Unfriendly shores: how immigrant children fare in the U.S. health system

Determinants of ethnic differences in the uptake of child healthcare services in New Zealand: a decomposition analysis

BACKGROUND

There are persistent ethnic gaps in uptake of child healthcare services in New Zealand (NZ), despite increasing policy to promote equitable access. We examined ethnic differences in the uptake of immunisation and primary healthcare services at different ages and quantified the contribution of relevant explanatory factors, in order to identify potential points of intervention.

METHODS

We used data from the Growing Up in New Zealand birth cohort study, including children born between 2009 and 2010. Econometric approaches were used to explore underlying mechanisms behind ethnic differences in service uptake. Multivariable regression was used to adjust for mother, child, household, socioeconomic, mobility, and social factors. Decomposition analysis was used to assess the proportion of each ethnic gap that could be explained, as well as the main drivers behind the explained component. These analyses were repeated for four data time-points.

RESULTS

Six thousand eight hundred twenty-two mothers were enrolled during the antenatal survey, and children were followed up at 9-months, 2-years and 4-years. In univariable models, there were ethnic gaps in uptake of immunisation and primary care services. After adjusting for covariates in multivariable models, compared to NZ Europeans, Asian and Pacific children had higher timeliness and completeness of immunisation at all time-points, while indigenous Māori had lower timeliness of first-year vaccines despite high intentions to immunise. Asian and Pacific mothers were less likely to have their first-choice lead maternity caregiver (LMC) than NZ Europeans mothers, and Māori and Asian mothers were less likely to be satisfied with their general practitioner (GP) at 2-years. Healthcare utilisation was strongly influenced by socio-economic, mobility and social factors including ethnic discrimination. In decomposition models comparing Māori to NZ Europeans, the strongest drivers for timely first-year immunisations and GP satisfaction (2-years) were household composition and household income. Gaps between Pacific and NZ Europeans in timely first-year immunisations and choice of maternity carer were largely unexplained by factors included in the models.

CONCLUSIONS

Ethnic gaps in uptake of child healthcare services vary by ethnicity, service, and time-point, and are driven by different factors. Addressing healthcare disparities will require interventions tailored to specific ethnic groups, as well as addressing underlying social determinants and structural racism. Gaps that remain unexplained by our models require further investigation.

Effects of the Children's Health Insurance Reauthorization Act on immigrant children's healthcare access

OBJECTIVE

To estimate the effects of Children's Health Insurance Reauthorization Act (CHIPRA), a policy that provided states the option to extend Medicaid/CHIP eligibility to immigrant children who have not been legal residents for five years or more, on insurance coverage, access, utilization, and health outcomes among immigrant children.

DATA SOURCES

Restricted use 2000-2016 National Health Interview Survey (NHIS).

STUDY DESIGN

We used a difference-in-differences design that compared changes in CHIPRA expansion states to changes in non-expansion states.

DATA COLLECTION

Our sample included immigrant children who were born outside the US, aged 0-18 with family income below 300% of the Federal Poverty Level (FPL). Subgroup analyses were conducted across states that did and did not have a similar state-funded option prior to CHIPRA (state-funded vs. not state-funded), by the length of time in the US (5 years vs. 5-14 years), and global region of birth (Latin American vs. Asian countries).

PRINCIPLE FINDINGS

We found that CHIPRA was associated with a significant 6.35 percentage point decrease in uninsured rates (95% CI: -11.25, -1.45) and an 8.1 percentage point increase in public insurance enrollment for immigrant children (95% CI: 1.26, 14.98). However, the effects of CHIPRA became small and statistically not significant 3 years after adoption. Effects on public insurance coverage were significant in states without state-funded programs prior to CHIPRA (15.50 percentage points; 95% CI:8.05, 22.95) and for children born in Asian countries (12.80 percentage points; 95% CI: 1.04, 24.56). We found no significant changes in health care access and utilization, and health outcomes, overall and across subgroups due to CHIPRA.

CONCLUSIONS

CHIPRA's eligibility expansion was associated with increases in public insurance coverage for low-income children, especially in states where CHIPRA represented a new source of coverage versus a substitute for state-funded coverage. However, we found evidence of crowd-out in certain subgroups and no effect of CHIPRA on access to care and health. Our results suggest that public coverage may be an important tool for promoting the well-being of immigrant children but other investments are still needed.

Improving Syrian refugees' knowledge of medications and adherence following a randomized control trial assessing the effect of a medication management review service

BACKGROUND

Syrian refugees living in Jordan have many chronic conditions and use many medications. Pharmacists delivering the Medication Management Review (MMR) service can have a role in improving this growing global refugees' problem.

OBJECTIVES

To assess the effect of the MMR service on adherence to treatment therapy and knowledge of chronic medications for Syrian refugees residing in Jordan.

METHODS

This randomized intervention control single-blinded study was conducted in Jordan. Syrian refugees were recruited and randomized into intervention and control groups. Two home visits were delivered to each participant, at baseline and three months later. All participants completed questionnaires regarding adherence and knowledge. As a part of the MMR service, treatment-related problems (TRPs) were recognized for all patients; recommendations to resolve these TRPs were only delivered to intervention group refugees' physicians; TRPs were corrected. At follow-up, TRPs assessment, adherence and medication knowledge were assessed for all refugee participants.

RESULTS

Participants (n = 106; intervention n = 53, control n = 53) had a number of medications and diagnosed chronic diseases of 5.8 ± 2.1 and 2.97 ± 1.16 per participant respectively. A significant improvement in the adherence and knowledge scores were noted in the intervention (P < 0.001 for both) but not the control group (P = 0.229, P = 0.07 respectively).

CONCLUSION

The MMR service can significantly improve refugees' TRPs, adherence to therapy and knowledge of chronic medications. If this approach was extended to the large scale, many refugees in need would be able to access a quality essential health-care service; a step towards achieving universal health coverage.

TRIAL REGISTRATION

Registry: ClinicalTrials.gov Identifier: NCT04554810.

Management of Diabetes Mellitus in Refugee and Migrant Patients in a Primary Healthcare Setting in Greece: A Pilot Intervention

Over the past years there is a substantial wave of migrants and refugees all over the world. Europe accepts approximately one-third of the international migrant population with Greece, in particular, having received large numbers of refugees and migrants by land and sea since the beginning of the civil war in Syria. Diabetes, a non-communicable disease, is a global health problem, affecting people in developing countries, refugees and migrants, and its basic treatment tool includes self-management and education. In this pilot study, we organized educational, interactive group sessions for diabetic refugees, based on culture, health, and nutritional needs according to a questionnaire developed for the study. The sessions were weekly, for two months, in the context of primary healthcare, organized by a dietitian. Nine individuals completed the sessions, five of nine were diagnosed in Greece and seven of nine needed diabetes education. Their waist circumference was above normal and they were all cooking at home. Their nutritional habits improved by attending the sessions and the interaction helped their social integration. They all found the sessions useful, and felt more self-confident regarding diabetes control and healthier.

