Health care for Latino children: impact of child and parental birthplace on insurance status and access to health services

The association of maternal country/region of origin and nativity with infant mortality rate among Hispanic preterm infants

OBJECTIVES

Among US-born preterm infants of Hispanic mothers, we analyzed the unadjusted and adjusted infant mortality rate (IMR) by country/region of origin and maternal nativity status.

STUDY DESIGN

Using linked national US birth and death certificate data (2005-2014), we examined preterm infants of Hispanic mothers by subgroup and nativity. Clinical and sociodemographic covariates were included and the main outcome was death in the first year of life.

RESULTS

In our cohort of 891,216 preterm Hispanic infants, we demonstrated different rates of infant mortality by country and region of origin, but no difference between infants of Hispanic mothers who were US vs. foreign-born.

CONCLUSION

These findings highlight the need to disaggregate the heterogenous Hispanic birthing population into regional and national origin groups to better understand unique factors associated with adverse perinatal outcomes in order to develop more targeted interventions for these subgroups.

Hypothesized Explanations for the Observed Lung Cancer Survival Benefit Among Hispanics/Latinos in the United States

Hispanic/Latino ethnicity is associated with improved survival from non-small cell lung cancer compared to that for non-Hispanic Whites even though Hispanics/Latinos are more likely to potentially have inferior access-to-care and experience greater health disparities. To this end, we conducted a literature review to identify possible explanations for this survival benefit, including the role of chronic obstructive pulmonary disease and cardiovascular diseases, genetic variation, cultural influences, and immigration factors. Overall, intermittent smoking patterns, genetic variation, co-morbidities, and cultural influences were all factors likely to partially explain this survival benefit. On the other hand, immigration factors, acculturation, and access-to-care were less likely to support the survival advantage. Future research should analyze relevant Hispanic/Latino subgroups (e.g., Mexican, Puerto Rican, Cuban, Dominican, Central American, South American) and specifically focus on the relationship between Hispanic/Latino ethnicity and different lung cancer subtypes. If the Hispanic/Latino mortality benefit observed in lung cancer truly exists, a better understanding of the underlying mechanism(s) may help extend these benefits to other ethnic and racial groups.

Exploring Latinidad, Migration Processes, and Immigrant Experiences: Experiences Influencing Latino Health

INTRODUCTION

Over the last few decades, Latino migration to the U.S. has re-shaped the ethnic composition of the country, and influenced the meaning of "ethnic" and "racial" identity. The purpose of this qualitative study was to explore the definition and meaning of being Latino and how this may guide the development of interventions to promote their health.

METHODS

Twenty-six Latino immigrants living in Kansas completed a socio-demographic survey and semi-structured interviews to assess and explore personal immigration experiences and perspectives on the meaning of being Latino in the U.S.

RESULTS

Participant reports were grouped into eight themes on Latino identity that were organized by geographic origin, family roots/ties, and acculturation. Immigration experiences were described as both positive and negative with most participants experiencing discrimination and loneliness, but also reports of improved quality of life. Further, most participants reported a strong sense of Latinidad; that Latino immigrant communities in the U.S. are interdependent and supportive of each other.

CONCLUSIONS

The experience of being a member of a minority group might contribute to the development of a cohesive sense of Latino identity as participants acculturate to the U.S. while preserving a sense of attachment to their culture of origin. Future interventions should be sensitive to migration experiences as they might influence changes in health behaviors.

A Realist Synthesis of Literature Informing Programme Theories for Well Child Care in Primary Health Systems of Developed Economies

INTRODUCTION

Well-child Care is the provision of preventative health care services for children and their families. The approach, however, to the universal provision of those services is contentious.

METHODS

We undertook a realist synthesis to enhance understanding of the theoretical mechanisms driving Well-child Care by searching for published and grey literature from multiple databases.

FINDINGS

Well-child Care is re-conceptualised as an integrated program delivered in the continuum of pregnancy, infancy and childhood. Depending on the context, Well-child Care can be a policy, a strategy, or an actual clinical practice that promotes child and family health. The main mechanisms include: role, training and continuity of health providers; administrators' views of the return of investment on achieved outcomes; access to services by families; and the adaptation of programs to meet the dynamic needs of stakeholders. Evidence indicates that for most outcomes, Well-child Care is best delivered in partnerships between community health, social care, and early childhood education sectors.

