Steven P. Wallace

Variations in Healthcare Access and Utilization Among Mexican Immigrants: The Role of Documentation Status

The objective of this study is to identify differences in healthcare access and utilization among Mexican immigrants by documentation status. Cross-sectional survey data are analyzed to identify differences in healthcare access and utilization across Mexican immigrant categories. Multivariable logistic regression and the Blinder-Oaxaca decomposition are used to parse out differences into observed and unobserved components. Mexican immigrants ages 18 and above who are immigrants of California households and responded to the 2007 California Health Interview Survey (2,600 documented and 1,038 undocumented immigrants). Undocumented immigrants from Mexico are 27% less likely to have a doctor visit in the previous year and 35% less likely to have a usual source of care compared to documented Mexican immigrants after controlling for confounding variables. Approximately 88% of these disparities can be attributed to predisposing, enabling and need determinants in our model. The remaining disparities are attributed to unobserved heterogeneity. This study shows that undocumented immigrants from Mexico are much less likely to have a physician visit in the previous year and a usual source of care compared to documented immigrants from Mexico. The recently approved Patient Protection and Affordable Care Act will not reduce these disparities unless undocumented immigrants are granted some form of legal status.

Heading South: Why Mexican Immigrants in California Seek Health Services in Mexico

Objectives:To Identify factors that explain why some Mexican immigrants in California use health services in Mexico. Methods:California Health Interview Survey 2001 data were analyzed for medical care, dental care, and/or prescription drug purchases in Mexico in the previous year. Logistic regressions estimated the effect on use of need, availability, accessibility, and acceptability among immigrants from Mexico. Results:An estimated 952,000 California adults used medical, dental, or prescription services in Mexico during the past year, of whom 488,000 were Mexican immigrants. Long-stay Mexican immigrants had the highest rate (15%), followed by short-stay Mexican immigrants (11.5%), US-born Mexican Americans (5.4%), and US-born nonLatino whites (2.1%). Predictors of use by immigrants included need, no insurance, delay seeking care, more recent immigration, limited English, and nonphysician provider use. Living closer to the border increased use, although half of immigrants seeking services lived more than 120 miles from the border. Mexican immigrants with long stays in the US have a somewhat different pattern of predictors from those with short stays. Conclusions:Mexican immigrants are the most likely to seek medical, dental, and prescription services in Mexico. A large number, but small percentages, of US-born nonLatino whites purchase prescription drugs there. Although proximity facilitates use, access and acceptability barriers in the US medical care system encourage immigrants to seek care in Mexico who would be helped by expanded binational health insurance.

Equity of access to health care for older adults in four major Latin American cities

OBJECTIVES To identify if older adults have equitable access to health services in four major Latin American cities and to determine if the inequities that are found follow the patterns of economic inequality in each of the four nations studied. METHODS Data from persons age 60 and over in the cities of São Paulo, Brazil (n = 2,143); Santiago, Chile (n = 1,301); Mexico City, Mexico (n = 1,247); and Montevideo, Uruguay (n = 1,450) were collected through a collaboration led by the Pan American Health Organization. For our study, three process indicators of access (availability, accessibility, and acceptability) and one indicator of actual health services use (visit to a medical doctor in the past 12 months) were analyzed by wealth quintiles, health insurance type, education, health status, and demographic characteristics. RESULTS Each of the four cities had a different level of access to care, and those levels of access were only weakly related to per capita national wealth. Given the relatively high level of wealth inequality in Brazil and the lower level in Uruguay, older persons in São Paulo had better-than-expected equity in access to care, while older persons in Montevideo had less equity than expected. Inequity in Mexico City was driven primarily by low levels of health insurance coverage. In Santiago, inequity followed socioeconomic status more than it did health insurance. CONCLUSIONS In the four cities studied, health insurance and the operation of health systems mediate the link between economic inequality and inequitable access to health care. Therefore, special attention needs to be paid to equity of access in health services, independent of differences in economic inequality and national wealth.

