Health Disparities and Delayed Health care ... - Wiley Online Library

Public Health Nursing Vol. 33 No. 5, pp. 383–394 0737-1209/© 2016 Wiley Periodicals, Inc. doi: 10.1111/phn.12260

POPULATIONS

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Health Disparities and Delayed Health Care among Older Adults in California: A Perspective from Race, Ethnicity, and Immigration Yan Du, MPH, RN1 and Qingwen Xu, PhD2 1 Center for Aging, School of Medicine, Tulane University, New Orleans, Louisiana; and 2School of Social Work, Tulane University, New Orleans, Louisiana

Correspondence to: Yan Du, Center for Aging, School of Medicine, 1430 Tulane Ave, SL-12, New Orleans, LA, 70112. E-mail: [email protected]

ABSTRACT Objectives: To examine racial/ethnic/immigration disparities in health and to investigate the relationships among race/ethnic/immigration status, delayed health care, and health of the elderly. Design and Sample: Responses from 13,508 people aged 65 and above were analyzed based on the California Health Interview Survey (CHIS) 2011–2012. Measures: Key variables include race/ethnicity/immigration status, health outcome, and delayed health care. Age, gender, education, work status, and annual family income are used as covariates. Results: The findings indicate that Whites (regardless of country of birth) and U.S.-born Asians enjoy better health than Latinos, African-Americans, and Foreign-born Asians. Foreign-born Asians and foreign-born Latinos have the poorest self-reported health and mental health, respectively. Delayed use of health care is negatively associated with both self-reported health and mental health status. Conclusions: Health disparities exist among older adult populations; the combined effects of minority and immigrant status can be approximated from the results in this study. Health care accessibility and the quality of care should be promoted in minority/immigrant populations. Public health nurses have a strong potential to aide in reducing health disparities among an aging American population that continues to exhibit increasing racial/ethnic diversity. Key words: delayed health care, health disparity, older adults, race/ethnicity and immigration.

The population in the United States is aging at an unprecedented rate. In 2013, 44.7 million Americans were age 65 and over, one in seven of the U.S. population, and this number is projected to reach 98 million by 2060 (Administration on Aging [AoA], 2014). Racial and ethnic diversity is one important feature of the aging American population. In 2012, 21% of older Americans were members of a racial/ethnic minority and one in eight senior adults was foreign-born (AoA, 2013). Between 2012 and 2030, the White (not Hispanic) population 65+ is projected to increase by 54% compared with 126% for older racial and ethnic

minority populations, including Hispanics (155%), African-Americans (104%), American Indian and Native Alaskans (116%), and Asians (119%; AoA, 2013). The disparities in the health status among various groups of older Americans with diverse ethnic/ immigration status are stunning. A considerable body of literature has documented health disparities among older populations using various health indicators. Overall, older members of various minority groups, including non-Hispanic AfricanAmericans, American Indians/Alaska Natives, nonHispanic Asians, and Hispanics, are less likely to

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rate their health status as excellent or very good when compared with older non-Hispanic Whites (Min, Rhee, Lee, Rhee, & Tran, 2014). Furthermore, older immigrants reported having poorer self-rated health when compared with nonimmigrants (Heron, Schoeni, & Morales, 2003). Specifically, given the prevalence of chronic conditions in older adult populations, available literature indicates that the elderly who are members of ethnic minorities are more likely to suffer from a greater number of chronic conditions and/or disabilities. For instance, Hispanics and non-Hispanic Blacks have higher rates of obesity, when compared with non-Hispanic Whites (Fakhouri et al., 2012). According to the 2004–2007 National Health Interview Survey, the prevalence of diabetes and hypertension in Hispanics, non-Hispanic Blacks, and Asians is higher than non-Hispanic Whites (U.S. Census Bureau, 2014). In contrast, this report stated that older non-Hispanic Whites have a higher rate in heart disease than all minority groups. In addition, note that the mortality rates from heart disease and cancer, the two leading causes of death in the general American population, are highest among African-Americans (Centers for Disease Control and Prevention [CDC], 2013). When compared with non-Hispanic Whites, elderly AfricanAmericans face higher rates of difficulties related to the activities of daily living (ADL; Garrett et al., 2013). Overall, a higher rate of poor mental health was reported in older members of several minority groups. National studies reported that the incidence of major depression was more frequent in preretirement Hispanics and African-Americans when compared with non-Hispanic Whites (Dunlop, Song, Lyons, Manheim, & Chang, 2003), and levels of depressive symptoms were higher among Black women relative to White women throughout later life (Spence, Adkins, & Dupre, 2001). In addition, while the rate of suicide at a later age declines in other ethnic groups, older Asian Americans experience the greatest risk, and older Asian American women had the highest suicide rate among older women of all ethnic groups between 2005 and 2009 (Crosby, Ortega, & Stevens, 2013). Furthermore, when compared with nonimmigrant elderly, it is well documented that older adults who were immigrants have a more stressful life and poorer mental health status than nonimmigrants (Kim,