CONCLUSIONS

We conclude that Well-child Care policy and program leaders should shift their focus to the integration of: human and physical resources; policy instruments; and shared agreement on outcomes measures across health, social and education sectors. In addition, countries should work towards strengthening universal early education programs and parents' health literacy regarding child development, health and safety.

Parent-Teen Communication about Sexual and Reproductive Health: Cohort Differences by Race/Ethnicity and Nativity

Parent-teen discussions about sexual and reproductive health (SRH) are associated with delayed sex and higher contraceptive use among teens. Using the National Survey of Family Growth, we conducted bivariate and multivariate analyses of different types of parent-teen SRH discussions among two cohorts of teens. We describe differences in patterns for males and females by race/ethnicity and nativity, and test for racial/ethnic interactions within each cohort. Analyses found that the prevalence of parent-teen discussions about SRH increased across cohorts. For males and females, there were increases in parent-teen discussions about condoms, and for males only, there were increases in any SRH discussions and discussions about contraception and STIs. Based on interactions, parent-teen discussions and STI discussions increased most for Hispanic females, and among Hispanics, increased most for the foreign-born. These data indicate increases in different types of parent-teen SRH discussions, particularly for males and foreign-born teens overall, and for Hispanic teen females regarding condom use. Future research should examine what factors are driving these changes, including changes in the structure of U.S. Hispanic communities and expansion of evidence-based teen pregnancy prevention programs.

Intra-Ethnic Coverage Disparities among Latinos and the Effects of Health Reform

OBJECTIVE

To examine the patterns of insurance coverage among nine Latino subgroups and assess heterogeneous effects of the Affordable Care Act (ACA) among these groups.

DATA SOURCES

American Community Survey (2010-2014).

STUDY DESIGN

We examined pre-ACA disparities in coverage using linear probability models. Then, we used interrupted time series and triple-difference models to evaluate coverage changes associated with the ACA and Medicaid expansion, respectively.

PRINCIPAL FINDINGS

Pre-ACA coverage disparities between Latino subgroups were nearly 30 percentage points-larger than the gap between whites and Latinos as a whole. Coverage changes associated with the ACA and Medicaid expansion differed significantly between subgroups, with the largest gains among South Americans, Central Americans, and Mexicans.

CONCLUSIONS

Latino subgroups show marked heterogeneity in baseline coverage rates and responses to the ACA.

Insurance Coverage and Well-Child Visits Improved for Youth Under the Affordable Care Act, but Latino Youth Still Lag Behind

OBJECTIVE

To examine whether there have been changes in insurance coverage and health care utilization for youth before and after the national implementation of the Patient Protection and Affordable Care Act (ACA) and to assess whether racial and ethnic inequities have improved.

METHODS

Data are from 64,565 youth (ages 0-17 years) participants in the 2011 to 2015 National Health Interview Survey. We conducted multivariate logistic regression analyses to determine how the period after national implementation of the ACA (years 2011-2013 vs years 2014-2015) was associated with health insurance coverage and utilization of health care services (well-child visits, having visited an emergency department, and having visited a physician, all in the past 12 months), and whether changes over the pre- and post-ACA periods varied according to race and Latino ethnicity.

RESULTS

The post-ACA period was associated with improvements in insurance coverage and well-child visits for all youth. Latino youth had the largest absolute gain in insurance coverage; however, they continued to have the highest proportion of uninsurance post national ACA implementation. With regard to health care equity, non-Latino black youth were less likely to be uninsured and Latino youth had no significant improvements in insurance coverage relative to non-Latino white youth after national ACA implementation. Inequities in health care utilization for non-Latino black and Latino youth relative to non-Latino white youth did not improve.

CONCLUSIONS

Insurance coverage and well-child visits have significantly improved for all youth since passage of the ACA, but inequities persist, especially for Latino youth.