Mandatory Reporting of Elder Abuse: Between a Rock and a Hard Place

PURPOSE Despite mandated reporting laws that require physicians to report elder abuse, physicians have low rates of reporting. The purpose of this study was to identify physician’s perspectives on mandated reporting of elder abuse. METHODS Individual, semistructured interviews were conducted with 20 primary care physicians practicing in a variety of settings and caring for a diverse patient population in the Los Angeles area. Interviewers collected information on physicians’ perspectives about factors that may influence physicians’ likelihood to report elder abuse. The interviews were recorded and transcribed verbatim. Transcripts were analyzed using a grounded theory approach based on the constant comparative method and the emergence of the core category of paradox to best account for the most problematic elder abuse situations faced by physicians. RESULTS During the interviews 3 paradoxes were expressed by physicians about the mandatory reporting of elder abuse. Specifically, mandatory reporting was related to both perceptions of increases and decreases in physician-patient rapport, patient quality of life, and physician control or ability to decide what is in the best interest of the patient. These paradoxes appear to be primarily hidden or unconscious, yet they influence the conscious decision process of whether to report. CONCLUSIONS Primary care physicians appear to be subject to paradoxes of reporting that contribute to the underreporting of elder abuse. These paradoxes and alternative modes of managing paradoxes are important and should be addressed in educational and training programs for physicians, and systematic evaluation of these issues may help to inform future legislation in this area. Further studies are needed to assess the generalizability of these findings to other groups of clinicians.

Use of mammography screening among older Samoan women in Los Angeles county: a diffusion network approach

Minority migrant populations, such as older Samoan women, are likely to underuse preventive health services, including mammography screening. The purpose of this paper is to explore how informal (lay peers from churches) and formal (health care providers) health communication networks influence mammography screening use among older Samoan women. To do so, we apply diffusion of innovation theory and network analysis to understand how interpersonal networks may affect mammography use in this urban-dwelling, migrant population. The data come from a survey of 260 Samoan women, aged 50 years or older, who attended 39 randomly sampled Samoan churches in Los Angeles County (USA) between 1996 and 1997. Retrospective data, based over a 20-year period from this samples year of first use of mammography screening, suggest that interpersonal networks may have accounted for the dramatic increase in the rate of adoption within the past 5 years of the survey. Using this information, we categorized women into mutually exclusive stages of mammography use and regressed these stages of mammography use on formal (had a provider referral) and informal (level of connectedness with peers in churches) health communication networks. The results indicated that being well-connected within womens informal, church-based health communication networks increased the likelihood of being in the decision (planned to have) and implementation and confirmation (had a recent mammogram) stages, but having a provider referral for a mammogram (formal networks) only increased the likelihood of being in the latter stages compared to women in the knowledge and persuasion stages. Formal and informal health communication networks influence recent use of mammography screening, but informal networks, in and of themselves, are also influential on future intention to use mammography screening.

Access to Preventive Services for Adults of Mexican Origin

Immigrants arrive in the U.S. with better than average health, which declines over time. Clinical preventive services can prevent or delay some of that decline, but little research in this area focuses specifically on Mexican immigrants who are the largest contemporary immigrant group. This article finds that recent Mexican immigrants were the least likely to receive preventive care services, even after adjusting for sociodemographic differences in the population. Long-stay Mexican immigrants were more similar to U.S.-born Mexican Americans in preventive service use rates, who in turn had lower rates than U.S.-born non-Latino whites. Monolingual Spanish speaking Mexican immigrants were the least likely to have obtained preventive services. Having no usual source of care is the strongest predictor of the underuse. The persistent gap in preventive services across all subgroups of adults of Mexican origin suggests structural barriers to their preventive care.

Migration Circumstances, Psychological Distress, and Self-Rated Physical Health for Latino Immigrants in the United States

OBJECTIVES We determined the impact of premigration circumstances on postmigration psychological distress and self-rated physical health among Latino immigrants. METHODS We estimated ordinary least squares and logistic regression models for Latino immigrants in the 2002-2003 National Latino and Asian American Study (n = 1603). RESULTS Mean psychological distress scores (range = 10-50) were 14.8 for women and 12.7 for men; 35% of women and 27% of men reported fair or poor physical health. A third of the sample reported having to migrate; up to 46% reported unplanned migration. In multivariate analyses, immigration-related stress was significantly associated with psychological distress, but not with self-rated health, for both Latino men and women. Having to migrate was associated with increased psychological distress for Puerto Rican and Cuban women respondents and with poorer physical health for Puerto Rican migrant men. