Foreign-born Asians Research Articles

Racial and Ethnic Disparities in Contraceptive Method Choice in California

Unintended pregnancy, an important public health issue, disproportionately affects minority populations. Yet, the independent associations of race, ethnicity and other characteristics with contraceptive choice have not been well studied. Racial and ethnic disparities in contraceptive use among 3,277 women aged 18-44 and at risk for unintended pregnancy were assessed using 2006-2008 data from of the California Women's Health Survey. Sequential logistic regression analyses were used to examine the independent and cumulative associations of racial, ethnic, demographic and socioeconomic characteristics with method choice. Differences in contraceptive use persisted in analyses controlling for demographic and socioeconomic characteristics. Blacks and foreign-born Asians were less likely than whites to use high-efficacy reversible methods-that is, hormonals or IUDs (odds ratio, 0.5 for each). No differences by race or ethnicity were found specifically for IUD use in the full model. Blacks and U.S.-born Hispanics were more likely than whites to choose female sterilization (1.9 and 1.7, respectively), while foreign-born Asians had reduced odds of such use (0.4). Finally, blacks and foreign-born Asians were less likely than whites to rely on male sterilization (0.3 and 0.1, respectively). Socioeconomic factors did not explain the disparities in method choice among racial and ethnic groups. Intervention programs that focus on improving contraceptive choice among black and, particularly, Asian populations need to be developed, as such programs have the potential to reduce the number of unintended pregnancies that occur among these high-risk groups.

Reexamining the ethnic hierarchy of locational attainment: Evidence from Los Angeles

Because of a lack of data, the locational attainment literature has not incorporated documentation status into models examining group differences in neighborhood quality. I fill this void by using the Los Angeles Family and Neighborhood Survey, which permits the identification of undocumented respondents, allowing a reexamination of the ethnic structure of locational attainment in this important immigrant-receiving city. Results first suggest that while undocumented Latinos live in the poorest quality communities, blacks live in neighborhoods that are similar to native-born Latinos and better than foreign-born Asians and Latinos. Second, the effects of education are strongest for blacks, allowing the highly educated an opportunity to reside in communities that are of better quality than educated Latinos and Asians. Thus, undocumented Latinos replace blacks at the bottom of the locational attainment hierarchy, allowing educated blacks in Los Angeles to reside in better neighborhoods than blacks in the nation at large.

Poverty among Asian Americans in the 21St Century

Using the American Community Survey from 2005 to 2007, this study investigates absolute and relative poverty among Asian-Americans. The results indicate that both absolute and relative poverty are slightly higher among Asians than among whites overall as well as by nativity status (i.e., foreign born vs. native born). More detailed analysis suggests, however, that these racial differences appear to be largely associated with factors relating to immigration. Poverty is much higher among recent immigrants than among those who have been in the United States for more than five years, and foreign-born Asians are more likely to be recent immigrants than are foreign-born whites. Furthermore, after controlling for basic demographic characteristics, poverty is actually lower among foreign-born Asians than among foreign-born whites. Among native-born adult Asians (i.e., those who are not dependent on the incomes of immigrant parents), poverty is lower than among whites especially in terms of being characterized as members of the “working poor.” However, significant ethnic differentials within the Asian category are evident. Poverty rates higher than those for whites continue to be evident among the native-born adult offspring of Cambodians, Hmong, and Thai. The theoretical implications of these findings are discussed.

Disparity in disability between native-born non-Hispanic white and foreign-born Asian older adults in the United States: Effects of educational attainment and age at immigration

It is widely known that educational attainment has considerable influence on the prevalence of disability among native-born non-Hispanic older adults in the US. However, few studies have examined whether educational attainment has a similar effect on disability among foreign-born Asian older adults. If it does not have a similar effect on these adults, why not, and is its effect influenced by the age at which they immigrated to the US? This study addresses these questions by using the 2006 American Community Survey Public Use Microdata Sample (ACS PUMS). Logistic regression analyses reveal that education has differential effects on the two racial groups. Education protects foreign-born Asians less than native-born non-Hispanic whites. In addition, Asian adults who immigrated earlier are less likely to experience disability. Interestingly, the interaction between age at immigration and educational attainment for foreign-born Asian older adults indicates that less educated Asians are more likely to benefit from early immigration. Heterogeneity within the Asian group is also examined. The findings suggest that educational attainment has differential effects not only on the two racial groups but also on the foreign-born Asian group depending on age at immigration.

Disparities in Liver Cancer Incidence by Nativity, Acculturation, and Socioeconomic Status in California Hispanics and Asians

Asians and Hispanics have the highest incidence rates of liver cancer in the United States, but little is known about how incidence patterns in these largely immigrant populations vary by nativity, acculturation, and socioeconomic status (SES). Such variations can identify high-priority subgroups for prevention and monitoring. Incidence rates and rate ratios (IRR) by nativity among 5,400 Hispanics and 5,809 Asians diagnosed with liver cancer in 1988-2004 were calculated in the California Cancer Registry. Neighborhood ethnic enclave status and SES were classified using 2000 U.S. Census data for cases diagnosed in 1998-2002. Foreign-born Hispanic males had significantly lower liver cancer incidence rates than U.S.-born Hispanic males in 1988-2004 (e.g., IRR = 0.54, 95% confidence interval [CI] = 0.50-0.59 in 1997-2004), whereas foreign-born Hispanic females had significantly higher rates in 1988-1996 (IRR = 1.42, 95% CI = 1.18-1.71), but not 1997-2004. Foreign-born Asian males and females had up to 5-fold higher rates than the U.S.-born. Among Hispanic females, incidence rates were elevated by 21% in higher-enclave versus lower-enclave neighborhoods, and by 24% in lower- versus higher-SES neighborhoods. Among Asian males, incidence rates were elevated by 23% in higher-enclave neighborhoods and by 21% in lower-SES neighborhoods. In both racial/ethnic populations, males and females in higher-enclave, lower-SES neighborhoods had higher incidence rates. Nativity, residential enclave status, and neighborhood SES characterize Hispanics and Asians with significantly unequal incidence rates of liver cancer, implicating behavioral or environmental risk factors and revealing opportunities for prevention. Liver cancer control efforts should especially target foreign-born Asians, U.S.-born Hispanic men, and residents of lower-SES ethnic enclaves.

The residential segregation of mixed-nativity married couples.

This article examines the ways in which mixed-nativity marriage is related to spatial assimilation in metropolitan areas of the United States. Specifically, we examine the residential patterns of households with a mixed-nativity-and, in some cases, interracial-marriage to determine whether they are less segregated from the native-born than entirely foreign-born households. Using restricted-use data from the 2000 census, we find that compared with couples in which both spouses are foreign-born, mixed-nativity couples tend to be less segregated from various native-born racial and ethnic groups. Further, among both foreign-born Asians and Hispanics, those with a native-born non-Hispanic white spouse are considerably less segregated from native-born white households than from other foreign-born Asian and Hispanic households. We also find that even though nativity status matters for black couples in a manner consistent with assimilation theory, foreign-born and mixed-nativity black households still each display very high levels of segregation from all other native-born racial/ethnic groups, reaffirming the power of race in determining residential patterns. Overall, our findings provide moderate support for spatial assimilation theory and suggest that cross-nativity marriages often facilitate the residential integration of the foreign-born.

Tuberculosis and the Asian Population of Tarrant County, Texas

The research in this paper examines the incidence of tuberculosis (TB) among foreign-born Asians living in Tarrant County, Texas.

Interview Language: A Proxy Measure for Acculturation Among Asian Americans in a Population-Based Survey

We examined health status and access to care among Asian Americans by the following acculturation indicators: nativity, percent lifetime in the US, self-rated English proficiency, and interview language, to assess whether any measure better distinguishes acculturation. Data from the 2003 California Health Interview Survey were used to study the sample of 4,170 US-born and foreign-born Asians by acculturation indicators. We performed t-tests to compare differences in demographics, health status and behaviors, and access to care between the foreign-born and US-born Asians, and between various classifications within foreign-born and the US-born Asian group. Our results showed that foreign-born Asians who interviewed in English more closely resembled US-born Asians than foreign-born Asians who interviewed in languages other than English. Compared to interview language, dichotomizing the sample by other acculturation indicators showed smaller differences between the divided groups. Interview language may serve as a better measure for acculturation especially among foreign-born populations with a high proportion of limited English proficiency. In immigrant public health research studies, interview language may be used as an important covariate for health disparities.

Prevalence of infantile hypertrophic pyloric stenosis in Texas, 1999–2002

The cause of infantile hypertrophic pyloric stenosis (IHPS) is poorly understood. This descriptive study of IHPS focuses on the effect of maternal nativity, maternal Hispanic ethnicity, subtypes of maternal Asian ethnicity, and the timing of the infant's surgery, that is, pyloromyotomy. All cases of IHPS born in Texas from 1999 through 2002 were retrieved from the Texas Birth Defects Registry. Crude prevalence ratios and adjusted prevalence ratios (aPRs) were calculated using logistic regression. IHPS occurred predominantly in boys (aPR 4.21; 95% CI: 3.81, 4.65) compared with girls. Compared with Whites, there was a lower prevalence among Blacks (aPR 0.36; 95% CI: 0.30, 0.43), foreign-born Hispanics (aPR 0.61; 95% CI: 0.54, 0.69), Chinese (aPR 0.11; 95% CI: 0.01, 0.78), Vietnamese (aPR 0.17; 95% CI: 0.06, 0.46), Asian Indians (aPR 0.33; 95% CI: 0.15, 0.75), and Filipinos (aPR 0.22; 95% CI: 0.05, 0.91). In aggregate, foreign born Asians had a decreased risk of IHPS (aPR 0.20; 95% CI: 0.11, 0.37) compared to Whites. We observed no decrease in the risk of IHPS among US-born Asians (in aggregate) or US-born Hispanics. The strength of these risk factors did not vary according to the timing of the pyloromyotomy. This study confirmed previous findings that female infants and Black infants have a lower rate of IHPS. Large decreases in rates of IHPS were observed among foreign-born Hispanics and foreign-born Asians, but not among their US-born counterparts. These findings may be explained by differences in the frequency of behavioral risk factors for IHPS or differences in the frequency of ascertainment of mild cases of IHPS by ethnicity or nativity.

Race/Ethnicity, Gender and Job Earnings across Metropolitan Areas in the United States: A Multilevel Analysis

Using the US 5 per cent Public Use Microdata Samples (PUMS) and Census Summary Files from the year 2000, and a multilevel linear modelling strategy, this study examines the effects of a range of individual and metropolitan-area characteristics on the job earnings of US-born Whites and Blacks, foreign-born Hispanics and Asians, separately by men and women. The key findings suggest that macroeconomic structure and racial composition have significant influences on interracial and gender earnings disparities, although the direction and magnitude are different among groups. Results also show that all racial and gender groups would benefit from a more evenly distributed labour market among ethnic minorities and immigrants. With respect to gender issues, the earning gaps between racial groups are greater than between men and women. However, compared with men, women workers are more sensitive to macroeconomic conditions, racial residential segregation and labour market segmentation.

Nativity Status and Patient Perceptions of the Patient-Physician Encounter

Although racial and ethnic differences in healthcare have been extensively documented in the United States, little attention has been paid to the quality of health care for the foreign-born population in the United States. This study examines the association between patient perceptions of the patient-physician interaction and nativity status. Cross-sectional telephone survey. A total of 6674 individuals (US-born = 5156; foreign-born = 1518) 18 years of age and older. Seven questions measuring the quality of patient-physician interactions. Of the 7 outcome variables examined in the unadjusted logistic regression model, only 2 remained statistically significant in the fully adjusted model. For both the total sample and for Asians only, compared with US-born, foreign-born individuals were at greater odds [total sample, odds ratio (OR) = 1.43; 95% confidence interval (CI) = 1.01-2.04; Asians, OR = 3.25; 95% CI = 1.18-8.95] of reporting that their physician did not involve them in their care as much as they would have liked. Compared with US-born Asians, foreign-born Asians were at greater odds of reporting that their physician did not spend as much time with them as they would have liked (OR = 4.19; 95% CI = 1.68-10.46). Findings from our study suggest that we should not only track disparities by race and ethnicity but also by nativity status.

Unsuitable Suitors: Anti-Miscegenation Laws, Naturalization Laws, and the Construction of Asian Identities

In this article, I use state-level anti-miscegenation legislation to examine how Asian ethnic groups became categorized within the American racial system in the period between the Civil War and the civil rights movement of the 1960s. I show how the labels used to describe Asian ethnic groups at the state level reflected and were constrained by national-level debates regarding the groups eligible for U.S. citizenship. My main point is that Asian ethnic groups originally were viewed as legally distinct—racially and ethnically, and that members of these groups recognized and used these distinctions to seek social rights and privileges. The construction of “Asian” as a social category resulted primarily from congressional legislation and judicial rulings that linked immigration with naturalization regulations. Anti-miscegenation laws further contributed to the social exclusion of those of Asian ancestry by grouping together U.S.-born and foreign-born Asians.