Why Employed Latinos Lack Health Insurance: A Study in California

This article assesses the relative importance of several factors believed to reduce the likelihood of health insurance coverage among working Latinos in California, including cost, immigration history, availability of insurance, beliefs about insurance, and beliefs about health and health care. According to a survey of 1,000 randomly selected adults, the most prominent factors contributing to working Latinos’ lack of health insurance include low income, absence of or ineligibility for a planat work, birth outside the United States, and recent immigration. Although the availability of affordable plans plays a predominant role, the importance of potentially inaccurate perceptions of the cost of health insurance and unidentified factors associated with recent immigration may also be important in some segments of the population. Maintenance and redesign of employer-provided or public insurance programs seem essential for increasing health insurance among working Latinos, as may be encouragement of low-cost clinics in some Latino communities.

Emergency Department Use Among Hispanic Adults: The Role of Acculturation

OBJECTIVES

We provide the first known examination of differences in nonurgent and urgent emergency department (ED) usage between Hispanic and non-Hispanic white individuals, with varying levels of acculturation.

MATERIALS AND METHODS

We pooled cross-sectional data for Hispanic and non-Hispanic white adults (ages 18-64) from the 2011 to 2013 National Health Interview Surveys. Using logistic regression models, we examined differences in past-year ED use, urgent ED use, and nonurgent ED use by acculturation level, which we measure by combining information on respondents' citizenship status, birthplace, and length of stay (immigrants <5, 5-10, >10 y in the United States; naturalized citizens; US born).

RESULTS

Overall, 17.8% of Hispanic individuals and 18.5% of non-Hispanic white individuals use the ED annually. Compared with US-born non-Hispanic white individuals, the least acculturated Hispanic individuals are 14.4% points (P<0.001) less likely to use the ED for any reason, 9.8% points (P<0.001) less likely to use it for a nonurgent reason, and 5.3% points (P<0.01) less likely to use it for an urgent reason.

CONCLUSIONS

Contrary to popular perception, the least acculturated Hispanic individuals are the least likely to use the ED. As acculturation level rises, so does one's likelihood of using the ED, particularly for nonurgent visits.

The Hispanic health paradox across generations: the relationship of child generational status and citizenship with health outcomes

OBJECTIVES

In examining the Hispanic health paradox, researchers rarely determine if the paradox persists across immigrant generations. This study examines immigrant respiratory health disparities among Hispanic children in terms of current asthma, bronchitis, and allergies using an expanded six-group immigrant cohort framework that includes citizenship and the fourth-plus generation.

STUDY DESIGN

Cross-sectional primary survey data from 1568 caretakers of Hispanic schoolchildren in El Paso, Texas (USA), were utilized.

METHODS

Data were analyzed using generalized linear models.

RESULTS

Results indicate that a healthy immigrant advantage lasts until the 2.5 generation for bronchitis and allergies (P < 0.05), and until the third generation for asthma (P < 0.10). Citizenship was not an influence on the likelihood of a child having a respiratory health condition.

CONCLUSIONS

Findings demonstrate the utility of the expanded six-group cohort framework for examining intergenerational patterns in health conditions among immigrant groups.

The Durability of Immigration-Related Barriers to Health Care Access for Hispanics Across Generations

Conventional manners of operationalizing generational status in studies of health care access in the United States implicitly assume that individuals assimilate into U.S. culture by the 3rd generation. This limits understandings of immigrant health care access as it remains unknown if disparities persist beyond the 3rd generation. Survey data from caretakers of Hispanic schoolchildren in El Paso (Texas, USA; n = 1,568) were utilized in generalized linear models to analyze relationships between immigrant generational status and access to health care. Results showed that higher immigrant generations had better access to care. The greatest disparities between consecutive generational groups occurred between 1st generation noncitizens/naturalized citizens, the 2.5/3rd generations, and the 3rd/4th generations. Results reveal greater durability of barriers in access to health care than has previously been documented.