Coverage for low-income immigrant children increased 24.5 percent in states that expanded CHIPRA eligibility

The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 provided states with the option of expanding eligibility for federally funded public insurance to low-income immigrant children within their first five years of legal residence in the United States. By 2011 twenty states and the District of Columbia had adopted that option. Using cross-sectional data from the 2003, 2007, and 2011-12 National Survey of Children's Health, we compared trends in coverage and access to care among immigrant children in states that did expand eligibility to children in states that did not. Compared to immigrant children in states that did not expand eligibility, children in states expanding eligibility experienced a 24.5 percent increase in insurance coverage, largely due to greater enrollment in public insurance. Immigrant children in states that expanded eligibility also experienced significant reductions in unmet health care needs, compared to their counterparts in nonexpansion states. Disparities relative to children in nonimmigrant families were substantially reduced in states that expanded eligibility, compared to states that did not. Expanding eligibility for federally funded public insurance to immigrant children within their first five years of legal residence in other states could improve coverage for immigrant children and might also increase access to care.

Human Papilloma Virus and Cervical Cancer Education Needs among HIV-Positive Haitian Women in Miami

BACKGROUND

Haitian immigrant women, the largest growing Black ethnic group in Miami, experience the highest rates of cervical cancer and account for one of the largest populations diagnosed with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in South Florida. Using community-based participatory research methods, we conducted a pilot study to examine human papilloma virus (HPV)/cervical cancer knowledge and identify intervention preferences among HIV positive Haitian women.

METHODS

Community health workers conducted three focus groups with 21 HIV-positive Haitian women. All sessions were conducted in Haitian Kreyol, digitally recorded, and subsequently interpreted and transcribed into English. The first focus group assessed HPV/cervical cancer knowledge, the second session explored HPV/cervical cancer considerations specific to HIV-positive women, and the third focus group discussed HPV/cervical cancer screening and intervention preferences. Data analysis was guided by a grounded theory approach.

FINDINGS

Our sample had limited HPV/cervical cancer knowledge. Misconceptions about screening, transmission, and treatment were common. Participants felt that stigma by providers impacted negatively the care they received and that stigma by the community diminished social support. Strong support for culturally tailored interventions to improve HPV/cervical cancer knowledge was expressed. Although no participants had participated in research previously, all were willing to participate in future trials.

CONCLUSIONS

There is critical need for culturally relevant interventions to improve HPV/cervical cancer knowledge among HIV-positive Haitian women.

Undocumented Immigrants and Access to Health Care: Making a Case for Policy Reform

The growth in undocumented immigration in the United States has garnered increasing interest in the arenas of immigration and health care policy reform. Undocumented immigrants are restricted from accessing public health and social service as a result of their immigration status. The Patient Protection and Affordability Care Act restricts undocumented immigrants from participating in state exchange insurance market places, further limiting them from accessing equitable health care services. This commentary calls for comprehensive policy reform that expands access to health care for undocumented immigrants based on an analysis of immigrant health policies and their impact on health care expenditures, public health, and the role of health care providers. The intersectional nature of immigration and health care policy emphasizes the need for nurse policymakers to advocate for comprehensive policy reform aimed at improving the health and well-being of immigrants and the nation as a whole.

Disparities in health insurance among children with same-sex parents

OBJECTIVES

The objectives of this study were to examine disparities in health insurance coverage for children with same-sex parents and to investigate how statewide policies such as same-sex marriage and second-parent adoptions affect children's private insurance coverage.

METHODS

We used data from the 2008-2010 American Community Survey to identify children (aged 0-17 years) with same-sex parents (n = 5081), married opposite-sex parents (n = 1369789), and unmarried opposite-sex parents (n = 101678). We conducted multinomial logistic regression models to estimate the relationship between family type and type of health insurance coverage for all children and then stratified by each child's state policy environment.

RESULTS

Although 77.5% of children with married opposite-sex parents had private health insurance, only 63.3% of children with dual fathers and 67.5% with dual mothers were covered by private health plans. Children with same-sex parents had fewer odds of private insurance after controlling for demographic characteristics but not to the extent of children with unmarried opposite-sex parents. Differences in private insurance diminished for children with dual mothers after stratifying children in states with legal same-sex marriage or civil unions. Living in a state that allowed second-parent adoptions also predicted narrower disparities in private insurance coverage for children with dual fathers or dual mothers.

CONCLUSIONS

Disparities in private health insurance for children with same-sex parents diminish when they live in states that secure their legal relationship to both parents. This study provides supporting evidence in favor of recent policy statements by the American Academy of Pediatricians endorsing same-sex marriage and second-parent adoptions.

Learning strengths from cultural differences: a comparative study of maternal health-related behaviors and infant care among Southern Asian immigrants and Taiwanese women

Background

Many studies have indicated that most immigrant women come from underdeveloped countries, and this can have negative effects on their lives, children’s adaptation to school, and medical care utilization. However, there is insufficient literature about differences in infant caretaking, pre-postpartum health care, and health outcome between immigrant and native Taiwanese populations. The aim of this study was to investigate the differences between Southern Asia immigrants and Taiwanese women in their access to medical care, postnatal growth, and infant care throughout the first six months postpartum.

Methods

Comparative and descriptive designs were applied. Immigrant women were eligible if they visited three suburban settings of the Outpatient Department of Obstetrics and Gynecology and the Outpatient Department of Pediatrics in Northern Taiwan during the period up to six months postpartum.

Results

Immigrant women appeared to have a lower frequency of antenatal examinations and obtained less health information from health care providers. However, they did not differ significantly from native Taiwanese women in maternal body size, postnatal growth curves, exclusive breastfeeding rates or vaccination awareness at the 6^th month postpartum.

Conclusions

Learning strengths from cultural differences between immigrant and native women and closing the gaps in health inequality are important issues. Despite the limitation of small sample size, the present findings can be used as references to help health care providers to develop further health policies in Taiwan.

High prevalence of chronic non-communicable conditions among adult refugees: implications for practice and policy

The global rise in non-communicable disease (NCD) suggests that US-based refugees are increasingly affected by chronic conditions. However, health services have focused on the detection of infectious disease, with relatively limited data on chronic NCDs. Using data from a retrospective medical record review of a refugee health program in the urban Northeast (n = 180), we examined the prevalence of chronic NCDs and NCD risk factors among adult refugees who had recently arrived in the US, with attention to region of origin and family composition. Family composition was included because low-income adults without dependent children are at high risk of becoming uninsured. We found that half of the adult refugees in this sample had at least one chronic NCD (51.1%), and 9.5% had three or more NCDs. Behavioral health diagnoses were most common (15.0%), followed by hypertension (13.3%). Half of adults were overweight or obese (54.6%). Chronic NCDs were somewhat more common among adults from Iraq, but this difference was not significant (56.8 vs. 44.6%). Chronic NCDs were common among adults with and without dependent children (61.4 vs. 44.6%, respectively), and these two groups did not significantly differ in their likelihood of having a chronic NCD after adjustment for age and gender (AOR = 0.78, 95% CI = 0.39, 1.55). This study suggests that chronic NCDs are common among adult refugees in the US, including refugees at high risk for uninsurance. We propose that refugee health services accommodate screening and treatment for chronic NCDs and NCD risk factors, and that insurance outreach and enrollment programs target recently arrived refugees.

Parental immigrant status and adolescent mental health in the United States: do racial/ethnic differences exist?

AIMS

  To examine the relationship between mental health problems and parental immigrant status in a representative sample of US adolescents aged 12-17.

