Nativity, Language Spoken at Home, Length of Time in the United States, and Race/Ethnicity: Associations with Self-Reported Hypertension

Abstract

BACKGROUND

Characterization of health conditions in recent immigrant subgroups, including foreign-born whites and Asians, is limited but important for identifying emerging health disparities. Hypertension, a major modifiable risk factor for cardiovascular disease, has been shown to be associated with acculturation, but the acculturative experience varies for different racial/ethnic groups. Assessing the impact of race/ethnicity on the relationship between acculturation-related factors and hypertension is therefore of interest.

METHODS

Data from the 2005–2008 waves (n = 36,550) of the NYC Community Health Survey were combined to estimate self-reported hypertension prevalence by nativity, language spoken at home, and time spent in the United States. Multivariable analyses were used to assess (i) the independent associations of acculturation-related factors and hypertension and (ii) potential effect modification by race/ethnicity. Sensitivity analysis recalibrating self-reported hypertension using measured blood pressures from a prior NYC population-based survey was performed. Prevalence was also explored by country of origin.

RESULTS

Being foreign vs. US born was associated with higher self-reported hypertension in whites only. Speaking Russian vs. English at home was associated with a 2-fold adjusted odds of self-reported hypertension. Living in the United States for ≥10 years vs. less time was associated with higher self-reported hypertension prevalence in blacks and Hispanics. Hypertension prevalence in Hispanics was slightly lower when using a recalibrated definition, but other results did not change substantively.

CONCLUSIONS

Race/ethnicity modifies the relationship between acculturation-related factors and hypertension. Consideration of disease prevalence in origin countries is critical to understanding health patterns in immigrant populations. Validation of self-reported hypertension in Hispanic populations is indicated.

Cardiovascular disease is the leading cause of death both in the United States nationally¹ and in New York City (NYC),² and hypertension is a leading modifiable risk factor affecting approximately 1 in 4 NYC adults.³ Since the Immigration Act of 1965, the influx of immigrants from Latin America, Eastern Europe, and Asia has increased steadily,⁴ with many of these individuals settling in metropolitan areas such as NYC.^5,6 Characterization of chronic conditions in these newcomers is critical for understanding health patterns and identifying emerging health disparities.

Acculturation, or the process where a person raised in one culture comes into contact with a second culture, has been shown to be associated with hypertension in the United States.^7–9 The acculturation experience differs for each racial/ethnic group; white immigrants, for instance, may assimilate faster than other groups, owing to their phenotypic similarity with the racial/ethnic majority in the United States.¹⁰ Asian immigrants tend to have more education and higher starting wages at time of immigration than Hispanics¹¹ and therefore may experience less socioeconomic-related stress. Aside from 2 studies,^8,12 research on acculturation and hypertension has focused on single racial/ethnic groups^7,13–16 and differences by race/ethnicity have not been well characterized. Given the changing demographics of NYC and the differences in the assimilation experience among racial/ethnic groups,¹⁰ hypertension prevalence estimates that account for the complex relationships between acculturation-related factors and race/ethnicity are warranted.

Aside from 1 recent publication using national data,¹² the study of granular groups, particularly those representing newer immigrants such as foreign-born whites or Asians, are limited. The diverse population in NYC provides an ideal backdrop in which to characterize hypertension in these groups. The aims of this analysis were to estimate the prevalence of self-reported hypertension (SRH) by acculturation-related factors (nativity, language spoken at home, and length of time in the United States) in an urban environment and to assess potential effect modification of these relationships by race/ethnicity.

METHODS

Data were from the Community Health Survey (CHS), a random-digit-dial, cross-sectional survey conducted annually since 2002 by the NYC Health Department in English, Spanish, Russian, and Chinese. The CHS includes self-reported health data on approximately 9,000 participants each year and is weighted to be representative of NYC as a whole.¹⁷ Data from 2005–2008 survey years were combined (n = 36,673). Observations were excluded if SRH was missing (n = 123), resulting in an unweighted sample size of n = 36,550.