Parental immigration status is associated with children's health care utilization: findings from the 2003 new immigrant survey of US legal permanent residents

Our objective was to examine the association between parental immigration status and child health and health care utilization. Using data from a national sample of immigrant adults who had recently become legal permanent residents (LPR), children (n = 2,170) were categorized according to their parents' immigration status prior to LPR: legalized, mixed-status, refugee, temporary resident, or undocumented. Logistic regression with generalized estimating equations was used to compare child health and health care utilization by parental immigration status over the prior 12 months. Nearly all children in the sample were reported to be in good to excellent health. Children whose parents had been undocumented were least likely to have had an illness that was reported to have required medical attention (5.4 %). Children whose parents had been either undocumented or temporary residents were most likely to have a delayed preventive annual exam (18.2 and 18.7 %, respectively). Delayed dental care was most common among children whose parents had come to the US as refugees (29.1 %). Differences in the preventive annual exam remained significant after adjusting for socioeconomic characteristics. Parental immigration status before LPR was not associated with large differences in reported child health status. Parental immigration status before LPR was associated with the use of preventive annual exams and dental services. However, no group of children was consistently disadvantaged with respect to all measures.

Sociocultural issues in african american and Hispanic minorities seeking care for attention-deficit/hyperactivity disorder

OBJECTIVE

To review the sociocultural factors that may affect the diagnosis and management of attention-deficit/hyperactivity disorder (ADHD) in African American and Hispanic minorities seen in the primary care setting in the United States.

DATA SOURCES

Searches on MEDLINE and PubMed were conducted in April and September 2012 on ADHD and its related problems and disabilities. A general search was conducted using the terms (attention deficit hyperactivity disorder OR attention deficit/hyperactivity disorder OR ADHD OR AD/HD) AND (ethnicity OR cultural OR culture). Issues of particular relevance to racial and ethnic minorities utilizing health care services were researched using the string (black OR African OR Hispanic OR Latino OR minority OR racial) combined with terms relating to access, insurance, comorbidity, high-risk behavior, treatment compliance, and nonpharmacologic modalities. Searches were limited to English-language citations, and no date parameters were used. References identified as pertinent to this review were selected for citation.

STUDY SELECTION/DATA EXTRACTION

Information revealing contrasts between minorities and the US non-Hispanic white population was organized in distinct categories, such as access to medical care and insurance, cultural attitudes, and the effects of stigmatization. The authors also provide perspectives for the primary care physician from their own clinical experience.

DATA SYNTHESIS

Rates of diagnosis of in the United States are higher for non-Hispanic whites than for minorities, yet true prevalence is probably similar across racial-ethnic groups. When the stigma of mental illness is added to the challenges faced by racial/ethnic minorities or immigrant status, patients may be especially sensitive. Underuse of clinical services may reflect economic limitations on access to care, cultural attitudes toward mental illness, and the effects of real or perceived prejudice and stigmatization.

CONCLUSIONS

Primary care clinicians in the United States should seek to become more aware of cultural factors that could interfere with the recognition and management of ADHD.

The association of acculturation and health literacy, numeracy and health-related skills in Spanish-speaking caregivers of young children

Little is known about the relationship among acculturation, literacy, and health skills in Latino caregivers of young children. Latino caregivers of children < 30 months seeking primary care at four medical centers were administered measures of acculturation (SASH), functional health literacy (STOFHLA), numeracy (WRAT-3) and health-related skills (PHLAT Spanish). Child anthropomorphics and immunization status were ascertained by chart review. Caregivers (N = 184) with a median age of 27 years (IQR: 23-32) participated; 89.1% were mothers, and 97.1% had low acculturation. Lower SASH scores were significantly correlated (P < 0.01) with lower STOFHLA (ρ = 0.21), WRAT-3 (ρ = 0.25), and PHLAT Spanish scores (ρ = 0.34). SASH scores predicted PHLAT Spanish scores in a multivariable linear regression model that adjusted for the age of child, the age and gender of the caregiver, number of children in the family, the type of health insurance of the caregiver, and study site (adjusted β: 0.84, 95% CI 0.26-1.42, P = 0.005). This association was attenuated by the addition of literacy (adjusted β: 0.66, 95% CI 0.11-1.21, P = 0.02) or numeracy (adjusted β: 0.50, 95% CI -0.04-1.04, P = 0.07) into the model. There was no significant association between acculturation and up-to-date child immunizations or a weight status of overweight/obese. Lower acculturation was associated with worse health literacy and diminished ability to perform child health-related skills. Literacy and numeracy skills attenuated the association between acculturation and child health skills. These associations may help to explain some child health disparities in Latino communities.