METHOD

  We analyzed the US 2007 National Survey of Children's Health (NSCH) restricted to 32,849 adolescents aged 12-17. Parents or guardians in random-digit-dial sampled households were interviewed by telephone from April 2007 through July 2008 about one of their children, selected at random. Five mental health measures were used: prior medical diagnoses of (a) depression, (b) anxiety, and (c) behavioral problems; parental reports of the adolescent (d) feeling inferior/worthless, and (e) episodes of being withdrawal from others. Logistic regression models were employed to examine the relationship between mental health problems and parental immigrant status.

RESULTS

  Overall, 19.4% of adolescents had at least one immigrant parent. After adjusting for sociodemographic factors, all adolescents with immigrant parents have decreased odds of behavioral problems (OR 0.43, p < .000), but no significant differences in the odds of depression, anxiety, worthlessness, and withdrawal compared to adolescents with US-born parents. Similarly, White, Black, and Hispanic adolescents with immigrant parents had decreased odds of behavioral problems (OR 0.35, p < .000; OR 0.31, p < .01; and OR 0.24, p < .05, respectively) compared to their counterparts with US-born parents.

CONCLUSION

  Evaluation of psychological and mental health problems among adolescents in the United States should take parental immigrant status and other sociodemographic factors into account.

High parenting aggravation among US immigrant families

OBJECTIVES

We examined the association between the joint effects of children's immigrant family type and race/ethnicity on parenting aggravation.

METHODS

We analyzed data on a nationally representative sample of 101 032 children aged birth through 17 years from the 2003 National Survey of Children's Health.

RESULTS

Analysis of the Aggravation in Parenting Scale showed that 26% of foreign-born parents with foreign-born children were highly aggravated, followed by 22% of foreign-born parents with US-born children and 11% of US-born parents. Multivariable analyses indicated that all minority parents experienced high parenting aggravation compared with non-Hispanic White US-born parents; the odds of reporting parenting aggravation were 5 times higher for Hispanic foreign-born parents. All foreign-born parents, regardless of race/ethnicity, reported significantly elevated parenting aggravation. Parents of adolescents, children with special health care needs, and nontraditional and lower-income households were also more likely to report high parenting aggravation.

CONCLUSIONS

Our findings clearly document significantly elevated levels of parenting aggravation among immigrant and minority families. Public health programs and clinicians should target referrals and interventions for these families to avoid potential health problems for both children and their families.

Medical expenditures associated with nonfatal occupational injuries among immigrant and U.S.-born workers

Background

No national study has investigated whether immigrant workers are less likely than U.S.-workers to seek medical treatment after occupational injuries and whether the payment source differs between two groups.

Methods

Using the 2004–2009 Medical Expenditure Panel Survey (MEPS) data, we estimated the annual incidence rate of nonfatal occupational injuries per 100 workers. Logistic regression models were fitted to test whether injured immigrant workers were less likely than U.S.-born workers to seek professional medical treatment after occupational injuries. We also estimated the average mean medical expenditures per injured worker during the 2 year MEPS reference period using linear regression analysis, adjusting for gender, age, race, marital status, education, poverty level, and insurance. Types of service and sources of payment were compared between U.S.-born and immigrant workers.

Results

A total of 1,909 injured U.S.-born workers reported 2,176 occupational injury events and 508 injured immigrant workers reported 560 occupational injury events. The annual nonfatal incidence rate per 100 workers was 4.0% (95% CI: 3.8%-4.3%) for U.S.-born workers and 3.0% (95% CI: 2.6%-3.3%) for immigrant workers. Medical treatment was sought after 77.3% (95% CI: 75.1%-79.4%) of the occupational injuries suffered by U.S.-born workers and 75.6% (95% CI: 69.8%-80.7%) of the occupational injuries suffered by immigrant workers. The average medical expenditure per injured worker in the 2 year MEPS reference period was $2357 for the U.S.-born workers and $2,351 for immigrant workers (in 2009 U.S. dollars, P = 0.99). Workers’ compensation paid 57.0% (95% CI: 49.4%-63.6%) of the total expenditures for U.S.-born workers and 43.2% (95% CI: 33.0%-53.7%) for immigrant workers. U.S.-born workers paid 6.7% (95% CI: 5.5%-8.3%) and immigrant workers paid 7.1% (95% CI: 5.2%-9.6%) out-of-pocket.

Conclusions

Immigrant workers had a statistically significant lower incidence rate of nonfatal occupational injuries than U.S.-born workers. There was no significant difference in seeking medical treatment and in the mean expenditures per injured worker between the two groups. The proportion of total expenditures paid by workers’ compensation was smaller (marginally significant) for immigrant workers than for U.S.-born workers.

The association between acculturation and health insurance coverage for immigrant children from socioeconomically disadvantaged regions of origin

Among immigrant children whose parents have historically had lower education, the study explored which immigrant children were most likely to have coverage based on maternal region of origin. The direct and indirect relationship of acculturation on immigrant children's coverage was also assessed. A subsample of US-born children with foreign-born mothers from the Early Childhood Longitudinal Survey-Kindergarten Cohort was analyzed using multinomial logistic regressions (n = 1,686). Children whose mothers emigrated from the Caribbean or Indochina had greater odds of being insured compared to children whose mothers emigrated from Mexico. Moreover, Latin American children did not statistically differ from Mexican children in being uninsured. Maternal citizenship was positively associated with children's coverage; while living in a household with a mother who migrated as a child was negatively associated with private insurance. To increase immigrant children's coverage, Latin American and Mexican families may benefit from additional financial assistance, rather than cultural assistance.

Life on the Edge: Immigrants Confront the American Health System

On the basis of a study of forty health care delivery institutions in Florida, California, and New Jersey, this paper examines the interaction the immigration and health systems in the USA. We investigate barriers to care encountered by the foreign-born, especially unauthorized immigrants, and the systemic contradictions between demand for their labor and the absence of an effective immigration policy. Lack of access and high costs have forced the uninsured poor into a series of coping strategies, which we describe in relation to commercial medicine. We highlight regional differences and the importance of local politics and history in shaping health care alternatives for the foreign-born.

Factors influencing healthcare utilization within a free community clinic

The purpose was to explore the relationship between the presence of a free community clinic and factors associated with utilization of healthcare through a secondary data analysis. Using a descriptive correlational design, results were analyzed to explore relationships between potential utilization of healthcare, identification of a regular source of healthcare, and health insurance status. Most subjects would not seek healthcare if the free community clinic was not available. Subjects with health insurance were significantly more likely to have a regular source of healthcare and seek healthcare in the absence of the free community clinic. Subjects with a regular source of healthcare were significantly more likely to seek healthcare in the absence of the free community clinic. Emergency room utilization was not impacted by regular source of healthcare or health insurance. This study supports the need for free community clinics in areas with high percentages of uninsured, immigrant, and refugee populations.

Use of HIV primary care by HIV-positive Haitian immigrants in Miami, Florida

Little is known about the use of HIV primary care among Haitian immigrants in the USA. The present study utilizes data from a survey of HIV-positive Haitians recruited from an HIV primary care clinic in Miami, Florida, to examine barriers and facilitators of regular use of HIV care by this population. Selection of measures was guided by the Andersen Model of Health Services Utilization for Vulnerable Populations. The dependent variable, regular use of HIV primary care, was operationalized as completion of four or more HIV primary care visits during the previous 12 months. Of the 96 participants surveyed, approximately three-fourths did not graduate from high school and reported an annual income of up to $5000. Seventy-nine percent of participants completed four or more visits in the past year. On univariate as well as multivariate analyses, participants without formal education or those with high psychological distress were significantly less likely to have used HIV primary care regularly than those who attended school or who were less distressed, respectively. The findings emphasize the need for health care practitioners to pay close attention to the education level and the mental health status of their Haitian HIV patients. The data also suggest that once these individuals are linked to care and offered assistance with their daily challenges, they are very likely to stay connected to care and to take their antiretroviral medicines.

