‘Nativity’ research looks to tease apart health risks not just by race and ethnicity, but where a person was born
When it comes to health status, where a person is born, known as nativity, may be as critical as race or ethnicity. Country of origin can impact many aspects of a person’s physical and mental health, from environment and diet to social status and experiences with immigration.
Researchers at the Kaiser Permanente Division of Research (DOR) are able to identify patients in their medical records by a stated race or ethnicity, and by country of birth. They are now using this information to learn more about how nativity affects health risks and outcomes, such as prenatal depression.
In a previous paper published in March, DOR Research Fellow Kendria Kelly-Taylor, PhD, and co-authors reported differences in prenatal depression diagnosis and symptoms by race and ethnicity.
In their new study published Sept. 15 in JAMA Network Open, the authors also looked at country of birth. They examined medical records for 252,171 Kaiser Permanente Northern California members who gave birth between 2013 and 2019 and found some interesting differences:
- Overall, those born outside the U.S. were about half as likely to be diagnosed with prenatal depression as those born in the U.S. (8.4% vs. 19.1%). But there were similar rates of reporting moderate to severe depression symptoms on a survey before a medical visit during pregnancy, at around 10%.
- Among Black patients, those born outside the U.S. had 70% less chance of a depression diagnosis than Black patients born in the U.S., and 75% lower chance of reporting symptoms.
- Non-U.S.-born Asian Indian, Chinese, Filipina, Korean, Vietnamese, Central/South American, Mexican, and White individuals were less likely to have a prenatal depression diagnosis than U.S.-born patients of these ethnic and racial groups.
- Many of these same groups were more likely to report symptoms related to depression on the pre-visit survey.
The findings are complex and raise questions, and do not provide definitive answers, the authors said.
One complicating factor, the researchers said, is that not all people who are depressed will get a depression diagnosis from a doctor during pregnancy. Black and Latina patients have told researchers they worry about potential economic or legal consequences if their medical records show depression diagnosis and treatment, including threats to immigration status or employment, said senior author Lyndsay Avalos, PhD, MPH, a DOR research scientist.
The studies found that for multiple subgroups, pregnant patients were apparently more likely to report symptoms of depression on an online form before a visit than they were to discuss them with a doctor in person.
Guidance for physicians
For ob/gyn physicians, the study could provide new insight into and suggest new ways to approach conversations they have with patients whose prenatal depression may be masked, said co-author Mibhali Bhalala, MD, an ob/gyn with The Permanente Medical Group. “Some patients may underplay their symptoms and think it’s just transient feelings related to work, life, or pregnancy itself,” she said. “They may not be totally open to discussions about addressing or treating those feelings.”
Pregnant patients may also worry about what comes after a diagnosis, Bhalala said. “They may think that if they are diagnosed and referred for mental health treatment, the only treatment option is medication. Though medications can be safely used in pregnancy, there are alternatives to medication for depression treatment, such as cognitive behavioral therapy.”
Kelly-Taylor said other research about health and nativity has suggested a role for language and cultural barriers, trauma from immigration experiences, and racial discrimination. “We see in the research literature that Black individuals coming from sub-Saharan Africa generally have better health compared with their U.S. counterparts,” she said. “That’s true even if they are coming from lower socioeconomic status. And those immigrants can have a negative trajectory after years of living in the U.S., getting less healthy.”
Future research, she said, should delve into the complexities of life experiences of people in the same racial or ethnic group. “It’s possible that people who have less exposure to social and systemic discrimination in the U.S. have lower depression risk,” Kelly-Taylor said. “Future research is needed to learn if this is true.”
The study was funded by Kaiser Permanente Community Health and the National Institute of Child Health and Human Development.
Additional co-authors were Sara Aghaee, MPH, Joshua Nugent, PhD, Nina Oberman, MPH, Ai Kubo, PhD, MPH, Elaine Kurtovich, MPH, Charles P. Quesenberry, PhD, Ayesha C. Sujan, PhD, and Kathryn Erickson-Ridout, MD, PhD, all of the Division of Research.
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About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes, and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. KPDOR seeks to understand the determinants of illness and well-being and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 720-plus staff, including 73 research and staff scientists, are working on nearly 630 epidemiological and health services research projects. For more information, visit divisionofresearch.kp.org or follow us @KPDOR.
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