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Auh, Lee, & Ahn, 2013; Kim, Jang, Chiriboga, Ma, & Schonfeld, 2010). These racial/ethnic health disparities are believed to be the result of variations in biological characteristics, individual behavior, health services, social factors, government policies, and various interactions among these factors (U.S. Department of Health and Human Services, 2000). Race/ethnicity is a complex trait that is particularly important when examining health disparities, because it includes both biologic and social dimensions necessary to understand health outcomes. Although it is still in exploratory stage, current evidence suggests that the higher observed prevalence of obesity and diabetes in African-Americans may be partially explained by genetic variations (Waters et al., 2010; Edwards, et al., 2012; Maruthur, 2015). Studies have also consistently reported that individual behaviors, such as physical activity and diet, often interact with genetics to shape health outcomes (Edwards, et al., 2012; Maruthur, 2015). However, minorities are reported to be less likely to engage in a variety of healthy behaviors (Freedman, et al., 2011). The effects of race/ethnicity as a social dimension on health outcomes are often examined from the aspects of racial discrimination and inequality in social economic status (SES). For minorities and/or immigrants, racial discrimination and oppression is typically experienced across generations and becomes both a personal and shared experience (Tummala-Narra, 2007). Everyday discrimination is associated with greater prevalence of unhealthy behaviors such as smoking, alcohol use, and relatively poor health outcomes among the elderly (Borrell et al., 2010). Chronic exposure to discrimination may lead to the depletion of an individual’s physical and psychological reserves (Pascoe & Richman, 2009; Williams & Mohammed, 2009). More importantly, structural discrimination based on race, manifested in an unequal distribution of resource related to education, income, health care, and social services that is observed as racial and class discrimination in the United States contributes significantly to health disparities among minorities (Karlsen & Nazroo, 2002). Meanwhile, differences in SES across racial/ethnic groups have consistently been found to make a substantial contribution to ethnic disparities related to health (Williams, Mohammed, Leavell, & Collins, 2010).

Du and Xu: Race/Ethnicity/Immigration, Delayed Health care, and Health Disparities in Older Adults For example, the observed Black-White differences in physical and mental health were markedly reduced after controlling for education and especially for income (Williams, Yu, Jackson, & Anderson, 1997). The underlying mechanisms of SES that can be used to explain racial/ethnic health disparities include but limited to: a less desirable physical environment (Green & Hart-Johnson, 2012; Williams & Jackson, 2005), a lack of insurance (Freedman, et al., 2011), lower health literacy (Howard, Sentell, & Gazmararian, 2006), and less of a tendency to engage in healthy behaviors (Pampel, Krueger, & Denney, 2010). For older adults, who have a considerable number of chronic conditions and/or disabilities, health care use behavior plays a very important role for their health outcomes, and disparities in health care use have been widely studied as they relate to racial/ethnic disparities in health status (Adler & Rehkopf, 2008; Dunlop, Manheim, Song & Chang, 2002). Since the creation of Medicare in 1965, older adults have gained improved access to health care in the United States. However, disparities in access to and use of health care services have been observed along the lines of race/ethnicity, despite the nearly universal health care system for older adults (e.g., Jimenez, Bartels, Cardenas, Daliwal, & Alegrıa, 2012). Minority older adults may lack adequate access to and have full use of health care, including mental health care, because of various barriers such as a high level of distrust of physicians (e.g., Betancourt, Green, Carrillo, & Park, 2005), cultural beliefs against seeking mental health services (e.g., Jimenez et al., 2012), and a lack of health literacy and English language skills (e.g., Kim et al., 2011). However, most available studies that examined health disparities related to race/ethnicity have focused on the differences between Whites and African-Americans, while sometimes including Hispanics (Kenik, Jean-Jacques, & Feinglass, 2014; Park et al., 2012; Pinto, Schumm, Wroblewski, Kern, & McClintock, 2014). In addition, for studies that emphasize health disparities among older immigrant adults, a general lack of investigation of ‘double-disadvantage’ exists that looks at the interaction between minority and immigrant status. Moreover, timely and adequate access to and use of health care is critical to the health of the elderly (Card, Dobkin, & Maestas, 2008), but the role of