Measurement and definition of covariables

Race/ethnicity was assessed using 2 questions on Hispanic origin and race group and was categorized as non-Hispanic white, non-Hispanic black, Hispanic, and non-Hispanic Asian (hereafter referred to as “white,” “black,” or “Asian”). SRH was defined as a “yes” answer to the question: “Have you ever been told by a doctor or other health care professional that you have hypertension, also called high blood pressure?” Owing to validity issues with SRH,¹⁸ a sensitivity analysis was performed to recalibrate the estimates. The recalibration method requires use of local data to calculate the probability of clinical hypertension (systolic blood pressure (BP) ≥140mm Hg, diastolic BP ≥90mm Hg, or use of antihypertensive medication) and application of these probabilities to the analyst’s sample.¹⁹ For the recalibration, data from the NYC-based 2010 Heart Follow-Up Study were used.²⁰ In brief, Heart Follow-Up Study participants were recruited from the 2010 CHS and at a home visit had 3 seated BP measures taken using validated, clinic-grade BP monitors²¹ according to the National Health and Nutrition Examination Survey protocol. BP measurements included a 5-minute rest period before measurement, standardized arm/body position, and instruction to not consume caffeine or exercise 30 minute before the visit. All analyses were repeated using the recalibrated SRH prevalence.

Nativity was defined as self-report of being born in the United States or elsewhere. Puerto Ricans and those born in US territories were defined as being foreign born. Languages spoken at home were English, Spanish, Russian, or other (includes Chinese and Indian language speakers). The length of time spent in the United States was assessed in foreign-born adults; subjects could report <5 years, 5–9 years, or ≥10 years in the United States. Length of time was stratified as <10 years or ≥10 years based on sample size and comparability with prior analyses using NYC data.³ All analyses with time spent in the United States were restricted to 2006–2008 owing to response category differences in 2005. All other covariables (age, sex, poverty group, education, height, weight, smoking status, insurance, having a regular primary care provider) were self-reported using the same methodology from 2005 to 2008. Household poverty was grouped according to federal poverty guidelines (<200%, 200%–400%, >400% of the federal poverty level). Body mass index was calculated from self-reported height and weight, and values that were <12 or >99.99 were considered as missing in the analysis.²²

SRH in individuals in the 3 most common regions of birth was compared with that of US-born individuals of the same racial/ethnic category (countries included in each region may be found in the Supplementary Materials).

Statistical analyses

All results were weighted to be representative of the NYC population. The age-adjusted prevalence of SRH was assessed by (i) race/ethnicity, (ii) nativity, (iii) both race/ethnicity and nativity, (iv) language spoken at home, (v) years in United States among the foreign born, and (vi) both race/ethnicity and years in the United States among the foreign born. Language spoken at home was not stratified by race/ethnicity given the large overlap of these 2 categories. SRH prevalence was then assessed in each of the top 3 birth regions within each racial/ethnic group and compared with prevalence in the US-born group for that racial/ethnic group. Differences in SRH prevalence among subgroups were assessed using t tests for proportions.

Multivariable logistic regression models were used to assess the effects of nativity and language on the prevalence of SRH, independent of the effects of age, sex, race, poverty, education, body mass index, smoking, insurance, and having a regular primary care provider; the interaction terms with race/ethnicity was included for the nativity model (i.e., race x nativity). To assess the association of years in the United States and SRH prevalence, a regression model restricted to foreign-born individuals was built, adjusting for the same covariables and including a similar interaction term (i.e., race × years in the United States).

To quantify the associations of nativity and years in the United States by race/ethnicity, the adjusted odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) were calculated using models with each racial/ethnic category coded as a dummy variable (i.e., black = 1, 0).²³ Note, this is equivalent to dividing the within-race adjusted ORs by each other (e.g., black foreign-born/black US-born). If the OR differed from 1.0 and the 95% CI did not include 1.0, then the effect within that racial/ethnic group was considered significant.²³ This approach is subsequently referred to as the OR comparison method. This method did not need to be used for whites because the originally calculated OR in the interaction already compared foreign-born whites with US-born whites.