Development and implementation of a collaborative, multistakeholder research and practice model on HIV prevention targeting Asian/Pacific Islander men in the United States who have sex with men

We describe lessons learned from a national HIV prevention research program grounded in community-based participatory research, the Men of Asia Testing for HIV (MATH) Study, which targeted self-identified Asian/Pacific Islander men in the United States who have sex with men. We discuss the genesis of and impetus for the study and then describe its various facets, including accomplishments, challenges, and unanticipated consequences. We conclude with a discussion about the real-world practice of community-based participatory research with respect to the MATH Study in particular and similar research in general.

Assessing linguistic and cultural equivalency of two Chinese-version sexual health instruments among Chinese immigrant youth

This study aimed to evaluate the linguistic and cultural equivalency of two Chinese-version instruments measuring sexual knowledge, attitudes, and behaviors among 10 bilingual and 2 monolingual Chinese immigrant youth aged 13-19 years. We used a rigorous design to translate, back-translate, and pilot test the instruments. Kappa coefficient, percentage agreement, and qualitative feedback from participants were used to examine reliability and validity of the instruments. Telephone interviews revealed that answer discrepancies in different language versions were due to external factors rather than lack of linguistic and cultural equivalency. This study offers preliminary evidence supporting the cultural and linguistic equivalence of two Chinese-version sexual scales.

Health status and health services access and utilization among Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese children in California

OBJECTIVES

We examined health status and health services access and utilization of Chinese, Filipino, Japanese, Korean, South Asian, Vietnamese, and non-Hispanic White children in California.

METHODS

We analyzed aggregated data from the 2003 and 2005 California Health Interview Survey (648 Chinese, 523 Filipino, 235 Japanese, 308 Korean, 314 South Asian, 264 Vietnamese, and 8468 non-Hispanic White children aged younger than 12 years), examining the relationship between Asian ethnicities and outcomes.

RESULTS

Compared with non-Hispanic White children, Korean children were 4 times more likely to lack health insurance; Filipino children were twice as likely to not have had recent contact with a doctor; Chinese, Korean, and Vietnamese children were less likely to have visited an emergency room in the past year; and Chinese, Korean, and Vietnamese children were more likely to be in fair or poor health. Age, gender, poverty, citizenship-nativity status, health insurance, and parental marital and child health statuses were related to most outcomes.

CONCLUSIONS

Asian ethnicities have heterogeneous health care access and utilization patterns, suggesting the need for targeted outreach to different Asian ethnic groups.

Routine physical examination and forgone health care among Latino adolescent immigrants in the United States

Knowledge concerning patterns of health care utilization among Latino-adolescent immigrants is needed to develop culturally-appropriate programs. The objectives of this study were to estimate the annual prevalence of having had a routine physical exam and episodes of adolescents' not seeking health care when they thought they should (forgone health care) among Latino adolescents by immigrant-generational status. Cross-sectional analysis of data from Latino adolescents in Wave I of the National Longitudinal Adolescent Health Study. First-generation immigrants who had lived in the U.S. < or = 5 years were less likely to receive routine care than third-generation immigrants (39.0% vs. 54.9%). This disparity decreased after adjustment for insurance status, parental education and poverty among Mexican origin adolescents. On average, 16.0% of first-generation immigrants who had lived in the U.S. < or = 5 years and 22.5% of third-generation immigrants reported forgoing health care. After adjustment for age, insurance status, parental education and routine care, recent arrivals were less likely than third-generation immigrants to forgo health care. Recent arrivals were less likely to receive a routine physical exam and to forgo care than third-generation immigrants. Future studies should explore the effect of acculturation on knowledge, beliefs and perceptions about health, illness and care-seeking behaviors.

Children with special health care needs: how immigrant status is related to health care access, health care utilization, and health status

To compare health care access, utilization, and perceived health status for children with SHCN in immigrant and nonimmigrant families. This cross-sectional study used data from the 2003 California Health Interview Survey to identify 1404 children (ages 0-11) with a special health care need. Chi-square and logistic regression analyses were used to examine relations between immigrant status and health access, utilization, and health status variables. Compared to children with special health care needs (CSHCN) in nonimmigrant families, CSHCN in immigrant families are more likely to be uninsured (10.4 vs. 4.8%), lack a usual source of care (5.9 vs. 1.9%), report a delay in medical care (13.0 vs. 8.1%), and report no visit to the doctor in the past year (6.8 vs. 2.6%). They are less likely to report an emergency room visit in the past year (30.0 vs. 44.0%), yet more likely to report fair or poor perceived health status (33.0 vs. 16.0%). Multivariate analyses suggested that the bivariate findings for children with SHCN in immigrant families largely reflected differences in family socioeconomic status, parent's language, parental education, ethnicity, and children's insurance status. Limited resources, non-English language, and limited health-care use are some of the barriers to staying healthy for CSHCN in immigrant families. Public policies that improve access to existing insurance programs and provide culturally and linguistically appropriate care will likely decrease health and health care disparities for this population.

Review: immigrants and health care access, quality, and cost

Inadequate access and poor quality care for immigrants could have serious consequences for their health and that of the overall U.S. population. The authors conducted a systematic search for post-1996, population-based studies of immigrants and health care. Of the 1,559 articles identified, 67 met study criteria of which 77% examined access, 27% quality, and 6% cost. Noncitizens and their children were less likely to have health insurance and a regular source of care and had lower use than the U.S. born. The foreign born or non-English speakers were less satisfied and reported lower ratings and more discrimination. Immigrants incurred lower costs than the U.S. born, except emergency department expenditures for immigrant children. Policy solutions are needed to improve health care for immigrants and their children. Research is needed to elucidate immigrants' nonfinancial barriers, receipt of specific processes of care, cost of care, and health care experiences in nontraditional U.S. destinations.

State-level health care access and use among children in US immigrant families

OBJECTIVES

We examined the association between children's state of residence and their access to health care among specific types of immigrant families: foreign-born children, US-born children with 1 foreign-born parent, US-born children with both foreign-born parents, and nonimmigrant families.

METHODS

We analyzed data from 12 400 children from the 2003 National Survey of Children's Health in the 6 states with the highest proportion of immigrants (California, Florida, Illinois, New York, New Jersey, and Texas).

RESULTS

Multivariable analyses indicated that among foreign-born children, those living in California, Illinois, and Texas were more likely to lack access to health care compared with those living in New York. Among foreign-born children with 1 or 2 US-born parents, Texas children were most likely to lack health insurance. Within nonimmigrant families, children from California, Florida, and Texas had significantly more access and use problems.

CONCLUSIONS

Our findings document differential health care access and use among states for specific immigrant family types.

Health insurance and access to care for families with young children in California, 2001-2005: differences by immigration status

OBJECTIVES

To examine differences and trends in health insurance coverage and access to care for California families by immigration status.