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health care use and/or its effect on health disparities across different older adult populations of minority in the United States remain unclear. Therefore, this study aims to: (1) compare health status across older U.S. adults with different race/ ethnicity and immigrant status, and (2) examine relationships among minority/immigrant status, delayed health care, and elderly health.

Methods Design and sample This study analyzed data from the California Health Interview Survey (CHIS) Adult Survey from 2011 to 2012. A total of 44,559 households in the state of California participated in the project; populationbased random-digit-dial (RDD) telephone interviews, including both landline and cellular service, were conducted that adopted a two-stage geographical sampling strategy. The CHIS (2013) reported detailed information for the sampling strategy and study design. Adults aged 65 and over, who selfreported as non-Hispanic White, Hispanic White, African-American, and Asian were included in this analysis (n = 13,508). Based on immigrant status, the sample were further divided into U.S.- and foreign-born non-Hispanic White (n = 9,507 and 852, respectively), U.S.- and foreign-born Hispanic White (n = 637 and 758, respectively), U.S.- and foreign-born Asian (n = 171 and 1,022, respectively), and U.S.- and foreign-born Black (n = 561 and 22, respectively). Foreign-born Blacks were not included in the present study because the sample size was inadequate. Measures Health status was assessed through four indicators, including self-rated health, mental health, number of chronic diseases, and activity of daily living. Selfrated health ranged from 1 to 5 where 1 refers to the best health status. Mental health status was assessed by the Kessler scale (K6), which has been widely used among researchers as an indicator of psychological distress or as a screening tool for mental illness (Drapeau et al., 2010). The K6 scale ranges from 6 to 30 with the higher score indicating a higher level of stress (Cronbach’s alpha is 0.79). Chronic disease was assessed by counting the number of chronic conditions per individual includ-

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ing diabetes, heart disease (of any kind), high blood pressure, asthma, stroke, and arthritis/lupus/gout. The ADL scale is composed of three conditions: having difficulty dressing, bathing, with mobility, having difficulties going outside the home alone, and having conditions limiting basic physical activity. Respondents answered yes/no to questions related to these conditions; the scale ranges from 0 to 3 with a higher score indicating a higher level of physical limitation (Cronbach’s alpha is 0.64). Delay in health care refers to a patient’s delay in consulting medical personnel after being aware of symptoms of an illness, or a delay of treatment for illness (Safer, Tharps, Jackson, & Leventhal, 1979). In this study, delayed health care was assessed as delayed medical care and delayed prescription. Delayed prescription was identified by responding to the question “During the past 12 months, did you delay or not get a medicine that a doctor prescribed for you?” Delayed medical care was assessed by asking “During the past 12 months, did you delay or not get any other medical care you felt you needed, such as seeing a doctor, a specialist, or other health professional?” Response categories were coded as yes = 1, and no = 0. Age, gender, level of education, annual family income, and work status were included as demographic controls. Age and annual family income were continuous variables (annual family income was log transformed to increase normality). Education level (less than high school graduate = 0, high school graduate or over = 1) and work (not work = 0, fullor part-time work = 1) were dichotomized.

Analysis strategy Bivariate analyses were performed to examine the differences across groups. Two-Step cluster analysis was conducted with the belief that major health indicators (i.e., self-rated health, K6, number of chronic diseases, and ADL) would help reveal structures concerning the health or the elderly; the results from cluster analysis, using bivariate analyses, were further used to elaborate the role that minority/immigration status played in the health of the elderly. Logistic regressions were used to assess associations between minority/immigration status and delayed health care. The study then adopted multiple linear regression models to estimate the difference of self-rated health status and mental health between minority/immigrant groups and


Whites (U.S.-born, non-Hispanic White served as the reference group), and to examine the role of delayed health care. Normality and linearity assumptions required in multivariate regression analyses were attested while multicollinearity and bivariate correlations were carried out to ensure that measures such as education, total family income, and others were not highly correlated in the models (i.e., VIF High school*** Working* Annual family income*** Delayed health care Delayed medical care Delayed prescription** Health outcomes Self-rated health*** K6*** Chronic disease*** ADL***