SUDAAN software (version 10.0; Research Triangle Institute, Research Triangle Park, NC) was used for all analysis.

RESULTS

In the overall weighted sample, >70% of respondents were aged 25–64 years, approximately half were female, half were black or Hispanic, and 2 in 5 had an income <200% of the federal poverty level (Table 1). In addition, 46% were foreign born, and of those, 76% had been in the United States for ≥10 years. Most of the population spoke English at home (70%).

Table 1.

Characteristics of analytic sample, Community Health Survey 2005–2008

Characteristic	No.	Weighted no.	Weighted %
Overall	36,550	6,068,000	100.0%
Age group
18–24	2,173	795,000	13.2
25–44	12,600	2,618,000	43.4
45–64	13,528	1,687,000	28.0
≥65	8,167	934,000	15.5
Female participants	22,392	3,256,000	53.8
Race
Non-Hispanic white	14,745	2,351,000	38.9
Non-Hispanic black	9,299	1,386,000	22.9
Hispanic	8,868	1,496,000	24.7
Non-Hispanic Asian	2,585	623,000	10.3
Other	1,053	193,000	3.2
Poverty/incomea
<200%	13,000	2,150,000	38.6
200%–399%	5,633	928,000	16.7
≥400%	12,328	2,000,000	36.0
Education
Less than high school	6,123	975,000	16.3
Grade 12 or GED	8,892	1,475,000	24.7
Some college	7,437	1,258,000	21.1
College graduate	13,613	2,261,000	37.9
BMI, kg/m2
Underweight, <18.5	748	139,000	2.5
Normal, 18.5–<25	13,342	2,361,000	41.7
Overweight, 25–<30	12,171	1,985,000	35.1
Obese, ≥30	7,882	1,178,000	20.8
Smoking status
Never	21,392	3,682,000	61.6
Current	6,124	1,051,000	17.6
Former	8,611	1,247,000	20.8
Has medical insurance	30,899	4,817,000	82.8
Has regular primary care provider	30,335	1,191,000	80.2
Self-reported hypertension	12,109	1,611,000	26.6
Nativity
US born	20,591	3,239,000	54.1
Foreign bornb	15,566	2,744,000	45.9
In US for <10 yearsc	1,954	659,000	24.1
In US for ≥10 yearsc	9,426	2,077,000	75.9
Language spoken at home
English	26,954	4,213,000	70.0
Spanish	5,306	932,000	15.5
Russian	1,028	175,000	2.9
Other	3,069	698,000	11.6

Prevalence estimates were weighted to the New York City adult (aged ≥18 years) population according to the 2000 US Census.

^aPoverty status as “unknown” is part of denominator but not reported here. Hence percentages do not sum to 100%.

^bForeign born includes individuals born in Puerto Rico and other US territories.

^cAll estimates using length of time in the United States are based on the Community Health Survey 2006–2008 data only.

The prevalence of SRH was 26.6% and was higher in blacks and Hispanics vs. whites (36.1% and 29.6% vs. 23.2%; P < 0.001 for both). SRH prevalence was higher in foreign-born vs. US-born individuals (28.6% vs. 27.2%; P = 0.01) (Table 2). When stratified by race/ethnicity, foreign-born whites had a higher prevalence of SRH than US-born whites (25.3% vs. 22.5%; P < 0.001), and foreign-born blacks had a lower prevalence of SRH than US-born blacks (33.9% vs. 37.7%; P < 0.001). No difference was seen among Hispanics or Asians. Prevalence of SRH differed by the primary language spoken at home. Those speaking Spanish or Russian had a higher SRH prevalence compared with English speakers (29.7% and 34.6% vs. 27.5%; P < 0.001 for both), and those speaking a language other than English, Russian, or Spanish at home reported a lower prevalence than English speakers (25.2%; P = 0.01). Among the foreign born, SRH differed by duration of time in the United States, with those living in the United States for ≥10 years vs. <10 years having a higher SRH prevalence (29.2% vs. 23.6%; P < 0.01). Further, the association between SRH and time in the United States varied by race/ethnicity. Length of time in the United States was associated with higher SRH prevalence in blacks (34.7% for ≥10 years vs. 26.3% for <10 years; P = 0.01) and Hispanics (30.4% for ≥10 years vs. 21.5% for <10 years; P < 0.001) but not in whites (25.7% for ≥10 years vs. 25.1% for <10 years; P = 0.79) or Asians (24.2% for ≥10 years vs. 20.8% for <10 years; P = 0.25).