METHODS

Cross-sectional data on 37,236 families with young children <18 years of age from the 2001, 2003 and 2005 California Health Interview Survey are used to assess trends in health insurance and access to care for children and their parents by four immigration dyads: (1) both are Citizens; (2) child is a legal resident/citizen, and parent is legal resident (Documented); (3) child is a citizen, and parent is undocumented (Mixed); and (4) both are Undocumented.

RESULTS

Before and after adjustment for covariates, only children in Undocumented dyads were less likely than Citizen dyads to have insurance (OR = 0.20, CI: 0.16-0.26) and all three measures of access: physician visits (OR = 0.69, CI: 0.52-0.91), dental visits (OR = 0.47, CI: 0.35-0.63), and a regular source of care (OR = 0.51, CI: 0.37-0.69). Parents in all non-Citizen dyads had poorer access than Citizen dyads across all measures, with the exception of dental visits and a regular source for parents in Documented dyads. Children of all dyads except Citizens were more likely to be insured in 2005 vs. 2001. The largest gain was for undocumented dyad children with 2.77 times higher odds (CI: 1.62-4.75) of being insured in 2005 vs. 2001. All children dyads except Mixed were also more likely to have a physician visit. For parents, there was only a decrease in insurance coverage for Citizen dyads (OR = 0.79, CI: 0.67-0.93) and few changes in access. Conclusions While there were relatively few disparities and some improvements in insurance coverage and access for children in California (except for undocumented children), concomitant changes for parents were not observed. Without attention to the family in health care reforms, disparities may not fully resolve for children and may continue or even increase for parents.

Parental nativity affects children's health and access to care

OBJECTIVE

To examine the effect of parental nativity on child health and access to health care.

DATA SOURCE

The 2002 National Survey of America's Families.

RESULTS

Among US children, 14% have foreign-born parents; 5% have one foreign- and one native-born parent ("mixed-nativity"). In multivariate logistic regression analyses, children with foreign-born parents were less likely than children with US-born parents to be perceived in "very good" or "excellent health" [OR = 0.68; 95% CI (0.56-0.82)] and to have a usual health care site [OR = 0.52 (0.38-0.69)]; having mixed-nativity parents is associated with better perceived child health. These effects persisted for minority, but not white, children. Regardless of race and ethnicity, non-citizen children have worse access to care.

CONCLUSION

Efforts to improve children of immigrants' health and access to care should focus on families in which both parents are immigrants, particularly those who are ethnic or racial minorities. Efforts to increase use of health services should focus on non-citizen children.

Self-reported HIV testing behaviors among a sample of southeast Asians in an urban setting in the United States

In light of the abruptness and severity of the HIV/AIDS epidemic in Asia, there has been growing concern in recent years about the HIV/AIDS risks with the steady rate of Asian and Pacific Islander (AAPI) migration to the United States. Little is known, however, about existing HIV risks among non-MSM (men who have sex with men) AAPIs. The purpose of this study was to examine self-reported HIV testing behaviors and their correlates among a sample of 604 Southeast Asians living in a U.S. urban setting. The HIV testing rate among our sample adults is 30.8%, lower than the median HIV testing rate in the U.S. adult population by state, lower than that of the general adult testing rate in the study city, and lower than that of the AAPI MSM population. A low sexually transmitted infection (STI) testing rate as a proxy for low perceived sexual risks and a dearth of HIV knowledge were associated with the low HIV testing rate. Traditional health care access measures, such as availability of medical insurance and a personal doctor, cannot explain the low HIV testing rate in this predominantly immigrant population. Culturally and linguistically appropriate HIV prevention campaigns could increase the awareness of HIV/STI risk in this AAPI population.

Parental nativity is an important factor associated with where children usually go for health care

PURPOSE

Few studies of children's access to care account for the independent effects of parental immigration characteristics. To address this gap in knowledge, we examine the association between parental nativity and where children usually obtain health care.

DATA SOURCE

The 2002 National Survey of America's Families (N = 34,332).

RESULTS

Fourteen percent of the sampled children had only foreign-born parents. Most of the sampled children used physician's offices or HMOs (69%) and clinics or other hospital outpatient settings (24%) as usual sites for health care; few used hospital emergency departments or other care providers (1.4%). After adjusting for confounders, using multinomial logistic regression, both citizen [OR = 1.92 (1.44-2.56)] and non-citizen [OR = 5.21 (3.33-8.15)] children with foreign-born parents were more likely to lack a usual site for health care, compared to children with at least one US-born parent-regardless of the mother's citizenship and duration of stay in the US. After accounting for parental nativity, lack of citizenship and shorter durations of US stay among mothers were associated with children's greater use of public clinics or other hospital outpatient settings, rather than physician's offices or HMOs. The effect of parental nativity persisted for minority, but not white, children; however, non-citizen children lacked a usual site for health care regardless of their race and ethnicity.

CONCLUSION

The immigration characteristics of parents are important to disparities in where children usually go for health care. These results suggest that increasing the "biomedical acculturation" of immigrant mothers may improve access to care for their children.

Child health care decision making and experiences of Caribbean women

INTRODUCTION

The purposes of this study were to (a) obtain data about the child health care decision making and practices of immigrant English-speaking women from the Caribbean region and (b) describe their experiences with the U.S. health care system and providers of care.

METHOD

A qualitative design with purposeful sampling was used. Data were obtained from 12 women through focus group interviews.

RESULTS

Three descriptive categories were identified: child/family focus, childhood illnesses and remedies, and relationships with providers. Findings included use of "parallel utilization" practices by the caretakers; use of herbs and other alternative practices; a strong informal social support network within the community; and frustration with and lack of trust in health care providers.

DISCUSSION

Immigrant children and children of immigrant Caribbean adults are a vulnerable population that may be at risk for poor health and mental health outcomes when receiving care from multiple or inconsistent providers, when providers are unaware of folk practices administered to these children by caretakers, and because of a lack of research about the efficacy of folk medicines used in children either alone or in combination with prescribed Western medicines.

Knowledge, attitudes, and practices regarding antibiotic use among Latinos in the United States: review and recommendations

Inappropriate use of antibiotics contributes to antimicrobial resistance worldwide. In Latin America, antibiotics are easily obtained over the counter. In the United States, the Latino population is the largest and fastest growing immigrant group. Hence, it is necessary to understand Latino cultural practices in regards to antibiotic use to develop effective interventions that reduce inappropriate antibiotic use among this population. We conducted a systematic review of descriptive and intervention studies measuring knowledge, attitudes, and practices of antibiotic use among Latinos in the United States. The search yielded only 11 descriptive studies and no interventions. The literature suggests that many Latinos in the United States self-prescribe antibiotics because of financial and sociocultural barriers and inaccurately believe that antibiotics help treat viral infections. Increased access to health care and appropriate culturally tailored interventions specific to Latinos are needed to promote judicious antibiotic use among Latinos.

