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Friday, July 31, 2015

Acculturation and Diabetes Among Mexican Americans: Is There a Link?

by Aishwarya Rajagopalan, MHS

How can adapting to a different culture affect your health? This question is particularly relevant among Americans of Hispanic and Latino descent, who form an increasing proportion of the United States minority population. From beliefs on healthcare, to eating patterns, to family structures and social networks, the impact of culture is diverse and widespread.  

In a Medical Care paper published ahead of print today, Ortiz and colleagues assessed whether diabetes care was affected by acculturation among US-born and foreign-born adults of Mexican descent, aged 35 and older. Given that about 29.1 million Americans had diabetes in 2012, understanding psychosocial and cultural factors impacting access to and utilization of screening and treatment resources for diabetes is one important way in which clinicians and policymakers can begin to evolve how we approach this important disease. insulin-400x300.jpg

Previous research on this topic has found mixed results of the effects of increased levels of acculturation (in the US, identification with mainstream American culture) or more time spent in the United States . Some researchers suggest that acculturation increases access to insurance and  healthcare utilization (see Mainous, Majeed, Koopman et al, 2008), while others have found that acculturation is associated with the adoption of unhealthy dietary habits typical of the “Western” diet (Mainous, Diaz, Geezy) and can even be associated with increased risk for diabetes (O’Brien, Alos, Davey et al, 2014).

In this study, 3,072 self-identified Mexican adults, born in Mexico or the United States, were recruited through their participation in the California Health Interview Surveys in 2005, 2007, 2009, and 2011/2012. The California Health Interview Surveys are biannual surveys conducted over the telephone asking participants basic questions about their current health status, as well as their utilization of the healthcare system, using a multistage sampling strategy in  small, medium and large counties. The survey is conducted using a myriad of languages to ensure maximum participation and accuracy of responses.

Based on participant responses to the study, Ortiz and colleagues measured whether diabetic patients had received an eye exam, a hemoglobin A1C (HbA1c) test for average blood sugar values, or had received diabetes-related education from a healthcare provider. In addition, they assessed whether diabetic patients had received an annual flu shot or had a primary care clinician visit in the past year. The study was conducted in adults >35 years old because this captured the maximum number of adults with diabetes and also allowed for the inclusion of “younger immigrants.” Acculturation was measured primarily through the use of generational status. Respondents’ generational status was categorized such that immigrants were generation zero, while those with two foreign-born parents were first generation, and so on. The study controlled for various sociodemographic variables, including age, sex, socioeconomic status (household income in categories), smoking status, health insurance status, and employment.

Using logistical regression modeling, the study authors found that the highest mean age of diabetes onset occurred in the 2nd generation (66 years). First-generation individuals had the lowest mean age of diabetes onset at 53 years, were least likely to be in the highest income category, and had the highest rates of uninsurance. The modeling also indicated that there was an inverse linear relationship between generation number and utilization of diabetes care. Particularly for the diabetes eye exam, all groups had better odds of receiving an eye exam than generation 0. The diabetic foot exam showed mixed results, and the HbA1c was only statistically significant in its difference between a third generation individual and generation 0. More acculturation (higher generational status) was positively associated with receiving a flu shot and having a primary care clinician encounter in the past year.

These findings are important because they suggest a critical role for healthcare providers in understanding the cultural background of their patients. The study authors note that there are many values, such as respect and familism, that are highly prized in the Mexican community, and providers should keep these values  in mind to foster better doctor-patient relationships. Lack of cultural awareness in healthcare interactions could worsen these relationships  and also lead to decreased utilization of needed care.

The study authors note one key confounder within the measure of generational status. Because generational status is a proxy for the extent to which an individual or family identifies with their Mexican culture, it may not be an accurate measure of acculturation. These results may not be generalizable beyond the Mexican and Mexican-American populations, but the implications of this research should prompt further investigation into the role of culture in healthcare beliefs, access and utilization, particularly among those with costly chronic diseases such as diabetes.

Aishwarya Rajagopalan is a second year medical student at the Philadelphia College of Osteopathic Medicine. She completed her BA and MHS in Public Health from Johns Hopkins University and is interested in topics of health disparities, psychosocial determinants of health, access to care and cultural factors in health.