Table 2.

Age-adjusted prevalence of self-reported hypertension by race/ethnicity, nativity, and length of time in the United States, Community Health Survey 2005–2008

	Overall		Non-Hispanic white		Non-Hispanic black		Hispanic		Non-Hispanic Asian
	Weighted %	95% CI	Weighted %	95% CI	Weighted %	95% CI	Weighted %	95% CI	Weighted %	95% CI
US born	27.2	(26.5–27.9)	22.5	(21.7–23.4)	37.7***	(36.3–39.1)	27.8***	(25.3–30.5)	27.2	(21.5–33.8)
Foreign born	28.6*	(27.8–29.3)	25.3*	(23.7–26.9)	33.9*,***	(32.2–35.5)	29.7***	(28.4–31.0)	24.3	(22.4v26.3)
In US for <10 yearsa	23.6	(21.3–26.1)	25.1	(21.4v29.2)	26.3	(20.5–33.0)	21.5	(17.1–26.7)	20.8	(15.8–26.8)
In US for ≥10 yearsa	29.2	(28.2–30.3)	25.7	(23.5–28.1)	34.7**	(32.4–37.0)	30.4**	(28.8–32.1)	24.2	(21.9–26.7)

^aAll estimates using length of time in the United States are based on Community Health Survey 2006–2008 data only.

*P < 0.05 compared with US born.

**P < 0.05 compared with those in the United States for <10 years.

***P < 0.05 compared with Non-Hispanic white of the same nativity status (e.g., US-born black vs. US-born white).

In the multivariable model, nativity overall was associated with an increased odds of SRH (OR = 1.10; 95% CI = 1.01–1.19; P = 0.03) (Table 3). All racial/ethnic groups reported a higher odds of SRH than US-born whites. Nativity remained associated with higher SRH prevalence among whites only; foreign-born whites were 18% more likely to report hypertension than whites born in the United States (OR = 1.18; 95% CI = 1.04–1.34; P = 0.01). Using the OR comparison method, no association between nativity and SRH was found among blacks (OR = 0.99; 95% CI = 0.86–1.13; P = 0.87), Hispanics (OR = 1.16; 95% CI = 0.96–1.39; P = 0.12), or Asians (OR = 0.91; 95% CI = 0.55–1.53; P = 0.72).

Table 3.

Adjusted^a odds ratios of self-reported hypertension among adults aged ≥18 years, Community Health Survey, 2005–2008, by nativity, language spoken at home, and length of time in the United States

	Adjusted OR	95% CI
Nativity modelb
US born	Reference group
Foreign bornc	1.10	(1.01–1.19)
Race × nativity interaction (white, US born is reference)
White, foreign born	1.18	(1.04–1.34)
Black, US born	1.75	(1.56–1.96)
Black, foreign born	1.73	(1.52–1.97)
Hispanic, US born	1.21	(1.02–1.45)
Hispanic, foreign born	1.40	(1.24–1.58)
Asian, US born	1.43	(0.87–2.35)
Asian, foreign born	1.31	(1.11–1.54)
Language spoken at home model
English	Reference group
Spanish	1.14	(0.98–1.34)
Russian	1.94	(1.59–2.36)
Other	1.01	(0.86–1.18)
Length of time in United States modeld
<10 years	Reference group
≥10 years	1.44	(1.17–1.76)
Race × years in United States (white <10 years is reference)e
White, ≥10 years	1.19	(0.84–1.69)
Black, <10 years	0.94	(0.57–1.57)
Black, ≥10 years	1.85	(1.30–2.64)
Hispanic, <10 years	0.96	(0.61–1.54)
Hispanic, ≥10 years	1.42	(1.00–2.01)
Asian, <10 years	0.96	(0.55–1.69)
Asian, ≥10 years	1.37	(0.77–2.44)