Timely access to quality health care among Georgia children ages 4 to 17 years

We examined factors associated with children's access to quality health care, a major concern in Georgia, identified through the 2010 Title V Needs Assessment. Data from the 2007 National Survey of Children's Health were merged with the 2008 Area Resource File and Health Resources and Services Administration medically underserved area variable, and restricted to Georgia children ages 4-17 years (N = 1,397). The study outcome, access to quality health care was derived from access to care (timely utilization of preventive medical care in the previous 12 months) and quality of care (compassionate/culturally effective/family-centered care). Andersen's behavioral model of health services utilization guided independent variable selection. Analyses included Chi-square tests and multinomial logit regressions. In our study population, 32.8 % reported access to higher quality care, 24.8 % reported access to moderate quality care, 22.8 % reported access to lower quality care, and 19.6 % reported having no access. Factors positively associated with having access to higher/moderate versus lower quality care include having a usual source of care (USC) (adjusted odds ratio, AOR:3.27; 95 % confidence interval, 95 % CI 1.15-9.26), and special health care needs (AOR:2.68; 95 % CI 1.42-5.05). Lower odds of access to higher/moderate versus lower quality care were observed for non-Hispanic Black (AOR:0.31; 95 % CI 0.18-0.53) and Hispanic (AOR:0.20; 95 % CI 0.08-0.50) children compared with non-Hispanic White children and for children with all other forms of insurance coverage compared with children with continuous-adequate-private insurance. Ensuring that children have continuous, adequate insurance coverage and a USC may positively affect their access to quality health care in Georgia.

The association of child mental health conditions and parent mental health status among U.S. Children, 2007

The purpose of this study is to examine the association of child mental health conditions and parent mental health status. This study used data from the 2007 National Survey of Children's Health on 80,982 children ages 2-17. The presence of a child mental health condition was defined as a parent-reported diagnosis of at least one of seven child mental health conditions. Parent mental health was assessed via a 5-point scale. Logistic regression was used to assess the association of child mental health conditions and parent mental health status, while examining socioeconomic, parent, family, and community factors as potential effect modifiers and confounders of the association. 11.1% of children had a mental health condition (95% CI = 10.5-11.6). The prevalence of child mental health conditions increased as parent mental health status worsened. Race/ethnicity was the only significant effect modifier of the child-parent mental health association. After adjustment for confounders, the stratum-specific adjusted odds ratios (95% CI) of child mental health conditions related to a one-level decline in parent mental health were: 1.44 (1.35-1.55) for non-Hispanic whites, 1.24 (1.06-1.46) for non-Hispanic blacks, 1.04 (0.81-1.32) for Hispanics from non-immigrant families, 1.21 (0.96-1.93) for Hispanics from immigrant families, and 1.43 (1.21-1.70) for non-Hispanic other race children. The effect of parent mental health status on child mental health conditions was significant only among non-Hispanic children. Parent-focused interventions to prevent or improve child mental health conditions may be best targeted to the sub-populations for whom parent and child mental health are most strongly associated.

Generational status, health insurance, and public benefit participation among low-income Latino children

The objectives of this study were to (1) measure health insurance coverage and continuity across generational subgroups of Latino children, and (2) determine if participation in public benefit programs is associated with increased health insurance coverage and continuity. We analyzed data on 25,388 children income-eligible for public insurance from the 2003 to 2004 National Survey of Children's Health and stratified Latinos by generational status. First- and second-generation Latino children were more likely to be uninsured (58 and 19%, respectively) than third-generation children (9.5%). Second-generation Latino children were similarly likely to be currently insured by public insurance as third-generation children (61 and 62%, respectively), but less likely to have private insurance (19 and 29%, respectively). Second-generation Latino children were slightly more likely than third-generation children to have discontinuous insurance during the year (19 and 15%, respectively). Compared with children in families where English was the primary home language, children in families where English was not the primary home language had higher odds of being uninsured versus having continuous insurance coverage (OR: 2.19; 95% CI [1.33-3.62]). Among second-generation Latino children, participation in the Food Stamp (OR 0.26; 95% CI [0.14-0.48]) or Women, Infants, and Children (OR 0.40; 95% CI [0.25-0.66]) programs was associated with reduced odds of being uninsured. Insurance disparities are concentrated among first- and second-generation Latino children. For second-generation Latino children, connection to other public benefit programs may promote enrollment in public insurance.