A Comparison of Nonfatal Unintentional Injuries in the United States Among U.S.-Born and Foreign-Born Persons

The objective of this research was to compare the risk of nonfatal unintentional injuries between foreign-born and U.S.-born persons. Cross-sectional, nationally representative data were used from the 2000-2003 National Health Interview Survey to compare the risk of injury between 62,267 foreign-born and 322,200 U.S.-born persons. Nonfatal unintentional injuries occurring during the three months prior to the interview were compared by age, gender, education, poverty status, region of residence, family size, and health insurance coverage status. There were a total of 7,654 injured persons with U.S.-born persons having a weighted injury prevalence of 2.3% (95% confidence interval [CI]: 2.2, 2.4) and foreign-born persons having a weighted injury prevalence of 1.2% (95% CI: 1.0, 1.3). With the U.S.-born population as the reference and while controlling for sociodemographic characteristics, the odds ratio of injury risk was 0.54 (95% CI: 0.48, 0.62) for the foreign-born population. Transportation-related injuries occurred more frequently among foreign-born persons than among U.S.-born persons (23.7%, 95% CI: 19.7, 28.3 vs. 15.0%, 95% CI: 14.0, 16.2, respectively). This research is the first step in determining the morbidity from unintentional injuries among the foreign-born population in the U.S.

The effects of child-only insurance coverage and family coverage on health care access and use: recent findings among low-income children in California

OBJECTIVE

To compare the extent with which child-only and family coverage (child and parent insured) ensure health care access and use for low income children in California and discuss the policy implications of extending the State Children's Health Insurance Program (California's Healthy Families) to uninsured parents of child enrollees.

DATA SOURCES/SETTING

We used secondary data from the 2001 California Health Interview Survey (CHIS), a representative telephone survey.

STUDY DESIGN

We conducted a cross-sectional study of 5,521 public health insurance-eligible children and adolescents and their parents to examine the effects of insurance (family coverage, child-only coverage, and no coverage) on measures of health care access and utilization including emergency room visits and hospitalizations.

DATA COLLECTION

We linked the CHIS adult, child, and adolescent datasets, including the adolescent insurance supplement.

FINDINGS

Among the sampled children, 13 percent were uninsured as were 22 percent of their parents. Children without insurance coverage were more likely than children with child-only coverage to lack a usual source of care and to have decreased use of health care. Children with child-only coverage fared worse than those with family coverage on almost every access indicator, but service utilization was comparable.

CONCLUSIONS

While extending public benefits to parents of children eligible for Healthy Families may not improve child health care utilization beyond the gains that would be obtained by exclusively insuring the children, family coverage would likely improve access to a regular source of care and private sector providers, and reduce perceived discrimination and breaks in coverage. These advantages should be considered by states that are weighing the benefits of expanding health insurance to parents.

Health status and health service access and use among children in U.S. immigrant families

OBJECTIVES

We examined the health status and patterns of health care use of children in US immigrant families.

METHODS

Data from the 1999 National Survey of America's Families were used to create 3 subgroups of immigrant children: US-born children with noncitizen parents, foreign-born children who were naturalized US citizens, and foreign-born children with noncitizen parents. Chi-square and logistic regression analyses were used to examine relationships between immigrant status and health access variables. Subgroup analyses were conducted with low-income families.

RESULTS

Foreign-born noncitizen children were 4 times more likely than children from native families to lack health insurance coverage and to have not visited a mental health specialist in the preceding year. They were 40% and 80% more likely to have not visited a doctor or dentist in the previous year and twice as likely to lack a usual source of care. US-born children with noncitizen parents were also at a disadvantage in many of these aspects of care.

CONCLUSIONS

We found that, overall, children from immigrant families were in worse physical health than children from non-immigrant families and used health care services at a significantly lower frequency.

The health status of southern children: a neglected regional disparity

PURPOSE

Great variations exist in child health outcomes among states in the United States, with southern states consistently ranked among the lowest in the country. Investigation of the geographical distribution of children's health status and the regional factors contributing to these outcomes has been neglected. We attempted to identify the degree to which region of residence may be linked to health outcomes for children with the specific aim of determining whether living in the southern region of the United States is adversely associated with children's health status.

METHODS

A child health index (CHI) that ranked each state in the United States was computed by using state-specific composite scores generated from outcome measures for a number of indicators of child health. Five indicators for physical health were chosen (percent low birth weight infants, infant mortality rate, child death rate, teen death rate, and teen birth rates) based on their historic and routine use to define health outcomes in children. Indicators were calculated as rates or percentages. Standard scores were calculated for each state for each health indicator by subtracting the mean of the measures for all states from the observed measure for each state. Indicators related to social and economic status were considered to be variables that impact physical health, as opposed to indicators of physical health, and therefore were not used to generate the composite child health score. These variables were subsequently examined in this study as potential confounding variables. Mapping was used to redefine regional groupings of states, and parametric tests (2-sample t test, analysis of means, and analysis-of-variance F tests) were used to compare the means of the CHI scores for the regional groupings and test for statistical significance. Multiple-regression analysis computed the relationship of region, social and economic indicators, and race to the CHI. Simple linear-regression analyses were used to assess the individual effect of each indicator.

RESULTS

A geographic region of contiguous states, characterized by their poor child health outcomes relative to other states and regions of the United States, exists within the "Deep South" (Mississippi, Louisiana, Arkansas, Tennessee, Alabama, Georgia, North Carolina, South Carolina, and Florida). This Deep-South region is statistically different in CHI scores from the US Census Bureau-defined grouping of states in the South. The mean of CHI scores for the Deep-South region was >1 SD below the mean of CHI scores for all states. In contrast, the CHI score means for each of the other 3 regions were all above the overall mean of CHI scores for all states. Regression analysis showed that living in the Deep-South region is a stronger predictor of poor child health outcomes than other consistently collected and reported variables commonly used to predict children's health.

CONCLUSIONS

The findings of this study indicate that region of residence in the United States is statistically related to important measures of children's health and may be among the most powerful predictors of child health outcomes and disparities. This clarification of the poorer health status of children living in the Deep South through spatial analysis is an essential first step for developing a better understanding of variations in the health of children. Similar to early epidemiology work linking geographic boundaries to disease, discovering the mechanisms/pathways/causes by which region influences health outcomes is a critical step in addressing disparities and inequities in child health and one that is an important and fertile area for future research. The reasons for these disparities may be complex and synergistically related to various economic, political, social, cultural, and perhaps even environmental (physical) factors in the region. This research will require the use and development of new approaches and applications of spatial analysis to develop insights into the societal, environmental, and historical determinants of child health that have been neglected in previous child health outcomes and policy research. The public policy implications of the findings in this study are substantial. Few, if any, policies identify these children as a high-risk group on the basis of their region of residence. A better understanding of the depth and breadth of disparities in health, education, and other social outcomes among and within regions of the United States is necessary for the generation of policies that enable policy makers to address and mitigate the factors that influence these disparities. Defining and clarifying the regional boundaries is also necessary to better inform public policy decisions related to resource allocation and the prevention and/or mitigation of the effects of region on child health. The identification of the Deep South as a clearly defined subregion of the Census Bureau's regional definition of the South suggests the need to use more culturally and socially relevant boundaries than the Census Bureau regions when analyzing regional data for policy development.

Continuity of Health Insurance Coverage for Children with Special Health Care Needs

OBJECTIVES

To assess the continuity of health insurance coverage and its associated factors for children with special health care needs (CSHCN).

METHODS

Logistic regression and proportional hazard models were estimated on monthly insurance enrollment for 5594 children in the 1996 Medical Expenditure Panel Survey. CSHCN were identified using a non-categorical approach. Stratified analyses were conducted to determine whether any characteristics differentiated the effects of CSHCN status on children's coverage.