Bolding indicates statistical significance at P < 0.05.

Abbreviations: CI, confidence interval; OR, odds ratio.

^aAdjusted for age, sex, race/ethnicity, poverty, education, body mass index, smoking, insurance status, and having a regular primary care provider; not adjusted for race/ethnicity in race/ethnicity-stratified models.

^bInteraction term between race/ethnicity × nativity, P < 0.01.

^cForeign born includes individuals born in Puerto Rico and other US territories.

^dAll estimates using length of time in the United States are based on Community Health Survey 2006–2008 data only.

^eInteraction term between race/ethnicity × time in the the United States, P < 0.01.

Speaking Russian at home was associated with almost twice as high odds of hypertension than speaking English at home (OR = 1.94; 95% CI = 1.59–2.36; P < 0.01). No associations with hypertension were observed in those speaking Spanish or other languages compared with English speakers.

Among foreign-born individuals, living in the United States for ≥10 years vs. <10 years was associated with a higher odds of SRH prevalence (OR = 1.44; 95% CI = 1.17–1.76; P < 0.01). Blacks and Hispanics who had been in the United States ≥10 years had a higher SRH prevalence than whites in the United States for <10 years. Using the OR comparison method, the relationship between years living in the United States and SRH persisted only among blacks (OR = 1.96; 95% CI = 1.29–2.98; P < 0.01) and Hispanics (OR = 1.75; 95% CI = 1.04–2.09; P = 0.03).

Top 3 regions of birth analysis

The majority of whites and blacks were born in the United States (75.6% and 60.3%, respectively), whereas the majority of Hispanics and Asians were foreign born (69.5% and 83.9%, respectively) (Table 4). Whites born in Eastern Europe/Central Asia reported a higher SRH prevalence than whites born in Western Europe/Canada or the United States (28.4% vs. 20.8% and 22.5%; P < 0.001 for both). Caribbean-born blacks had a lower prevalence of SRH than US-born blacks (34.7% vs. 37.7%; P = 0.02). Hispanics born in Puerto Rico or the Dominican Republic had a higher prevalence of SRH than those born in the United States (36.1% and 34.1%, respectively, vs. 27.8%; P < 0.001 for both), whereas Hispanics born in the South/Central America birth region tended to have a lower prevalence of SRH (22.0%; P < 0.001) than those born in the United States.

Table 4.

Age-adjusted prevalence of self-reported hypertension by race/ethnicity and region of birth

Race/ethnicity and region of birth	Weighted % out of race subgroup	95% CI	Weighted prevalence of hypertension	95% CI	P value
Non-Hispanic whites
United States	75.6	(74.7–76.5)	22.5	(21.7–23.4)	Referent
Eastern Europe/ Central Asia	13.1	(12.5–13.8)	28.4	(26.1–30.7)	<0.001
Western Europe/ Canada/Australia	8.5	(7.9–9.1)	20.8	(18.5–23.4)	0.20
Middle East/Africa	2.1	(1.8–2.5)	23.1	(17.8–29.4)	0.85
Non-Hispanic blacks
United States	60.3	(59.0–61.6)	37.7	(36.3–39.1)	Referent
Caribbean	28.3	(27.2–29.5)	34.7	(32.7v36.7)	0.02
Latin America	5.2	(4.7–5.8)	33.3	(29.4–37.5)	0.05
Middle East/Africa	4.5	(4.0–5.1)	31.5	(25.6–38.2)	0.06
Hispanics
United States	30.5	(29.1–31.7)	27.8	(25.3–30.5)	Referent
Puerto Rico	12.2	(11.5–13.0)	36.1	(33.1–39.2)	<0.001
Dominican Republic	20.1	(19.1–21.1)	34.1	(31.7–36.7)	<0.001
Latin America	34.5	(33.2–35.9)	22.0	(20.1–24.1)	<0.001
Non-Hispanic Asians
United States	16.1	(14.2–18.1)	27.2	(21.5–33.8)	Referent
Asia Pacific	72.7	(70.5–74.9)	23.7	(21.7–25.8)	0.29
Latin America	4.5	(3.7–5.5)	29.1	(21.4–38.1)	0.73
Caribbean	2.7	(2.1–3.4)	27.1	(18.3–38.2)	0.99

