Demographic and socioeconomic factors
Demographic and socioeconomic factors of the populations at risk for TB including sex, age, length of residency in the U.S., education, poverty and English language proficiency differed by country of birth (Table 1). For example, the proportion of females by country of birth ranged from 60% (CI: 52-68) among Chinese-born persons to 43% (CI: 34-51) among Indian-born persons. The proportion of 18-29 year olds among US-born was 27% (CI: 27-27) with far lower proportions among persons born outside the US, ranging from 8% (CI: 4-11) among those born in Vietnam to 19% (CI: 14-24) among those born in China. Close to three-quarters of persons born in Vietnam or Mexico reported residing in the U.S. for 16 years or more compared with two-thirds of persons born in the Philippines and half of persons born in China or India.
There were also substantial differences in educational attainment by country of birth. Of persons born in Vietnam, 55% (CI: 48-63) had a high school education or less. Among persons born in Mexico, that estimate was 83% (CI: 81-85). The proportion with a high school education or less was 13% (CI: 8-19) among persons born in the Philippines. Poverty followed similar patterns to educational attainment, with some notable differences. Among persons born in Mexico or Vietnam, 56% (CI: 54-58) and 47% (CI: 37-55) respectively lived in poverty. In contrast, 19% (CI: 18-20) and 9% (CI: 5-13) of persons born in the U.S. or India lived in poverty.
Health insurance
Patterns of healthcare insurance were also notably different (Table 2). The proportion of 18-64 year olds who were uninsured ranged from 27% (CI: 25-30) among persons born in Mexico to 3% (CI: 1-7) among persons born in India. Among persons 65 years old and older, the proportion who reported both Medicare and Medi-Cal coverage ranged from 14% (CI: 12-16) among U.S.-born to 72% (CI: 59-84) among persons born in Vietnam. More than half of Indian-born persons, 51% (CI: 39-62), reported high deductible health insurance plans in contrast to a third of US-born persons who reported the same, 33% (CI: 32-34).
Healthcare utilization and barriers to care
The proportion of persons reporting visiting a doctor in the last 12 months differed by country of birth, even after age adjustment (Table 2). Report of age-adjusted recent doctor’s visit was highest among persons born in the Philippines, 84% (CI: 80-89) and lowest among Chinese-born persons, 70% (CI: 63-76). Age-adjusted recent doctor’s visit among persons born in the U.S. was 83% (CI: 83-84).
There was also a substantial difference in usual source of care by country of birth (Table 2). The proportion reporting a doctor’s office as usual source of care was highest among Vietnamese-born persons at 73% (CI: 66-81) and lowest among Mexican-born persons, 31% (CI: 24-34). The proportion reporting no usual source of care was highest among Mexican-born persons at 28% (CI: 26-30) and lowest among Indian-born persons at 11% (CI: 6-15).
On the basis of responses to survey questions, the proportion of persons experiencing barriers to care was low. Small proportions of these groups had delayed or forgone medicine or medical care. Whereas 11% (CI: 11-12) of U.S.-born persons had delayed or forgone medicine, 4% (CI: 2-7) of Chinese-born persons had done the same. Similarly, 14% (14%-15%) of U.S.-born persons had delayed or forgone medical care, whereas 7% (4-10) of Chinese-born persons had done the same.
With regard to racial discrimination and unfair treatment, the proportion reporting these barriers was low. Of U.S.-born persons, 10% (CI: 9-11) reported being treated unfairly sometimes or often when getting medical care. Of persons born Mexico, 14% (CI: 11-16) reported the same. In contrast, of persons born in China 7% (CI: 3-11) reported this. Low proportions reported that they would have gotten better care if a different race/ethnicity. Less than 10% reported having a hard time understanding the doctor at last visit with the highest proportion among Mexican-born persons at 7% (CI: 5-8) and Chinese-born persons 6% (CI: 2-9). For comparison, the estimate was 3% (CI: 2-3) for U.S.-born persons.
Overall Health and Risk factors for TB reactivation
Age-adjusted overall health differed widely by country of birth (Table 2). Among U.S.-born, 54% (CI: 52-55) reported very good or excellent health. Lower proportions of good or excellent health were reported by persons born in Mexico or in Vietnam: 26% (CI: 24-28) and 29% (CI: 21-38). The highest proportion with very good or excellent health was among persons born in India at 62% (CI: 52-71).
Current smoking was highest among persons born in Vietnam 11% (CI: 6-17) though the confidence interval was wide. Persons born in Mexico or the Philippines reported high proportions of former smoking, 18% (CI: 16-20) and 19% (CI: 14-23) respectively. Of persons born in the U.S., 24% (CI: 23-25) reported former smoking. Former smoking was lower among persons born in Vietnam, China or India, 8% (CI: 4-12), 8% (CI: 5-12) and 10% (CI: 6-15) respectively.
Of persons born in Mexico or the Philippines, 17% (CI: 14-19) and 17% (CI: 12-23) reported diabetes respectively (age-adjusted). Diabetes proportions were lower among persons born in Vietnam, China and India, similar to the level observed among the U.S.-born, 8% (CI: 8-9).
Language at medical visit and at home
Of adults with a medical visit in a non-English language, 96% (CI: 96-97) were non-U.S.-born (Table 4). This pattern was consistent across languages (Table 3). Of persons with visits in Spanish, 78% (CI: 75-81) were born in Mexico and 19% (CI: 12-21) elsewhere outside the U.S. Of persons with visits in Tagalog, 96% (CI: 88-100) were born in the Philippines. Of persons with visits in Vietnamese, 96% (CI: 92-100) were born in Vietnam. Proportion non-U.S.-born for visits in Mandarin, Cantonese or an Asian Indian language were similar.
Of non-U.S.-born, 42% (CI: 40-44) had medical visits in a non-English language. This proportion varied across countries of birth. Among persons born in Mexico or Vietnam, 60% (CI: 58-63) and 55% (CI: 46-63) had visits in Spanish or Vietnamese respectively. Similar results were found for persons born in China. In contrast, among persons born in India or the Philippines, 96% (CI: 94-99) and 91% (CI: 87-95) had a visit in English. Of U.S.-born, 0.7% (CI: 0.5-0.9) had visits in a non-English language.
Of adults who did not speak English at home, 89% (CI: 88-90) were non-U.S.-born. Among non-U.S.-born, 43% (CI: 41-44) did not speak English at home.
The proportion of persons residing in households in which no English was spoken ranged widely by country of birth (Table 1). Of persons born in the Philippines, 9% (CI: 6-12) spoke only Tagalog at home and, of persons born in India, 14% (CI: 9-19) spoke only an Asian Indian language at home. In contrast, 53% (CI: 46-61) of persons born in Vietnam spoke only Vietnamese at home and 50% (CI: 47-52) of persons born in Mexico spoke only Spanish at home. English proficiency estimates followed similar patterns with 53% (CI: 45-61) of Vietnamese-born persons and 67% (CI: 65-69) of Mexican-born persons reporting speaking English not well or not at all. Among persons born in the Philippines or in India, 7% (CI: 3-12) and 1% (CI: 0-3) reported speaking English not well or not at all although these estimates are statistically unstable.