Fernando S. Mendoza

Health Disparities and Children in Immigrant Families: A Research Agenda

Children in immigrant families now comprise 1 in 5 children in the United States. Eighty percent of them are US citizens, and 53% live in mixed-citizenship families. Their families are among the poorest, least educated, least insured, and least able to access health care. Nonetheless, these children demonstrate better-than-expected health status, a finding termed “the immigrant paradox” and one suggesting that cultural health behaviors among immigrant families might be protective in some areas of health. In this article the strength of the immigrant paradox, the effect of acculturation on health, and the relationships of acculturation, enculturation, language, and literacy skills to health disparities are reviewed. The current public policy issues that affect the health disparities of children of immigrant families are presented, and a research agenda for improving our knowledge about children in immigrant families to develop effective interventions and public policies that will reduce their health disparities is set forth.

Importance of Generational Status in Examining Access to and Utilization of Health Care Services by Mexican American Children

Objectives. To describe the sociodemographic differences among Mexican American children (first, second, and third generation), non-Hispanic black children, and non-Hispanic white children; to compare the health status and health care needs of Mexican American children (first, second, and third generation) with those of non-Hispanic black children and non-Hispanic white children; and to determine whether first-generation Mexican American children have poorer health care access and utilization than do non-Hispanic white children, after controlling for health insurance status and socioeconomic status. Methods. The Third National Health and Nutrition Examination Survey was used to create a sample of 4372 Mexican American children (divided into 3 generational groups), 4138 non-Hispanic black children, and 4594 non-Hispanic white children, 2 months to 16 years of age. We compared parent/caregiver reports of health status and needs (perceived health of the child and reported illnesses), health care access (usual source of health care and specific provider), and health care utilization (contact with a physician within the past year, use of prescription medications, physician visit because of earache/infection, and hearing and vision screenings) for different subgroups within the sample. Results. More than two thirds of first-generation Mexican American children were poor and uninsured and had parents with low educational attainment. More than one fourth of first-generation children were perceived as having poor or fair health, despite experiencing similar or better rates of illnesses, compared with other children. Almost one half of first-generation Mexican American children had not seen a doctor in the past year, compared with one fourth or less for other groups. Health care needs among first-generation Mexican American children were lower, on the basis of reported illnesses, but perceived health status was worse than for all other groups. After controlling for health insurance coverage and socioeconomic status, first-generation Mexican American children and non-Hispanic black children were less likely than non-Hispanic white children to have a usual source of care, to have a specific provider, or to have seen or talked with a physician in the past year. Conclusions. Of the 3 groups of children, Mexican American children had the least health care access and utilization, even after controlling for socioeconomic status and health insurance status. Our findings showed that Mexican American children had much lower levels of access and utilization than previously reported for Hispanic children on the whole. As a subgroup, first-generation Mexican American children fared substantially worse than second- or third-generation children. The discrepancy between poor perceived health status and lower rates of reported illnesses in the first-generation group leads to questions regarding generalized application of the “epidemiologic paradox.” Given the overall growth of the Hispanic population in the United States and the relative growth of individual immigrant subgroups, the identification of subgroups in need is essential for the development of effective research and policy. Furthermore, taking generational status into account is likely to be revealing with respect to disparities in access to and utilization of pediatric services.

Associations among familism, language preference, and education in Mexican-American mothers and their children

Latino families who express a higher degree of familism are characterized by positive interpersonal familial relationships, high family unity, social support, interdependence in the completion of daily activities, and close proximity with extended family members. Retention of cultural values, such as familism, may be linked to positive health outcomes; however, little is known about how families retain culture of origin values in the face of acculturation pressures. The current study explores acculturation influences as indexed by language preference and household education on maternal and child familism. Mothers and children of Mexican descent (fourth grade students) (n = 219) completed measures of demographics, household education, language preference, and familism. Three hypotheses were examined. First, we predicted that lower household education would be correlated with higher familism scores. However, contrary to our prediction, a higher familism score was significantly associated with a higher level of household education (p < .05). Second, we predicted that higher child familism would be associated with the preference for speaking Spanish. Children who preferred to use both English and Spanish (p < .01) or English alone (p < .05) had higher familism scores than those who preferred Spanish. Third, we predicted that lower child familism scores would be associated with greater differences in mother and child language preferences. There were no significant differences in child familism based on differences between parent and child language. Protective influences of cultural maintenance deserve further attention in longitudinal studies and in relation to the physical and mental health of youth.

Children with Special Health Care Needs: How Immigrant Status is Related to Health Care Access, Health Care Utilization, and Health Status

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

Sexual maturation of Mexican-American adolescents

The Sexual maturation patterns of 1,403 Mexican‐American adolescents are described. The report is based on data from the Hispanic Health and Examination Survey (HHANES), which was carried out by the National Center for Health Statistics from 1982 to 1984. Ages of subjects ranged from 10 through 17 years. The development of secondary sexual characteristics was measured by means of a five‐stage scale for specific traits (males: Pubic hair and genitalia; females: Pubic hair and breasts) following methods proposed by Tanner. Mean ages for “being in a stage” or the average age of the children classified as belonging to each particular stage were estimated. The Spearman‐Kärber procedure was used to estimate median ages at “entry” into the various stages. Comparison of median ages at entry to results from studies around the world reveals that Mexican‐Americans begin and end puberty a few months later than is usual.

Fatness and fat distribution in Mexican-American children and youths from the Hispanic health and nutrition examination survey

Mexican‐American children are shorter but relatively heavier than non‐Hispanic white children. The excess relative weight is probably due to increased fat rather than lean body mass and, more specifically, to increased fat deposition on the upper trunk sites. The objective of this paper is to describe the level of fatness and fat distribution in a large, representative sample of Mexican‐ American children and adolescents from the recently completed Hispanic Health and Nutrition Examination Survey (HHANES). As expected, Mexican‐American children are generally fatter than white children measured in previous national surveys (National Health and Nutrition Examination Survey [NHANES] II, Health Examination Survey [HES]). Differences are particularly evident for trunk skinfold thicknesses and generally increase with age. Indices of fat distribution clearly show a centralized, upper body adiposity pattern among Mexican‐Americans, a cause for concern since greater fat deposition on the trunk has been associated with increased risk of certain chronic disease.

Rhabdomyolysis Complicating Doxylamine Overdose

A 16-year-old male presenting with anticholinergic symptoms was found to have hematuria and oliguria. Evaluation of the patient revealed a serum creatinine of 2.2 mg/d1, myoglobinuria, and a creatine phosphokinase (CPK) level of 78, 750 IU/1 with 99 percent fraction 3 isoenzyme. A toxic screen showed the presence of doxylamine, an antihistamine of the ethanolamine class, at a level of 75 times therapeutic. The patient did not have a history of trauma or seizures. The extremely high CPK level with the doxylamine overdose suggests that doxylamine may be associated with nontraumatic rhabdomyolysis. This is the first case report of rhabdomyolysis being associated with an antihistamine overdose.

The effects of language concordant care on patient satisfaction and clinical understanding for Hispanic pediatric surgery patients.

BACKGROUND Hispanics account for over 60% of the U.S. population growth and 25% speak little-to-no English. This language barrier adversely affects both access to and quality of care. Surgical specialties trail other medical fields in assessing the effects of language barriers to surgical clinical care and patient satisfaction. This study was designed to assess the effects of patient-provider language concordance on a pediatric surgery practice. METHODS A surgery-specific, 7-point Likert scale questionnaire was designed with 14 questions modeled after validated patient satisfaction surveys from the literature. Questions concerning provider-patient language concordance, quality of understanding, and general satisfaction were included. Surveys were administered to families of patients in the General Pediatric Surgery Clinic at our institution. Families were categorized into three groups: English-speaking, regardless of race/ethnicity; Spanish-speaking using interpreter services with an English-speaking medical team; and Spanish-speaking communicating directly with a Spanish-speaking medical team (Hispanic Center for Pediatric Surgery, HCPS). One-way analysis of variance was used to test for group differences. RESULTS We administered 226 surveys; 49 were removed due to lack literacy proficiency. Families in the HCPS group reported a higher level of satisfaction than the interpreter and English groups (p<0.01). The HCPS group also indicated improved understanding of the information from the visit (p<0.001). Spanish-speaking only families felt that communicating directly with their health care team in their primary language was more important than their English-speaking counterparts (p<0.001). CONCLUSIONS In a pediatric surgery clinic, language concordant care improves patient satisfaction and understanding for Hispanic families in comparison to language discordant care. Other clinics in other surgery sub-specialties may consider using this model to eliminate language barriers and improve patient satisfaction and understanding of surgical care.

Caring for Children in Immigrant Families: Vulnerabilities, Resilience, and Opportunities

Demographics indicate that pediatricians increasingly care for children in immigrant families in routine practice. Although these children may be at risk for health disparities relating to socioeconomic disadvantage and cultural or linguistic challenges, immigrant families have unique strengths and potential for resilience. Adaptive and acculturation processes concerning health and well-being can be mediated by cultural media. Pediatricians have a professional responsibility to address the medical, mental health, and social needs of immigrant families. Advocacy and research at the practice level and beyond can further explore the unique needs of this population and evidence-based strategies for health promotion.

Disparities in Early Exposure to Book Sharing Within Immigrant Families

OBJECTIVE: This study examined the early developmental context of children in immigrant families (CIF), measured by the frequency with which parents share books with their children. METHODS: Trends in the frequency with which parents report book sharing, defined in this analysis as reading or sharing picture books with their young children, were analyzed across immigrant and nonimmigrant households by using data from the 2005, 2007, and 2009 California Health Interview Survey. Stepwise multivariate logistic regression assessed the likelihood that CIF shared books with parents daily. RESULTS: In this study, 57.5% of parents in immigrant families reported daily book sharing (DBS), compared with 75.8% of native-born parents. The lowest percentage of DBS was seen in Hispanic families with 2 foreign-born parents (47.1%). When controlling for independent variables, CIF with 2 foreign-born parents had the lowest odds of sharing books daily (odds ratio [OR]: 0.61; 95% confidence interval [CI]: 0.54–0.68). When stratified by race/ethnicity, separate multivariate logistic regressions revealed CIF status to be associated with lower odds of DBS for Asian (OR: 0.56; 95% CI: 0.38–0.81) and Hispanic CIF (OR: 0.49; 95% CI: 0.42–0.58). CONCLUSIONS: There is an association between the lower odds of DBS and parental immigrant status, especially for Hispanic and Asian children. This relationship holds after controlling for variables thought to explain differences in literacy-related practices, such as parental education and income. Because book sharing is central to children’s development of early literacy and language skills, this disparity merits further exploration with the aim of informing future interventions.