Influence of Patient Immigrant Status on Provider Diabetes Treatment Decisions: A Virtual Human Experimental Study

Indiana University-Purdue University Indianapolis (IUPUI)Immigrants are at elevated risk for not having their diabetes treatment appropriately intensified, likely resulting in poorly-controlled diabetes and increased morbidity and mortality. Immigrant status is a powerful sociodemographic cue, yet its influence on providers’ diabetes treatment decisions is unknown. The study objective was to determine the effect of patient immigrant status on providers’ decisions to (1) take no action, (2) add an oral hypoglycemic agent (OHA), (3) add/switch to insulin, or (4) refer the patient to an endocrinologist. Participants were 140 medical students/professionals (‘providers’). Providers viewed profiles (videos + vignettes) for virtual patients differing in immigrant status (born in Mexico or U.S.; other characteristics held constant). Analyses were completed at the group (‘nomothetic’) and individual (‘idiographic’) levels. Nomothetic results indicated providers were less likely to refer foreign-born patients to endocrinology than U.S.-born patients (p=0.03). No differences were detected for the other three treatment likelihood ratings. Idiographic results indicated that about half of provider decisions were influenced by patient immigrant status (i.e., Cohen’s d≥0.50) across all four treatment decisions. Effect size data show an almost even split between higher treatment ratings for foreign-born vs. U.S.-born patients for three decisions (take no action, add an OHA, add/switch to insulin), explaining why group-level differences for these ratings did not emerge (i.e., they were cancelled out). This study found that providers are less likely to refer foreign-born patients to endocrinology, potentially leading to therapeutic inertia. In addition, half of individual-level provider decisions were meaningfully influenced by patient immigrant status. However, traditional group-level analyses mask these important individual-level differences. These systematic differences in treatment based on non-relevant factors could lead to unintended adverse outcomes for the foreign-born population

Patient–Provider Language Concordance and Health Outcomes: A Systematic Review, Evidence Map, and Research Agenda

Although patient–provider language concordance has the potential to reduce health disparities for people with limited English proficiency, no previous work has synthesized this literature. Our systematic review sought to describe the characteristics of studies examining relationships between language concordance and health outcomes, summarize the nature of observed associations, and propose an evidence map and research agenda. A comprehensive search of published articles identified 38 quantitative studies for inclusion. Most studies were cross-sectional, conducted in primary care, concentrated in Western states, and focused on Spanish speakers and physician providers. Results were split between supporting a positive association versus no association of language concordance with patient behaviors, provider behaviors, interpersonal processes of care, and clinical outcomes. Several methodological limitations were identified. Based on these results, we developed an evidence map, identified knowledge gaps, and proposed a research agenda. There is a particular need for quasi-experimental longitudinal studies with well-characterized samples

Associations between immigrant status and pharmacological treatments for diabetes in U.S. adults

Objectives: Although treatment disparities in diabetes have been documented along racial/ethnic lines, it is unclear if immigrant groups in the United States experience similar treatment disparities. Our objective was to determine whether immigrant status is associated with differences in pharmacological treatment of diabetes in a nationally representative sample of adults with diabetes. We were specifically interested in differences in treatment with oral hypoglycemic agents (OHA) and insulin. Method: Respondents were 2,260 adults from National Health and Nutritional Examination Survey (NHANES) 2003–2012 with a self-reported diabetes diagnosis. Immigrant status was indicated by birth within (U.S.-born) or outside (foreign-born) the 50 U.S. States or Washington, DC. Multinomial logistic regression analyses examined associations between immigrant status and (a) treatment with OHAs only and (b) treatment with insulin only or insulin and OHA combination therapy, using no treatment as the reference group. Results: Adjusting for demographics, diabetes severity and duration, cardiovascular disease (CVD), and CVD risk factors, being foreign-born versus U.S.-born was not associated with treatment with OHAs only (odds ratio [OR] = 1.59; 95% confidence interval [CI] [0.97, 2.60]). However, being foreign-born was associated with decreased odds (OR = 0.53; 95% CI [0.28, 0.99]) of treatment with insulin. Conclusions: Pharmacological treatment of diabetes differs along immigrant status lines. To understand these findings, studies capturing the processes underlying treatment differences in diabetes among immigrants are needed. Findings raise the possibility that integrating information about a patient’s immigrant status, in addition to racial/ethnic identity, may be an important component of culturally sensitive diabetes care

Diabetes Risk Perception Among Immigrant and Racial/Ethnic Minority Adults in the United States