RESULTS

In 1996, more than 8% of CSHCN were uninsured for the entire year. For those who were insured in January 1996, 14% lost their coverage by December 1996. CSHCN were more likely than other children to be insured (92% vs. 89%), mainly due to their better access to public insurance (35% vs. 23%). Conversely, CSHCN were less likely than other children to stay insured if they were school-aged, non-Hispanic White, from working, low-income families or the US Midwest region. Higher parental education improved health insurance enrollment for CSHCN, whereas higher family income or having activity limitations protected them from losing coverage. Regardless of CSHCN status, being publicly insured was associated with a higher risk of losing coverage for children.

CONCLUSIONS

Despite increased health care needs, a considerable proportion of CSHCN is unable to access or maintain coverage. Compared to other children, CSHCN are more likely to have coverage but no more likely to stay insured. Improving continuity of coverage for publicly insured children is needed, especially CSHCN who are more likely to obtain their coverage through public programs.

Overcoming the Odds: Access to Care for Immigrant Children in Working Poor Families in California

OBJECTIVES

To explore the extent to which, among working poor families, uninsured immigrant children experience more barriers to care than uninsured nonimmigrants, and compare these differences to those of insured children.

METHODS

We used data from the 2001 California Health Interview Survey, a randomized, population-based telephone survey conducted from November 2000 through September 2001. Financial and nonfinancial access to health care and utilization of health services were examined for 3,978 nonimmigrant and 462 immigrant children and adolescents under the age of 18 years. We compared differences in crude rates across four subgroups (insured immigrants, uninsured immigrants, insured nonimmigrants, uninsured nonimmigrants) and in adjusted models controlling for socioeconomic and immigration characteristics, parental language, health status, and other demographic factors.

RESULTS

More immigrant than nonimmigrant children lacked health insurance at the time of the interview (44% vs. 17%, p < 0.0001). Among the uninsured, immigrants had higher odds of perceiving discrimination (11% vs. 5%, p < 0.05) and postponing emergency room (ER) (16% vs. 7%, p < 0.05) and dental care (40% vs. 30%, p < 0.05) after controlling for covariates. Among the insured, immigrants fared worse on almost every access and utilization outcome. Among insured immigrants, child and parent undocumented status and having a non-English-speaking parent contributed to missed physician and ER visits.

CONCLUSIONS

Disparities in access and use remain for immigrant poor children despite public insurance eligibility expansions. Insurance does not guarantee equitable health care access and use for undocumented children. Financial and nonfinancial barriers to health care for immigrant children must be removed if we are to address disparities among minority children.

Parental awareness of health and community resources among immigrant families

OBJECTIVES

To examine the association between parental immigrant status and awareness of health and community resources to help address common family problems.

METHODS

Using the 1999 National Survey of America's Families, a survey of the health, economic, and social characteristics of children and adults, bivariate and multivariate analyses were conducted on 35,938 children to examine the relationship between parents' immigrant status (U.S.-born citizens, naturalized citizens, and noncitizens) and their responses to questions about their awareness of specific health and community resources.

RESULTS

Compared to U.S.-born citizens, noncitizens were at the highest risk of not being aware of health and community resources for most outcomes, followed by naturalized citizens. The services of which noncitizens were most likely to be unaware were places to get help for family discord, child care issues, and family violence. Multivariate analyses indicate that parental race/ethnicity, education level, employment status, and child age were other significant independent risk factors.

CONCLUSIONS

Immigrant parents are at particularly high risk of alienation from systems of health care and support services that are available to low-income and other vulnerable populations in the United States. These findings clearly document disparate awareness among parents of different immigrant status. Community and health resources should reach out to immigrant populations, in linguistically and culturally appropriate ways, to alert them to the availability of their services.

Importance of generational status in examining access to and utilization of health care services by Mexican American children

OBJECTIVES

To describe the sociodemographic differences among Mexican American children (first, second, and third generation), non-Hispanic black children, and non-Hispanic white children; to compare the health status and health care needs of Mexican American children (first, second, and third generation) with those of non-Hispanic black children and non-Hispanic white children; and to determine whether first-generation Mexican American children have poorer health care access and utilization than do non-Hispanic white children, after controlling for health insurance status and socioeconomic status.

METHODS

The Third National Health and Nutrition Examination Survey was used to create a sample of 4372 Mexican American children (divided into 3 generational groups), 4138 non-Hispanic black children, and 4594 non-Hispanic white children, 2 months to 16 years of age. We compared parent/caregiver reports of health status and needs (perceived health of the child and reported illnesses), health care access (usual source of health care and specific provider), and health care utilization (contact with a physician within the past year, use of prescription medications, physician visit because of earache/infection, and hearing and vision screenings) for different subgroups within the sample.

RESULTS

More than two thirds of first-generation Mexican American children were poor and uninsured and had parents with low educational attainment. More than one fourth of first-generation children were perceived as having poor or fair health, despite experiencing similar or better rates of illnesses, compared with other children. Almost one half of first-generation Mexican American children had not seen a doctor in the past year, compared with one fourth or less for other groups. Health care needs among first-generation Mexican American children were lower, on the basis of reported illnesses, but perceived health status was worse than for all other groups. After controlling for health insurance coverage and socioeconomic status, first-generation Mexican American children and non-Hispanic black children were less likely than non-Hispanic white children to have a usual source of care, to have a specific provider, or to have seen or talked with a physician in the past year.

CONCLUSIONS

Of the 3 groups of children, Mexican American children had the least health care access and utilization, even after controlling for socioeconomic status and health insurance status. Our findings showed that Mexican American children had much lower levels of access and utilization than previously reported for Hispanic children on the whole. As a subgroup, first-generation Mexican American children fared substantially worse than second- or third-generation children. The discrepancy between poor perceived health status and lower rates of reported illnesses in the first-generation group leads to questions regarding generalized application of the "epidemiologic paradox." Given the overall growth of the Hispanic population in the United States and the relative growth of individual immigrant subgroups, the identification of subgroups in need is essential for the development of effective research and policy. Furthermore, taking generational status into account is likely to be revealing with respect to disparities in access to and utilization of pediatric services.

Delayed or forgone care among children with special health care needs: an analysis of the 2001 National Survey of Children with Special Health Care Needs

OBJECTIVE

To examine the associations of sociodemographic characteristics with both the prevalence and the causes of delayed or forgone care in a nationally representative sample of children with special health care needs.

METHODS

Data were abstracted from the 2001 National Survey of Children with Special Health Care Needs. The families of children with special health care needs (CSHCN) who reported delayed or forgone care were asked about the reasons. The 12 reasons in the questionnaire were grouped into 5 categories. Bivariate and multivariate logistic regression analyses were conducted in SUDAAN to examine the relationship between sociodemographic characteristics of CSHCN and the incidence of delayed or forgone care by its reasons.

RESULTS

Nearly 10% of CSHCN had experienced delayed or forgone health care in the past 12 months in 2001. Logistic regression showed that delayed or forgone care was more likely to be reported by the families of CSHCN who were adolescents, who had more severe limitations, lived in the South or West, lacked medical insurance, and who lived in families under or near the federal poverty line. Hispanics were more likely to report "lack of medical specialty" and "had language, communication, or cultural problems with provider." Both Hispanics and non-Hispanic others were twice as likely to report "provider not accessible" as reasons for the delayed or forgone care compared with non-Hispanic whites or blacks. conclusion: CSHCN with certain socioeconomic status and sociodemographic characteristics, as well as those with severe limitations in activity, were more likely to be affected by circumstances that result in delayed or forgone care.