Cancer stage at diagnosis, treatment, and survival among US- and foreign-born Asians and Pacific Islanders with gastric cancer

15018 Background: Asians and Pacific Islanders (APIs) have increased risk of developing gastric cancer, but whether cancer treatments and outcomes vary by birthplace is unknown. We examined the association between birthplace and cancer stage at diagnosis, treatment, and survival comparing API and non-Hispanic white (NHW) patients. Methods: We studied 6840 NHW and 4485 API patients diagnosed with gastric cancer from the Surveillance, Epidemiology and End Results Program between 1992 and 2003. We used bivariable analyses to compare stage, receipt of adequate lymph node assessment and surgery across groups: US-born APIs, foreign-born (FB) APIs and NHWs. We used multivariable polychotomous logistic and proportional hazards regression models to determine differences between US-born and FB APIs compared to NHWs in cancer stage and survival, respectively. Models included age, marital status, tumor grade, location, and stage (survival only). Results: Of API patients, 29% were US-born, 49% FB and 22% of unknown birthplace. APIs were more likely than NHWs to present with earlier-stage diagnoses and receive surgery and adequate lymph node assessment (p<0. 001). After adjustment, US-born [aOR=0.86 (0.75–0.93)] and FB APIs [aOR=0.76 (0.68–0.84)] were less likely to present at later stages than NHWs. Among APIs, FB patients had fewer lymph node assessed than US-born (p<0.001), but were as likely to present with earlier stage disease and receive surgery. After adjustment, US-born [aHR= 0.90 (0.85–0.98)] and FB APIs [(aHR= 0.85 (0.78–0.92)] had higher survival rates than NHWs. Results were similar after adjusting for treatment. *p <0.001 for comparison with NHW +p>0.05 for comparison among API Conclusions: Compared to US-born APIs, FB API patients with gastric cancer present at later stages and are less likely to receive adequate surgical lymph node assessment. However, both US-born and FB API patients present at earlier stages and experience better survival than non-Hispanic white patients. [Table: see text] No significant financial relationships to disclose.

The Impact of Nativity on Chronic Diseases, Self-Rated Health and Comorbidity Status of Asian and Hispanic Immigrants

This study examines the physical health status of immigrants with specific considerations of Asian and Hispanic populations and explores possible mechanisms through which health outcomes of interest can be explained. Analyses of the National Health Interview Surveys (NHIS) of 2000 and 2001 revealed that foreign-born individuals reported fewer chronic diseases (hypertension, heart disease, asthma, cancer and diabetes) and had lower prevalences of various chronic diseases compared with U.S.-born whites, controlling for possible confounders and mediators. However, U.S-born minority groups did not show the health advantage seen in foreign-born immigrants, reflecting the importance of nativity distinctions in studying immigrant health. Despite having fewer chronic diseases, foreign-born Asians were more likely to rate their health negatively relative to their U.S.-born counterparts and to U.S.-born whites. In addition, our findings provide evidence that failure to consider comorbid status may attenuate the nativity effect on certain chronic diseases.

Rethinking US Census racial and ethnic categories for the 21st century

Racial and ethnic categories in the US census have continually changed. In this paper, we address the question: How do high levels of immigration and a growing multiracial population challenge census racial and ethnic categories? We examined data from the 2000 Census 5 percent IPUMS to compare racial responses of native- and foreign-born Hispanics, Asians, and Middle Easterners, and native-born multiracial Hispanics, Asians, and Middle Easterners, by ancestry. The relationship between race and ancestry can be instructive. If people understand and identify with census racial categories, we expect considerable overlap between their reported race and ancestry. For some groups, including Europeans, Africans, and Middle Easterners (regardless of nativity) and foreign-born Asians, ancestry and race overlapped well. A serious challenge to current census racial categories is the large and growing numbers of people who reported Some Other Race (SOR) alone (primarily non-Cuban Hispanics) or in combination with another race (a diverse population that includes multiracial Hispanics, Middle Easterners, and Asians). One way of addressing this problem is to merge the current race and Hispanic questions, drop the SOR category, and add the ancestry question to the short-form census, changes that may more effectively meet statistical, government, and other needs.