Purpose The purpose of the study was to examine associations of immigrant and racial/ethnic status with diabetes risk perception among a population-based sample of US adults without diabetes. Racial/ethnic minorities are at increased risk of developing diabetes. Emerging research shows that immigrant (foreign born) individuals are also at increased risk, but less is understood about risk perception in this group. Methods Respondents were 11,569 adults from the NHANES (2011-2016; National Health and Nutrition Examination Survey) reporting no diabetes or prediabetes. Immigrant status was coded as foreign born or US born and analyses used NHANES racial/ethnic categories: white, black, Mexican American, other Hispanic, Asian, and other/multiracial. Immigrant status and variables comparing each minority group with whites were simultaneously entered into models predicting risk perception (yes/no), adjusting for demographic and diabetes risk factors. Results Being foreign born was associated with decreased odds of perceived risk, while being Mexican American, Asian, and other/multiracial were associated with increased odds of perceived risk. Discussion Foreign-born adults are less likely than US-born adults to report perceived risk for diabetes. Lower diabetes risk perception among immigrants could result in poorer preventative behaviors and later diabetes detection

Depressive Symptom Severity as a Predictor of Attendance in the HOME Behavioral Weight Loss Trial

Objective We examined whether total depressive symptoms and symptom clusters predicted behavioral weight loss attendance among economically disadvantaged adults in a randomized controlled trial. Methods 150 adults with obesity were randomized to 12 months of in-person, video conference, or enhanced usual care weight loss groups. We categorized percent session attendance in the intervention arms into three levels: no attendance, poorer attendance, and better attendance. Results Higher baseline Patient Health Questionnaire-8 (PHQ-8) score was associated with a greater odds of being in the poorer versus better attendance group (OR = 1.94, 95% CI: 1.02–3.69, p = .04). A similar relationship between PHQ-8 score and odds of being in the no attendance versus better attendance group was observed but was not statistically significant (OR = 1.63, 95% CI: 0.94–2.81, p = .08). Both cognitive/affective and somatic clusters contributed to the depressive symptoms-attendance relationships. Conclusion Greater depressive symptoms at the start of a behavioral weight loss program may predict poorer subsequent session attendance. Screening for and addressing depression may improve intervention uptake

Influence of Patient Immigrant Status on Provider Diabetes Treatment Decisions: A Virtual Patient Experimental Study

Immigrants are at elevated risk for not having their diabetes treatment appropriately intensified, likely resulting in poorly-controlled diabetes and increased morbidity and mortality. Immigrant status is a powerful sociodemographic cue, yet its influence on providers’ diabetes treatment decisions is unknown. The study objective was to determine the effect of patient immigrant status on providers’ decisions to (1) take no action, (2) add an oral hypoglycemic agent (OHA), (3) add/switch to insulin, or (4) refer the patient to an endocrinologist. Participants were 140 medical students/professionals (‘providers’). Providers viewed profiles (videos + vignettes) for virtual patients differing in immigrant status (born in Mexico or U.S.; other characteristics held constant). Analyses were completed at the group (‘nomothetic’) and individual (‘idiographic’) levels. Nomothetic results indicated providers were less likely to refer foreign-born patients to endocrinology than U.S.-born patients (p=0.03). No differences were detected for the other three treatment likelihood ratings. Idiographic results indicated that about half of provider decisions were influenced by patient immigrant status (i.e., Cohen’s d≥0.50) across all four treatment decisions. Effect size data show an almost even split between higher treatment ratings for foreign-born vs. U.S.-born patients for three decisions (take no action, add an OHA, add/switch to insulin), explaining why group-level differences for these ratings did not emerge (i.e., they were cancelled out). This study found that providers are less likely to refer foreign-born patients to endocrinology, potentially leading to therapeutic inertia. In addition, half of individual-level provider decisions were meaningfully influenced by patient immigrant status. However, traditional group-level analyses mask these important individual-level differences. These systematic differences in treatment based on non-relevant factors could lead to unintended adverse outcomes for the foreign-born population