Health Care for Children and Youth in the United States: Annual Report on Patterns of Coverage, Utilization, Quality, and Expenditures by Income

OBJECTIVES

To examine differences by income in insurance coverage, health care utilization, expenditures, and quality of care for children in the United States.

METHODS

Two national health care databases serve as the sources of data for this report: the 2000-2002 Medical Expenditure Panel Survey (MEPS) and the 2001 Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). In the MEPS analyses, low income is defined as less than 200% of the federal poverty level and higher income is defined as 200% of the federal poverty level or more. For the HCUP analyses, median household income for the patient's zip code of residence is used to assign community-level income to individual hospitalizations.

RESULTS

Coverage. Children from low-income families were more likely than children from middle-high-income families to be uninsured (13.0% vs 5.8%) or covered by public insurance (50.8% vs 7.3%), and less likely to be privately insured (36.2% vs 87.0%). Utilization. Children from low-income families were less likely to have had a medical office visit or a dental visit than children from middle-high-income families (63.7% vs 76.5% for office-based visits and 28.8% vs 51.4% for dental visits) and less likely to have medicines prescribed (45.1% vs 56.4%) or have utilized hospital outpatient services (5.2% vs 7.0%), but more likely to have made trips to the emergency department (14.6% vs 11.4%). Although low-income children comprise almost 40% of the child population, one quarter of total medical expenditures were for these children. Hospital Discharges. Significant differences by community-level income occurred in specific characteristics of hospitalizations, including admissions through the emergency department, expected payer, mean total charges per day, and reasons for hospital admission. Leading reasons for admission varied by income within and across age groups. Quality. Low-income children were more likely than middle-high-income children to have their parents report a big problem getting necessary care (2.4% vs 1.0%) and getting a referral to a specialist (11.5% vs 5.3%). Low-income children were at least twice as likely as middle-high-income children to have their parents report that health providers never/sometimes listened carefully to them (10.0% vs 5.1%), explained things clearly to the parents (9.6% vs 3.4%), and showed respect for what the parents had to say (9.2% vs 4.2%). Children from families with lower community-level incomes were more likely to experience ambulatory-sensitive hospitalizations. Racial/Ethnic Differences Between Income Groups. Use and expenditure patterns for most services were not significantly different between low- and middle-high-income black children and were lower than those for white children.

CONCLUSIONS

While health insurance coverage is still an important factor in obtaining health care, the data suggest that efforts beyond coverage may be needed to improve access and quality for low-income children overall and for children who are racial and ethnic minorities, regardless of income.

Assuring the health of immigrants: what the leading health indicators tell us

Over the past 20 years, the United States has experienced one of the largest waves of immigration in its history. Understanding the health status and needs of immigrants is important because of their growing numbers and their contribution to the health of the nation, but it is challenging because of gaps in national databases, the heterogeneity of immigrant populations, and uncertainty about how migration affects health. Healthy People 2010 outlines the nation's public health objectives for the current decade. It includes ten leading health indicators (LHIs) chosen because of their importance as public health issues, their ability to motivate action, and the availability of data to measure their progress. In this paper, we discuss the health of immigrants from the perspective of these LHIs, as they provide a framework for anticipating some of the future health needs of immigrants and help define priority areas for research and action.

Health status and health services utilization among US Chinese, Asian Indian, Filipino, and other Asian/Pacific Islander Children

OBJECTIVE

This study examines the health status and health services access and utilization characteristics of US Chinese, Asian Indian, Filipino, other Asian/Pacific Islander (API), and non-Hispanic white children by using nationally representative data.

METHODS

We analyzed the aggregated data file from the National Health Interview Survey from 1997 to 2000 including 334 Chinese, 287 Asian Indian, 292 Filipino, 696 "other API," and 29,016 non-Hispanic white children <18 years old. Bivariate and multivariate analyses were conducted to examine the relationship between Asian ethnicities and dependent variables including components of health status, health services access, and utilization.

RESULTS

Logistic regression reveals that all Asian American children were less likely to miss school because of illness or injury or have learning disabilities compared with non-Hispanic whites. Other APIs were less likely to be taking prescription medication for at least 3 months, and Asian Indian children were half as likely to have chronic conditions. Chinese, Filipino, and other API children were more likely to be without contact with a health professional within the past 12 months. Citizenship/nativity status, maternal education attainment, and poverty status were all significant independent risk factors for health care access and utilization.

CONCLUSIONS

Asian ethnicities and being foreign-born are generally associated with more favorable health status measures such as school absence, learning disability, use of prescription medications, and chronic conditions. However, these attributes are negatively associated with health care access and utilization, suggesting the need for outreach to Asian immigrant populations to educate them on accessing the US health care system.

Legal, financial, and ethical ambiguities for Mexican American families: caring for children with chronic conditions

The author reports findings from a study about experiences of 17 Mexican American families caring for children with serious chronic conditions. Legal, financial, and ethical ambiguities arose when parents' desire to provide necessary care for their children and providers' professional commitment to offer this care conflicted with United States laws, including welfare reform initiatives, requiring providers to determine eligibility before providing care to immigrants and to report undocumented care seekers to authorities. Families frequently felt intimidated because health care systems are complex, and legal residency status often varied among family members. Findings imply that official policy and education of family members should aim to assure that children with chronic conditions receive needed services without relying on providers to enforce immigration laws.

[Profile of the hospital case mix of the immigrant population in Barcelona, Spain]

OBJECTIVE

Although the immigrant population in cities such as Barcelona has tripled in the last five years, until now the impact of this group on the health system has not been rigorously evaluated. The aim of this study was to compare hospital resource utilization among the immigrant population with that among the native population through case mix, demographic characteristics and hospital day use. MATERIAL AMD METHODS: We analyzed 15,057 discharges from Hospital del Mar in Barcelona in 2000. This hospital attends 60% of admissions from the Ciutat Vella district. In 2000, 21% of the population of this district were immigrants. Socio-demographic patient characteristics and case mix were compared between the immigrant and the native population. Hospital resource use was compared according to age, case mix (diagnosis related groups) and seriousness (severity, complications and comorbidities) of the events requiring medical care.

RESULTS

The case mix of the immigrant population differed from that of the autochthonous population due to pronounced ge differences and a higher fertility rate. Thirty-three percent of immigrant admissions were for deliveries. The mean cost of discharge of immigrants from low-income countries was 30% lower than that for the remaining discharges. After adjusting for age, case mix and severity, length of stay among the immigrant population was significantly shorter. A 5% reduction was found after adjusting for case mix and a 10% reduction was found when all the factors were considered.

CONCLUSIONS

Case mix differences are due to age and socio-cultural factors. Immigrants are rejuvenating the ageing native population and the role of gynecology-obstetrics and pediatrics needs to be increased. The finding that resource use per discharge is lower among immigrants from low-income countries contradicts the expectation that lower socioeconomic status leads to higher hospital resource use intensity. Therefore, new hypotheses and analyses that explain this situation should be put forward.