1c monitoring; adherence to glucose-lowering, cardiovascular, and angiotensin-converting enzyme inhibitors/angiotensin receptor blocker medications; and nephrologist/primary care provider (PCP) visits. HCRU was evaluated for 12 months postindex.The final cohort of 241,628 patients was 55% female and 77% White, with an average age of 75 years. Approximately 90% of patients had Stage 3 CKD. Half had both diabetes and hypertension, and most of the remaining half had hypertension without diabetes. Patients meeting the criteria for good disease management, compared with patients not meeting those criteria, were less likely to experience an inpatient hospitalization, by as much as 40% depending on the criterion and the comorbidities present, or an emergency department visit, by as much as 30%. Total monthly healthcare costs were as much as 17% lower.Management of comorbid diabetes and hypertension in patients with CKD was associated with lower HCRU and costs. Care coordination programs targeting patients with CKD must give careful attention to glucose and blood pressure control.Not applicable. 

Managing comorbidities in chronic kidney disease reduces utilization and costs

OBJECTIVES
To evaluate the association of dialysis transition planning factors (eg, nephrologist care, vascular access placement, place of dialysis) with inpatient (IP) stays, emergency department (ED) visits, and mortality.


STUDY DESIGN
Retrospective cohort study.


METHODS
We used the Humana Research Database to identify 7026 patients with a diagnosis of end-stage renal disease (ESRD) in 2017 who were enrolled in a Medicare Advantage Prescription Drug plan with at least 12 months preindex enrollment, with first ESRD evidence as the index date. Patients with kidney transplant, hospice election, or dialysis preindex were excluded. Transition-to-dialysis planning was defined as optimal (vascular access placed), suboptimal (nephrologist care, but no vascular access), or unplanned (first dialysis in IP stay or ED visit).


RESULTS
The cohort was 41% female and 66% White, with a mean age of 70 years. Optimally planned, suboptimally planned, and unplanned transition to dialysis occurred for 15%, 34%, and 44% of the cohort, respectively. Among patients with preindex chronic kidney disease (CKD) stages 3a and 3b, 64% and 55%, respectively, had an unplanned dialysis transition. For patients with preindex CKD stages 4 and 5, 68% and 84%, respectively, had a planned transition. In adjusted models, patients with a suboptimally or optimally planned transition were 57% to 72% less likely to die, 20% to 37% less likely to experience an IP stay, and 80% to 100% more likely to experience an ED visit than patients with an unplanned dialysis transition.


CONCLUSIONS
A planned transition to dialysis was associated with reduced odds of IP stays and lower mortality.

Transition-to-dialysis planning, health care use, and mortality in end-stage renal disease.

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