U.S.-born (n = 9,507) M (SD) or %

Non-Hispanic White

TABLE 1. Characteristics of Older Adults by Race/Ethnicity/Immigration Status

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negatively, were at the edge of mental health disorder (thus should be strongly encouraged to seek help from mental health professionals), reported more than two chronic diseases, and had limitation to at least one daily activity. Further results from chi-square analysis indicated, while average older adults comprised the largest section of each group, White seniors (regardless of immigration status) and U.S.-born Asians were more likely to have the superior health, and Hispanics (regardless of immigration status) and African-American seniors were more likely to have declining health than the elderly in other groups. Note that more than one third of older immigrant Hispanic and AfricanAmerican adults were in the declining group. When considering delayed health care, the results from the logistic regression models (see Table 3) further proved the observations from bivariate analyses (Table 1). Specifically, the odds of having delayed medical care for all minority/immigrant groups were greater than these odds for TABLE 2. Distribution of Health Outcomes and Race/Ethnicity/Immigration Status across Health Profile Clusters Superior Average Declining (n = 4,206) (n = 5,915) (n = 3,387) M (SD) or % M (SD) or % M (SD) or % Health outcomes Self-rated 1.63 (.62) health*** K6*** 7.29 (1.76) Chronic .64 (.61) disease*** ADL*** .04 (.20) Group composition*** U.S.-born 34.2 White Foreign-born 36.9 White U.S.-born 19.5 Hispanic Foreign-born 19.3 Hispanic U.S.-born 29.8 Asian Foreign-born 21.3 Asian U.S.-born 17.8 Africa American

2.87 (.82)

3.8 1 (.94)

7.54 (1.70) 1.93 (.87)

11.65 (4.56) 2.56 (1.24)

.31 (.46)

1.51 (.89)

42.5

23.2

42.8

20.3

49.1

31.4

42.1

38.7

58.5

11.7

50.0

28.7

46.7

35.5

Note. Clusters of health profile are based on self-rated health, K-6 scores, number of chronic diseases, and ADL. ***p ≤ .001.


U.S.-born Whites. These odds were smaller than 1 when holding all other variables as fixed; that is race/ethnicity/immigration status did not show negative relationships with delayed medical care. Note that the likelihood of having delayed medical care was 0.612 smaller for older Asian immigrant adults than for their U.S.-born White peers. Only two Hispanic groups were more likely to have delayed prescriptions when compared with U.S.born Whites; after factoring in demographic variations, the likelihood of having delayed prescriptions for the two Hispanic groups was still larger than for U.S.-born Whites but the difference was not significant. By considering self-rated health and K6 as a simple and quick assessment of overall health, linear regression models were created (see Table 4) to examine the relationships among delayed health care, race/ethnicity/immigration status, and health outcomes. Overall, minority and/or immigration status significantly influences both self-rated health and mental health. Specifically, for self-rated health, Whites (regardless of country of birth) and U.S.-born Asians reported a similar level of health status. While Model 1 suggested that negative immigration (i.e., foreign-born) effects seemed prominent for both older Hispanic and Asian adults, after factoring in the effects of delayed health care and demographics, foreign-born Asians stood out. In other words, comparing to White peers, being immigrant and Asian led to 0.592 change of health status in a 5-point scale; elderly foreign-born Hispanic and AfricanAmericans were at a relatively same level of health disadvantage when compared to their White peers. The final model (Model 3) explains 17.5% of the variation of self-rated health. From the perspective of mental health, both U.S.-born and foreign-born Whites reported similar level of psychological well-being. Interestingly, elderly U.S.-born Asians had better mental health than the reference White peers. Model 1 singled out the foreign-born Hispanic group; after adjusting for delayed health care and demographic variables, the group of older immigrant Hispanic adults was the only group who had significant poorer mental health status than their White peers. Both delayed health care indicators (i.e., delayed medical care and prescriptions) were significantly associated with self-rated health and mental health (p < .0001; Table 4). Results from Model 2s