Low rates of colorectal, cervical, and breast cancer screening in Asian Americans compared with non‐Hispanic whites

Asian Americans have lower cancer screening rates compared with non-Hispanic whites (NHWs). Little is known about mechanisms that underlie disparities in cancer screening. The objectives of the current study were 1) to determine the relation between nativity, years in the United States, language, and cancer screening in NHWs and Asian Americans, independent of access to care and 2) to determine whether Asians reported different reasons than NHWs for not obtaining cancer screening. This population-based study included 36,660 NHWs, 1298 Chinese, 944 Filipinos, 803 Koreans, 857 Vietnamese, and 1036 Other Asians from the 2001 California Health Interview Survey. The main study outcomes were 1) self-reported colorectal, cervical, and breast cancer screening and 2) reasons for not obtaining cancer screening. After adjusting for access to care, several Asian subgroups still had significantly lower rates of all types of cancer screening compared with NHWs. Adjusting for nativity, years in the United States, and English language attenuated the relation between Asian ethnicity and lower rates of colorectal and breast cancer screening. When they were asked what the most important reason was for not having each screening test, foreign-born Asians were significantly more likely than United States-born NHWs to report that they "didn't have problems/symptoms" (P < .01). Nativity, years in the United States, and English language may be markers of cultural differences that are mediating cancer screening disparities. Foreign-born Asians may believe that cancer screening is in response to symptoms rather than tests that are used prior to the development of symptoms. Health education messages must consider how to communicate effectively that "cancer screening is valuable, because it finds cancer before it is advanced enough to cause symptoms."

Leisure Time, Non-leisure Time, and Occupational Physical Activity in Asian Americans

Asian American immigrants' risk of heart disease, diabetes, and obesity increase with duration of residence in the United States (US). Regular physical activity reduces the risk of these diseases, yet little is known about physical activity in Asian Americans and how it changes after immigration. Data from the 2001 California Health Interview Survey, which oversampled Asian Americans, were analyzed to investigate the effects of ethnicity, nativity, and years in the US on leisure time physical activity (LTPA), non-leisure time physical activity (NLTPA), and occupational physical activity. A total of 4226 Asian Americans and 29,473 US-born non-Asians were included. Asian Americans were much less likely to meet recommended levels of LTPA than US-born non-Asians (odds ratio [OR], men=0.51, 95% confidence interval [CI], 0.42, 0.61, OR, women = 0.48, 95% CI, 0.40, 0.57). Foreign-born Asians were least likely to participate in LTPA; LTPA increased as years in the US increased. After accounting for NLTPA, Asian Americans had significantly lower estimated weekly energy expenditure than US-born non-Asians. Asian Americans, especially immigrants, are at risk for low levels of LTPA and high levels of physical inactivity. NLTPA does not offset these lower levels of LTPA. Increasing physical activity is key to protecting the health of this rapidly growing population.

The Living Arrangements of African American and Immigrant Children, 1880-2000

Using data from the Integrated Public Use Microdata Series (IPUMS), the author compares the living arrangements of African American and immigrant children from 1880 through 2000. African American children were less likely than foreign-born white children to live with two parents throughout this protracted period, with the gap widening sharply after 1960. African Americans and the small group of nonwhite immigrants exhibited roughly similar family patterns before 1960. That difference also increased during later decades as both foreign-born Asian and foreign-born black children were more likely than African Americans to reside with two parents. Immigrant children from virtually all nationalities were more likely than black children to live with two parents. Over time, widowhood declined as a cause of paternal absence for all groups, and the influence of marital disruption increased. Nonmarital motherhood increased markedly as a cause of mother-only families for blacks after 1960.

Health, life expectancy, and mortality patterns among immigrant populations in the United States.

The US immigrant population has grown considerably in the last three decades, from 9.6 million in 1970 to 32.5 million in 2002. However, this unprecedented population rise has not been accompanied by increased immigrant health monitoring. In this study, we examined the extent to which US- and foreign-born blacks, whites, Asians, and Hispanics differ in their health, life expectancy, and mortality patterns across the life course. We used National Vital Statistics System (1986-2000) and National Health Interview Survey (1992-1995) data to examine nativity differentials in health outcomes. Logistic regression and age-adjusted death rates were used to examine differentials. Male and female immigrants had, respectively, 3.4 and 2.5 years longer life expectancy than the US-born. Compared to their US-born counterparts, black immigrant men and women had, respectively, 9.4 and 7.8 years longer life expectancy, but Chinese, Japanese, and Filipino immigrants had lower life expectancy. Most immigrant groups had lower risks of infant mortality and low birthweight than the US-born. Consistent with the acculturation hypothesis, immigrants' risks of disability and chronic disease morbidity increased with increasing length of residence. Cancer and other chronic disease mortality patterns for immigrants and natives varied considerably, with Asian Immigrants experiencing substantially higher stomach, liver and cervical cancer mortality than the US-born. Immigrants, however, had significantly lower mortality from lung, colorectal, breast, prostate and esophageal cancer, cardiovascular disease, cirrhosis, diabetes, respiratory diseases, HIV/AIDS, and suicide. Migration selectivity, social support, socio-economic, and behavioural characteristics may account for health differentials between immigrants and the US-born.