Bolding indicates statistical significance at P < 0.05.

Estimate’s Relative Standard Error (a measure of estimate precision) is >30% or the sample size is <50, making the estimate potentially unreliable.

Sensitivity analysis with recalibrated SRH

The prevalence of recalibrated SRH was 23.0%, which is lower than the SRH reported in the CHS (26.6%). In bivariable analyses, the difference between SRH and recalibrated SRH was largest in US-born Hispanics (recalibrated SRH of 20.8% vs. SRH of 27.8%), thus making the statistical comparison of foreign-born vs. US-born Hispanics significant (recalibrated SRH: 25.0% vs. 20.8%, P <0.01; SRH: 29.7% vs. 27.8%, P = 0.21). In the region of birth analysis, estimates in Puerto Rican and Dominican Hispanics were notably lower (recalibrated SRH: 28.6% and 28.0%; SRH: 36.1% and 34.1%, respectively), although statistical differences did not change. Lastly, in regression analyses, the comparison of foreign-born vs. US-born Hispanics also changed, with the OR comparison method resulting in a significant effect of nativity (OR = 1.59; 95% CI = 1.26–2.02; P < 0.01). No other substantial changes occurred within white, black, or Asian groups.

DISCUSSION

In the NYC adult population, prevalence of SRH varied by nativity, language spoken at home, and time spent in the United States. The relationship between acculturation-related factors and SRH appears to be modified by race/ethnicity. The odds of SRH was elevated among foreign-born (compared with US-born) whites, but no difference by nativity was found among blacks, Hispanics, or Asians. This effect appears to be driven by white immigrants from regions with high prevalence of hypertension, such as those from Eastern Europe/Central Asia.^24,25 Those who spoke Russian at home reported a higher prevalence of SRH compared with those who spoke English at home. This finding was corroborated by the higher SRH prevalence in white individuals born in Eastern/Central Europe (Russian is the common language among these individuals) compared with US-born whites. In NYC, where a sizable proportion of the white population is foreign born (24.4% in this analysis), distinguishing foreign-born whites from US-born whites may be of particular importance. Whites are often used as a reference category in health research, and failure to consider this may lead to inconsistent conclusions. Lastly, living in the United Statesfor ≥10 years vs. less time was associated with a higher odds of SRH only among blacks and Hispanics.

To correctly interpret results for foreign-born whites and Hispanics, an understanding of hypertension prevalence in the countries of origin was required. Foreign-born whites were most likely to emigrate from Eastern Europe/Central Asia, where prevalence of hypertension is high (Eastern Europe: 65%;²⁴ Central Asia: 39%²⁵). Prior studies have examined health outcomes in this immigrant population and highlight heavy smoking, diets high in processed foods, and a distrust of the medical system as likely reasons for poorer health outcomes.^26,27 In this context, the reverse finding of higher SRH prevalence in foreign-born vs. US-born whites is less surprising. Similarly, Hispanics born in Puerto Rico had a higher prevalence of SRH than Hispanics born in the United States, potentially owing to the high prevalence of hypertension in their region of origin (37.1%).²⁸ These findings are noteworthy given they are in contrast to the “healthy migrant effect” observed in other studies assessing the impact of acculturation on the health of US immigrants.^{13,15,16,29,30} Thus to best understand the expected directionality of change, it is critical in studies of health in immigrants to consider the baseline rate of disease in the country of origin.