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TABLE 3. Regression Results for Delayed Medical Care and Delayed Prescription Delayed medical care Model 1 OR (CI) Race/ethnicity/immigration Foreign-born White U.S.-born Hispanic Foreign-born Hispanic U.S.-born Asian Foreign-born Asian U.S.-born Africa American Demographics Age Female >High school Working Annual family income

.685 .864 1.022 .748 .741 1.104

(.495, .946) (.617, 1.211) (.762, 1.369) (.380, 1.470) (.554, .990) (.798, 1.527)

Delayed prescription

Model 2 OR (CI)

Model 1 OR (CI)

.696 .753 .805 .761 .612 .964

(.503, .964) (.534,1.061) (.576, 1.124) (.386, 1.500) (.452, .828) (.694, 1.339)

.955 1.260 1.243 1.193 .533

(.944, .966) (1.086, 1.462) (.954, 1.620) (.995, 1.430) (.443, .642)

.885 1.386 1.467 .514 .952 1.039

(.671, 1.168) (1.060, 1.811) (1.149, 1.872) (.240, 1.100) (.741, 1.222) (.757, 1.427)

Model 2 OR (CI) .898 1.205 1.102 .522 .783 .915

(.680, 1.186) (.917, 1.584) (.830, 1.463) (.243, 1.117) (.602, 1.018) (.664, 1.260)

.960 1.207 1.056 1.206 .575

(.950, .970) (1.053, 1.383) (.842, 1.325) (1.018, 1.428) (.484, .684)

Note. OR = odds ratio; 95% CI = 95% confidence interval. TABLE 4. Predictors of Health and Mental Health among Older Adults Self-rated health Model 1 B (SE)

Model 2 B (SE)

Race/ethnicity/immigration Foreign-born .008 (.039) .018 (.039) White U.S.-born .451*** (.083) .447*** (.045) Hispanic Foreign-born .882*** (.175) .873*** (.042) Hispanic U.S.-born .019 (.085) .034 (.084) Asian Foreign-born .923*** (.037) .931*** (.036) Asian .493*** (.048) .490*** (.048) U.S.-born AfricanAmerican Delayed health care .364*** (.038) Delayed medical care Delayed .258*** (.036) prescription Demographics Age Female >High school Working Annual family income R2adj 7.6% 8.7%

Mental health Model 3 B (SE)

Model 1 B (SE)

Model 2 B (SE)

Model 3 B (SE)

.001 (.037)

.012 (.116)

.043 (.113)

.006 (.111)

.233*** (.044)

.586*** (.133)

.564*** (.130)

.112 (.130)

.395*** (.045)

1.990*** (.124)

1.939*** (.121)

.905*** (.133)

.055 (.080)

.783** (.250)

.695** (.244)

.654** (.239)

.592*** (.036)

.454*** (.108)

.494*** (.105)

.142 (.108)

.351*** (.046)

.366* (.141)

.348* (.138)

.051 (.136)

.359*** (.037)

2.067*** (.111)

1.993*** (.109)

.249*** (.034)

1.523*** (.103)

1.451*** (.101)

.007*** .116*** .419 .312*** .625*** 17.5%

(.001) (.019) ( .419) (.026) (.026)

.016*** .222*** .035 .456*** 1.070*** 2.2%

Note. B = unstandardized coefficient; SE = stand error; R2adj = Adjusted R-square. ***p ≤ .001; **p ≤ .01; *p ≤ .05.

6.8%

10.2%

(.004) (.056) ( .973) (.076) (.076)

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suggested that delayed health care only contributed to 1.1% of the variation in self-rated health, but 4.6% of the variation in mental health. When compared to results from Model 1s and 2s, delayed health care seemed to not change the relationships between race/ethnicity/immigration and health outcomes. Nonetheless, note that having a younger age, being male, not working at all and having less family income were risk factors associated with poor mental health, and helped explain a great deal of the variation in mental health among older U.S.born Hispanic, foreign-born Asian, and AfricanAmerican adults.