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.

"Life grows between the rocks": Latino adolescents' and parents' perspectives on mental health stressors

Latino adolescents, an increasingly larger proportion of youth in the US, are at special risk for mental health problems, including depression and suicidal ideation. Little is known about the meaning of mental health stressors for Latino adolescents and their parents. We conducted a descriptive study to elicit Latino adolescents' and parents' perspectives regarding mental health stressors as a basis for future preventive interventions. Eight focus groups were conducted with 53 Latino participants, 2 per sub-group (boys, girls, mothers, fathers). Three categories of mental health stressors included discrimination, immigration, and familial disconnection. Findings support the need for collaborative interventions and multi-level strategies (individual, family, and community) to address stressors in Latino adolescents' experiences.

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.

Parental language and asthma among urban Hispanic children

BACKGROUND

Many Hispanics in the United States have limited English proficiency and prefer communicating in Spanish. Language barriers are known to adversely affect health care quality and outcomes.

OBJECTIVE

We explored the relationship between parent language preference in a Hispanic population and the likelihood that a child with symptoms receives a diagnosis of asthma.

METHODS

We conducted a school-based survey in 105 Chicago public and Catholic schools. Our sample included 14,177 Hispanic children 6 to 12 years of age with a parent who completed an asthma survey. Outcomes of diagnosed asthma and possible asthma (asthma symptoms without diagnosis) were assessed by using the Brief Pediatric Asthma Screen Plus instrument.

RESULTS

Overall, 12.0% of children had diagnosed asthma, and 12.7% had possible asthma. Parents of children at risk who completed the survey in English reported higher rates of asthma diagnosis compared with parents who completed it in Spanish (55.2% vs 36.3%, P < .001). Predictors of asthma diagnosis were child sex, parental language preference, parental asthma status, and other household members with asthma.

CONCLUSIONS

Parental language preference might be an important characteristic associated with childhood asthma diagnosis. Whether language itself is the key factor or the fact that language is a surrogate for other attributes of acculturation needs to be explored.

CLINICAL IMPLICATIONS

Our findings suggest that estimates of asthma among Hispanic schoolchildren might be low because of underdiagnosis among children whose parents prefer communicating in Spanish.

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.

Perceptions of mental health among recently immigrated Mexican adolescents

Rates of anxiety, depression, and suicidal ideation are high among Latino adolescents in the U.S., many of whom are immigrants. Immigration during adolescence creates risk factors for mental health problems. The purpose of this study was to explore the health-related perceptions of Mexican-origin immigrant adolescents to inform the design of culturally and developmentally appropriate mental health services. This focused ethnography was guided by Bronfenbrenner's ecological framework and symbolic interactionism. Fourteen adolescents were recruited from two non-health-based community settings. Data from one-to-one semi-structured interviews and a visual narrative project were coded and analyzed inductively. Three thematic patterns were identified: "mentally healthy," "mentally unhealthy," and "health promotion." Increased awareness of cultural influences and immigration on Latino adolescents' mental health is needed. Mental health nurses are in a unique position to educate and to influence accessibility of services.

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.

Why are Latinos the most uninsured racial/ethnic group of US children? A community-based study of risk factors for and consequences of being an uninsured Latino child

BACKGROUND

Latinos continue to be the most uninsured racial/ethnic group of US children, but not enough is known about the risk factors for and consequences of not being insured in Latino children.

OBJECTIVE

[corrected] The objective of this study was to identify the risk factors for and consequences of being uninsured in Latino children.

METHODS

A cross-sectional survey was conducted of parents at urban, predominantly Latino community sites, including supermarkets, beauty salons, and laundromats. Parents were asked 76 questions on access and health insurance.