Speaking Spanish vs. English at home was not associated with higher SRH prevalence, which is inconsistent with previous research in Hispanic populations using language-based acculturation measures.^7,13,30,31 This may be attributable to differences in the distribution of Hispanics in NYC (predominant subgroups: Puerto Ricans and Dominicans) compared with the United States (predominant subgroup: Mexicans).^28,32,33 As US citizens, Puerto Ricans may have differential access to health care and/or dietary experiences compared with other Hispanic subgroups. Insurance and having a regular primary care provider were included in multivariable regression analyses to adjust for differences in access, which may be particularly salient when assessing SRH in Hispanic immigrant groups.¹⁸

A longer amount of time spent in the United States was associated with a higher prevalence of SRH before and after adjustment for potential confounding factors. What is unclear is whether this is due to true effects of being in the United States for a longer period of time, a lack of awareness of hypertension among more recent immigrants, or a reflection of the fact that more recent immigrants may be emigrating from countries with lower rates of hypertension. The population of NYC is in constant flux and dynamically shifting⁵ with differential increases and decreases occurring in the populations of specific racial/ethnic subgroups³⁴ with potentially differing underlying rates of hypertension. This uncertainty cannot be clarified by this analysis.

The strengths of this analysis include the large sample size and the ability to assess granular subgroups stratified by both acculturation and race/ethnicity. A limitation of this work is the primary measure of hypertension being captured by self-report and not by measured BP. To address this, sensitivity analysis was performed using local measures of BP to recalibrate SRH and revealed overreporting of hypertension, primarily in Hispanics. This was a surprising finding given that conditions such as hypertension have been shown to be underreported by Mexican Americans and/or those without access to regular health-care providers.¹⁸ These results were likely due to the nature of the calibration dataset. Prior analyses in the Heart Follow-Up Study data revealed that a particular set of individuals without clinically defined hypertension were “overreporting”; these individuals tended to be women, Hispanic, or engaging in behaviors that indicated they were achieving BP control through lifestyle modification (e.g., reducing sodium, engaging in physical activity; unpublished data). These findings point to the need for characterizing how SRH operates in Hispanic populations other than those represented at the national level (Mexican Americans). Self-report of other covariables associated with hypertension, including income and height/weight, is an additional limitation.

Differences in environmental-level factors not captured in this analysis may have an impact on hypertension prevalence. Urban adults of similar racial/ethnic backgrounds, in particular Asians and Hispanics, cluster in similar geographic areas,³⁵ so our findings may reflect differences in neighborhood characteristics, such as racial segregation,³⁶ opportunities for exercise, or fast food availability, instead of actual differences by race/ethnicity. Despite the large sample size of this analysis, the small sample of Asians limited analyses in that race group. Research on acculturation and hypertension in Asians is limited and has produced mixed results,^14,37,38 potentially because of the different types of people captured by the category Asian (e.g., South vs. East Asian). Because of the growing Asian population both nationally and in NYC,^34,39 this topic warrants further investigation.

Acculturation-related factors were associated with SRH, with potential effect modification by race/ethnicity. Findings from this analysis highlight differences in SRH in a diverse population and point to the importance of the consideration of granular subgroups. Results suggest the importance of understanding the underlying racial/ethnic and immigrant distributions of the study population and the prevalence of the health condition in the country of origin. These results provide insight into the burden of disease in different cultural communities and will allow for the identification of health needs and targeting of health resources.

SUPPLEMENTARY MATERIAL

Supplementary materials are available at American Journal of Hypertension (http://ajh.oxfordjournals.org).

DISCLOSURE

The authors declared no conflict of interest.