Discussion This study employed various efforts to examine the concerns related to health disparities among older American adults across different race/ethnicity and immigration status groups. While the data might only be representative in the state of California, this study offered quite meaningful results for health and elder care researchers and practitioners. Results of this study did confirm the existence of health disparities based on race, ethnicity, and immigration. First, race matters. Older White adults led in almost all positive health indicators, and immigration status did not affect this group. Except for U.S.-born Asians, ethnic minority groups reported poorer self-rated health than their U.S.born White peers. While this study did not to examine the social mechanisms related to health disparities across racial and ethnic lines, given the results, we lean toward arguing that negative environmental factors—structural inequalities and/or various discrimination experience and/or acculturation—play a role throughout one’s life during which health status was shaped. Meanwhile, there is no health paradox for older Hispanics. Previous studies showed that Hispanics enjoy a greater mortality advantage compared with non-Hispanic Whites, and the advantage is greatest among older people (Markides & Eschbach, 2005); frequently, this type of health paradox is attributable to the theory of immigration selection, the idea that healthier people tend to be migrants (Anderson, Bulatao, & Cohen, 2004). However, results in this study suggested that older Hispanic adults were actually less healthy in all four health indicators, and elderly foreign-born Hispanics were


particularly vulnerable. In addition, evidence in recent years already indicates that a protracted morbidity accompanies an increase in life expectancy among Hispanic immigrants (Angel, Angel, & Hill, 2015). We would argue that simply using the mortality rate might not be helpful to understanding the full picture of healthy aging. In addition, there is no model minority elder. The model minority is always referred to the Asian American because of their relevantly higher education, income, and lower crime rates (Li & Wang, 2008). However, we found that education and income of elderly foreign-born Asians are lower than all other groups except for foreign-born Hispanics. Although health outcomes of older U.S.-born Asian adults were on a par with those of U.S.-born White peers, elderly foreign-born Asians reported the worst self-rated health among all older groups. The stereotype of model minority may lead American society and policymakers to ignore the racism and discrimination Asian Americans still face today (Wong & Halgin, 2006), and inaccurately portray Asian Americans’ health improvement as group effort and ignore structural factors. Therefore, using hard-working and self-reliant to designate a model minority is arbitrary. Moreover, the stereotype of the modern minority may hinder efforts to eliminate health disparities. Given the lack of a health paradox and model minority for older adults, we would initially conclude that Hispanic and Asian minorities continue to need additional attention. In particular, combined effects of both ethnicity and immigration influence the health of the elderly. For immigrant Hispanics and Asians, life in the United States has been subjected to additional risk factors, such as a lack of English proficiency, acculturation stress, and/or a lack of legal status, which would affect their ability to access adequate and quality health care throughout their lives (Huang, Appel, & Ai, 2011; Livingston, Minushkin, & Cohn, 2008). However, such effects are manifested in different ways for each immigrant group. We call for additional research to explore the health issues of Hispanic and Asian populations, especially for immigrants. Finally, older African-Americans in this study reported more chronic conditions and limited daily activities than any other group, and had the smallest portion of individuals with a superior health

Du and Xu: Race/Ethnicity/Immigration, Delayed Health care, and Health Disparities in Older Adults profile. The health outcomes in later life among African-Americans may reflect the health disadvantages found in this group across their life spans, including but not limited to a higher incidence of very low birth weight (Collins, David, Handler, Wall, & Andes, 2004), a higher prevalence of being overweight in adolescents (Gordon-Larsen, Adair, & Popkin, 2003), and a higher rate of chronic conditions in middle age (e.g., hypertension, diabetes; Carson et al., 2011; Sun et al., 2014; Wary, Alwn, Mccammon, Manning, & Best, 2006), which further reflects the historical oppression and long-term struggle this group has experienced in gaining equal access to health care, nutrition, education, and other social economic and political opportunities. While this study did not exam access to health care or use in a more detailed approach, we found that no large difference based on race/ethnicity/immigration for delayed medical care and prescription, especially after controlling for demographics. The nearly universal health care system available in the United States for older adults (i.e., Medicare and Medicaid) may partially explain the seemingly equal health care use observed in the present study. In addition, the high likelihood of older Hispanic adults delaying in obtaining prescriptions was eliminated when adjusting for covariates. We may argue that SES is surely significant because of the relatively high cost-sharing requirements of Medicare for covered benefits, particularly for older minority adults given their disadvantages in education, employment, and income. However, this need to be further explored. Furthermore, we note from the literature that older minorities receive a lower amount of preventive health care, such as screening services for breast, cervical, colorectal, and prostate cancer, diabetes (e.g., foot care, eye examination), and vaccinations (e.g., flu, pneumococcal; American Lung Association, 2010; Bonito, Eicheldinger, & Lenfestey, 2005). Our findings may concur to the idea that older minorities only use medical care and obtain prescriptions when get ill or injured; their overall low level of education and health literacy (Bennett et al., 2009; Paasche-Orlow & Wolf, 2010) may lead to their inadequate use of health care services. The study results also reveal that a delay of medical care and prescriptions did play an important role in health outcomes overall. However,