RESULTS

Interviews were conducted of 1100 parents, 900 of whom were Latino. Uninsured Latino children were significantly more likely than insured Latino children to be older (mean age: 9 vs 7 years) and poor (89% vs 72%) and to have parents who are limited in English proficiency (86% vs 65%), non-US citizens (87% vs 64%), and both employed (35% vs 27%). Uninsured Latinos were significantly less likely than their insured counterparts to have a regular physician (84% vs 99%) and significantly more likely not to be brought in for needed medical care because of expense, lack of insurance, difficulty making appointments, inconvenient office hours, and cultural issues. In multivariable analyses, parents who are undocumented or documented immigrants, both parents working, the child's age, and the $4000 to $9999 and $15000 to $19999 family income quintiles were the only factors that were significantly associated with a child's being uninsured; neither Latino ethnicity nor any other of 6 variables were associated with being uninsured. Compared with insured Latino children, uninsured Latino children had 23 times the odds of having no regular physician and were significantly more likely not to be brought in for needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers.

CONCLUSIONS

After adjustment, parental noncitizenship, having 2 parents work, low family income, and older child age are associated with being an uninsured child, but Latino ethnicity is not. The higher prevalence of other risk factors seems to account for Latino children's high risk for being uninsured. Uninsured Latino children are significantly more likely than insured Latino children to have no regular physician and not to get needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers. These findings indicate specific high-risk populations that might benefit most from targeted Medicaid and State Child Health Insurance Program outreach and enrollment efforts.

Immigration-Based Disparities in Adolescent Girls’ Vulnerability to Dating Violence

OBJECTIVES

Little data exists on dating violence among immigrant adolescents. The present study assessed disparities in experiences of physical and sexual dating violence based on immigrant status and language spoken at home among a large representative sample of adolescent girls.

METHODS

Data from the 1997-2003 Massachusetts Youth Risk Behavior Surveys (N = 7,970) were analyzed. Adjusted logistic regression analyses were conducted among the full sample and sexually active sub-sample. To further clarify immigration-based effects, separate analyses were conducted within age and racial/ethnic groups.

RESULTS

Being an immigrant was found to be protective against dating violence (OR 0.77, CI 0.60-0.98), but not among those reporting sexual intercourse. Stratified analyses revealed important differences in these effects based on age and race/ethnicity; only immigrant girls age 16 or older (OR 0.69, CI 0.48-0.99) and Hispanic immigrant girls (ORs 0.39-0.54) reported reduced risk for dating violence as compared to their non-immigrants peers. No differences in vulnerability to dating violence were detected based on immigrant status for Asian, Black, or White adolescents in stratified analyses.

CONCLUSIONS

The social context of immigration may offer protection regarding adolescent girls' vulnerability to dating violence, but effects are not uniform across age, sexual experience, or race and ethnicity. Additional research is needed to understand how immigration, social behavior, age, race and ethnicity may interact to produce disparities in vulnerability to gender-based violence.

Public Health Insurance Enrollment among Immigrants and Nonimmigrants: Findings from the 2001 California Health Interview Survey

We examine whether adult immigrants in California had the same likelihood of having public health insurance as nonimmigrants with comparable characteristics, using 44,434 non-elderly adult samples of the 2001 California Health Interview Survey public use data. Multinomial logistic regression was used to assess the likelihood of public health insurance relative to private (employment-based or privately purchased) health insurance by generation status, controlling for individual characteristics. The outcome of interest was public health insurance among three health insurance categories: private health insurance, public health insurance, and uninsured. Both first and second generation immigrants were more likely to have public health insurance than were nonimmigrants. However, the difference vanished, when demography, socioeconomic status, health status, employment sector, and English facility were controlled for. The combined effect of lower returns to education and lower employment-based insurance offer rates seems to be the underlying cause of higher prevalence of public health insurance among ethnic minorities.

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.

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.

Disparities for Latino Children in the Timely Receipt of Medical Care

OBJECTIVE

It is not known whether Latino children, the largest minority population in the United States, experience disparities in the timeliness of their access to health care. We compared timeliness of care among Latino, white, and African American children.

METHODS

DESIGN

cross-sectional cohort from the 2000 Medical Expenditure Panel Survey.

PATIENTS

children with a usual source of care.

OUTCOME MEASURE

timeliness of care was assessed using parent reports of their child's 1) routine care, 2) illness care, 3) phone help, and 4) experiencing of a brief wait time.