TESTING THE INVARIANCE OF ADOLESCENT SURVEY-BASED ALCOHOL-RELATED BEHAVIORS ACROSS RACE/ETHNICITY AND GENDER

Includes bibliographical references (pages 25-27).Alcohol consumption amongst adolescents continues to be a major public health concern in the United States. State and federal policies have been designed and implemented with the intention of curbing problematic drinking behaviors amongst the adolescents identified as being at the highest risk. These policies are often informed by surveys such as the Youth Risk Behavior Survey (YRBS), sponsored by the Center for Disease Control (CDC). Previous research, however, has found that such surveys lack invariance (or measurement equivalency) across different groups, such as race/ethnicity and gender. A lack of invariance indicates that valid group comparisons cannot be made, since group membership determines perception of the survey question. This project examined the factorial invariance of the 2013 YRBS alcohol-related behaviors across race/ethnicity and gender. Multigroup confirmatory factor analysis statistically tested the psychometric and factorial invariance of the "Alcohol-Related Behaviors" latent variable across four ethnic and two gender groups. Invariance was examined across Hispanic/Latino (n = 1,734), white (n = 5,449), Asian (n = 491), and black/African American (n = 2,991) adolescents, and across males (n = 5,439) and females (n = 5,224). The latent variable was indicated by five questions, representing "drinking and driving," "lifetime alcohol use," "30 day alcohol use," "binge drinking," and "maximum number of drinks, 30 days." Invariance was first examined across gender groups to determine if subsequent tests could be done collapsing across gender. While the models achieved configural invariance, metric invariance could not be established. This indicated that associations between measured variables (e.g., binge drinking) and the latent construct (i.e., "Alcohol-Related Behaviors") differed between males and females. Subsequent tests of invariance were therefore done within gender groups, comparing race/ethnicity groups in pairs. Configural invariance was established across race/ethnicity groups for both genders. However, metric invariance could only be achieved between certain groups. Results suggest that comparisons made between gender groups on alcohol-related behaviors as a construct may be inappropriate. Additionally, even when making comparisons within gender, caution should be taken when making comparisons between race/ethnic groups. Findings highlight the need to tailor alcohol prevention and intervention efforts to particular groups based on group membership

Assessment on the Use of the Suinn-Lew Asian Self Identity Acculturation Scale in Health Studies of Asian Immigrant Populations

The most widely used measure of acculturation among Asians populations is the Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA). Purpose: This systematic review aims to: (a) describe population characteristics and methodology used in health studies assessing acculturation, as measured by the SL-ASIA; (b) evaluate the use of the SL-ASIA in the included studies; (c) summarize associations between acculturation, as measured by the SL-ASIA, and health outcomes; and (d) provide recommendations for future research. Methods: An electronic search was conducted using PsycINFO and MEDLINE. Studies using the SL-ASIA in the context of mental or physical health outcomes in Asian adult populations were included, for a total of 14 studies. Results: Most studies were conducted with Chinese, Korean, and Vietnamese immigrants, with the majority being foreign-born. All studies used cross-sectional designs with convenience sampling. More than half used a modified version of the scale, and less than half used a translated version. Psychometric properties and pilot testing of modified/translated versions of the SL-ASIA were underreported. Most findings on the relationship between acculturation, as measured by the SL-ASIA, and health are consistent with research in other immigrant populations. Conclusions: Future studies should include underrepresented groups for a more representative picture of Asian immigrant health, and follow established methodologies for translations of the SL-ASIA. Associations drawn between health and acculturation from the use of the SL-ASIA will facilitate understanding of within-group Asian immigrant differences in the adaptation process, and identify at-risk populations

Undiagnosed diabetes among immigrant and racial/ethnic minority adults in the United States: National Health and Nutrition Examination Survey 2011–2018

Purpose Undiagnosed diabetes disproportionately affects medically underserved groups. It is unknown whether being an immigrant confers additional risk for undiagnosed diabetes. The purpose of this study was to examine independent associations of immigrant status and race/ethnicity with the prevalence of diagnosed and undiagnosed diabetes in a U.S.-based population sample. Methods Respondents were 21,306 adults from the 2011–2018 National Health and Nutrition Examination Survey. Immigrant status was coded as foreign-born or U.S.-born. Six racial/ethnic categories were white, Black, Mexican American, other Hispanic, Asian, and other/multiracial. Self-report and laboratory data yielded a three-level diabetes status outcome: no diabetes (88%), diagnosed diabetes (10%), and undiagnosed diabetes (2%). Results Adjusted multinomial logistic regression models evaluating immigrant status and race/ethnicity as simultaneous predictors revealed that foreign-born (vs. U.S.-born) adults had a similar prevalence of diagnosed diabetes (OR = 0.98, 95% CI: 0.79–1.22, P = .84) but a higher prevalence of undiagnosed diabetes (OR = 1.54, 95% CI: 1.21–1.97, P = .004). Models showed that all racial/ethnic minority groups except the other/multiracial group (vs. whites) had a higher prevalence of diagnosed and undiagnosed diabetes (Ps < .04). Conclusions Immigrants and racial/ethnic minority adults have increased odds of undiagnosed diabetes, even after accounting for health insurance. These groups are likely at increased risk for diabetes complications because of prolonged periods of undetected diabetes