Studying cancer incidence and outcomes in immigrants: methodological concerns.

The study of disease patterns in immigrant populations has become an increasingly important public health activity in the United States. For example, in 2000, 28.4 million foreign-born individuals resided in the United States, representing 10.4% of the population.1 The population-based Surveillance, Epidemiology, and End Results (SEER) program represents an important resource for the study of cancer incidence and outcomes in immigrant and minority racial/ethnic populations. Information on birthplace, an indicator of migrant status, is routinely collected by SEER registries and is generally derived from a patient’s medical records or death certificate.2 Unfortunately, these data are problematic for 2 reasons. First, to our knowledge, birthplace information in these registries is not validated, and thus its accuracy is unknown. Second, birthplace information is missing for a substantial proportion of patients, and its level of completeness continually decreases.3 Despite these methodological problems, this variable continues to be used in analyses of cancer incidence among Asian subgroups and their descendants,4–11 examinations of the relationship of birthplace to tumor size and stage among Asians12 and Hispanics,13 and investigations of the effect of birthplace on breast cancer survival among Asians.14 Hoping to inform and improve the quality of future analyses of birthplace as it relates to cancer patterns, we outline here some of our ongoing research on the utility of the birthplace variable in the San Francisco/Oakland and San Jose/Monterey SEER registries and discuss the results of previously published studies in the light of our findings involving this variable. We found that 67% of patients diagnosed in the period 1988 to 1996 had complete birthplace information in the registries.2 This percentage varied by race/ethnicity, with Vietnamese and other Southeast Asians having the highest level of complete data (88.5%) and non-Hispanic Whites having the lowest (65.3%). The most significant factor associated with birthplace completeness was vital status; information from death certificates can supplement existing information by supplying missing birthplace data. In addition, completeness of the birthplace variable in the registries examined was not random but varied according to characteristics such as patient age, year of diagnosis, and hospital teaching status, ownership status, and size. Preliminary results from an ongoing study comparing registry data and selfreported birthplace revealed that the sensitivity and positive predictive value of birthplace data among specific Asian subgroups were quite high, indicating generally good validity (Table 1 ▶). Overall, however, Asians with no birthplace information were less likely to be foreign born than Asians with birthplace information (Table 2 ▶). This pattern was seen across all Asian subgroups except for Vietnamese, of whom the vast majority were foreign born. TABLE 1 —Validity of Registry Data Birthplace Information, by Asian Subgroup: Greater Bay Area Cancer Registry, 1988–2000 TABLE 2 —Birthplace Distribution (Percent Foreign–Born) Among Participants With Known and Unknown Registry Birthplace Information, by Asian Subgroup: Greater Bay Area Cancer Registry, 1988–2000 Therefore, incidence rates computed under the assumption that patients with no birthplace data have the same birthplace distribution as those with complete data4–11,15 will represent overestimates for foreign-born Asians and underestimates for US-born Asians. For example, in a survival analysis conducted by Pineda et al.,14 inflation of the hazard rate of death due to breast cancer was greater for US-born Asians than for their foreign-born counterparts, because patients with missing birthplace information were excluded from the analysis (and because complete birthplace data are more likely to be available for deceased patients than for patients who are alive). Similarly, in 2 recently published studies examining birthplace in relation to breast cancer tumor size and stage among Asians12 and Hispanics,13 24.2% of Asians and 37.3% of Hispanics with unknown birthplace data were excluded. As a result, the findings of these studies are subject to selection bias in that completeness of birthplace information was likely to be associated with the outcomes under investigation, given that breast cancer patients at advanced stages and with larger tumor sizes generally have worse survival rates than patients at earlier stages and with smaller tumor sizes. Inclusion of birthplace information in research designs can result in the identification of vulnerable subpopulations to be targeted for public health services, and such data can provide etiological insights as well. However, if this increasingly important information is to be useful, hospitals need to adopt policies aimed at improving its collection; the quality and completeness of birthplace data can be improved only at the level of the reporting facilities.