ANALYSIS

multiple logistic regression was used to determine the adjusted odds of not always receiving timely medical care.

RESULTS

Four-thousand one-hundred twenty children were included. Latino children were less likely to always (P < .05) receive timely care compared with whites and African Americans, respectively, in 3 areas: routine care, phone help, and brief wait time. Multiple regression revealed decreased relative risks (RR, 95% CI) of always receiving timely medical care for Latinos in the same areas: routine care, compared with whites (0.88, 0.79-0.98) and African Americans (0.81, 0.70-0.93); phone help, compared with whites (0.84, 0.76-0.92) and African Americans (0.86, 0.76-0.960); and brief wait time, compared with whites (0.71, 0.65-0.80) and African Americans (0.81, 0.70-0.92). With parental survey language in the model, Latinos experienced decreased timeliness of care for routine care compared with African Americans (0.85, 0.72-0.98); phone help compared with whites (0.87, 0.77-0.96); and brief wait times compared with whites (0.79, 0.71-0.87).

CONCLUSIONS

Latino children experience marked disparities in obtaining timely medical care, only some of which is associated with language differences.

Acculturation and Latino health in the United States: a review of the literature and its sociopolitical context

This chapter provides an overview of the concept of acculturation and reviews existing evidence about the possible relationships between acculturation and selected health and behavioral outcomes among Latinos. The effect of acculturation on Latino health is complex and not well understood. In certain areas-substance abuse, dietary practices, and birth outcomes-there is evidence that acculturation has a negative effect and that it is associated with worse health outcomes, behaviors, or perceptions. In others-health care use and self-perceptions of health-the effect is mostly in the positive direction. Although the literature, to date, on acculturation lacks some breadth and methodological rigor, the public health significance of findings in areas in which there is enough evidence justifies public health action. We conclude with a set of general recommendations in two areas-public health practice and research-targeted to public health personnel in academia, community-based settings, and government agencies.

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.

Antibiotic use in Hispanic households, New York city

Trained interviewers visited 631 inner city households to determine community prevalence and predictors of antibiotic use. Infectious disease symptoms were reported in 911 (33.2%) of 2,743 household members in the previous 30 days: medical attention was sought by 441 (48.4%) of 911 persons, and 354 (38.9%) of 911 took antibiotics for symptoms. Reported symptoms were respiratory (68.9%), gastrointestinal (15.3%), fever (12.8%), and skin infection (2.8%). Medical attention was sought significantly more often among those with chronic illness, those born in the United States, and those with fever, runny nose, or skin infections (all p<0.05). Antibiotics were taken significantly more often among those with poor health, those who spent more time at home, and those with fever and respiratory symptoms. Interventions to promote judicious use of antibiotics must include clinicians and the public, and for the Hispanic population such interventions must also be culturally relevant and provided in Spanish.

Risk of opportunistic infection in the HAART era among HIV-infected Latinos born in the United States compared to Latinos born in Mexico and Central America

There are few studies that compare opportunistic infection (OI) rates for U.S.-born, Mexican-born, and Central American-born Latinos in the pre- or post-highly active antiretroviral therapy (HAART) era. Data on 803 Latino persons in treatment for HIV infection in Los Angeles, California, were examined to evaluate differences in risk for specific and total OIs by country of origin. In a Cox proportional hazards regression analysis that controlled for HAART use, CD4 counts, and age, U.S.-born Latino women were more likely than Central American-born Latino women to develop an OI from 1996 to 2000 (hazard ratio [HR] = 2.9, 95% confidence intervals [CIs]: 1.3, 6.5). In a Poisson regression analysis, U.S.-born Latino men and women combined were at greater risk for HIV encephalopathy (RR = 3.4, 95% CIs: 1.2, 10.0) and Kaposi's sarcoma (RR = 2.9, 95% CIs: 1.1, 7.6). In addition to underreporting that may result from the use of English-based criteria for diagnosing HIV encephalopathy among Spanish-speaking patients, these HAART era data suggest that variation in OI risk among Latinos may also be explained by acculturation factors, such as loss of social support systems and negative lifestyle changes.

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.