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these factors contributed little to health disparities across older race/ethnicity/immigrant groups. We would argue that the availability of health insurance at age 65 and above, and consequently the use of health care at a later age would not grant older adults the power to change their health trajectory which has been shaped over their entire lives. Specifically, we cannot discard the effects of health care use, the SES disadvantage, discrimination, and other factors on one’s health status before one becomes old. In addition, not only for older adults, health care use itself cannot explain health disparities for younger people (Newacheck, Hung, Jane Park, Brindis, & Irwin, 2003). Furthermore, given the understanding that race/ethnicity/immigration health disparities accumulate over time (Dowd & Bengtson, 1978; Liao, McGee, Cao, & Cooper, 2009), the delay of medical care and prescription use during the last 12 months, as used in this study, simply were not able to capture all aspects of the relationship of health outcomes and health care use behaviors. Moreover, access to and use of health care services does not guarantee quality care. Disparities in quality of care, caused by limited language proficiency, health literacy, discrimination and the health provider-patient relationship, have been widely reported among minorities (Betancourt et al., 2005; Casale, 2010). As previously reported, when compared to Whites, Asians, Blacks, and Hispanics received relatively poor quality health care for about 20%, 40%, and 60% of measures, respectively (Casale, 2010); this gap might be much wider if immigration status was taken into account. This study is not without limitations. First, given the nature of cross-sectional data, this study cannot prove or disapprove any causal associations. In addition, the findings from this study cannot be easily applied to the larger U.S. elderly population; as one of the major immigrant destination states, California has a multicultural heritage and is unique in its immigrant-friendly policies, such as providing foreign nationals with access to critical services including in-state tuition, driver’s licenses, and state-funded health care for children (Immigrantings, 2015). Meanwhile, this study aggregated data from a broad spectrum of Asian and Hispanic nationalities and thus ignored the subgroup variations that occurred between cultures and ethnicities. Lastly, all health-related information in the

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study was self-reported, which might lack the ability to capture actual health conditions.

Conclusions and Implications The findings from this study offer an overall picture of health disparities across different race/ethnicity/ immigration groups, as well as provide some preliminary results concerning delayed health care among elderly populations. Overall, health disparities exist among older ethnic and immigrant adults. Furthermore, double disadvantages related to ethnicity and immigration status exist. While researchers are making efforts to examine the detailed mechanisms behind health disparities, policy changes are urgently needed to assure the provisioning of adequate health care, including primary, secondary, and tertiary care, as well as home and community care by making health care equally accessible for minority and immigration groups of all ages. Health education that is designed to improve health literacy should emphasize communities with concentrated minority and immigrant populations. Given the growing number of community dwelling older adults, additional programs are recommended in the retirement community setting that focus on healthy behavior, beliefs, and the use of medical care. In practice, health care providers play a critical role in promoting adequate health care use and in ensuring the delivery of quality care to older clients. Public health nurses, who often work with underserved populations in communities, have a strong potential to help eliminate health disparities among different ethnic and immigrant groups. Public health nurses should recognize and understand the challenges and complexities of race/ethnicity and immigration status in their relevance to health care and health disparities, and become advocates of equal access to both high quality and adequate quantity health care for all. Raising awareness of these problems should be emphasized in nursing research, education, and throughout one’s nursing career. Cultural competence should be developed to meet the needs of our aging population that has an increasing level of ethnic and immigrant diversity.

Acknowledgment This study was supported by Tulane University COR Research Fellowship 2013-14.


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OUR HISTORY So the public health nurse must be a trained nurse skilled in the relief of suffering and the bedside care of the sick, but she must be much more. Her work is primarily that of the health teacher, the messenger who carries into the home and interprets to the individual mother the gospel of good health. She must work largely alone, not under the immediate direction of a physician. She must know her bacteriology and her physiology, her sanitation and hygiene, well enough to teach their principles to others; and she too must deal with the individual, not as an individual, but as an element in a complex social group. Winslow, C.-E. A. 1920, Jan. 9. The untilled fields of public health. Science, 31. Retrieved from https://archive.org/stream/jstor-1645011/1645011#page/n1/mode/2up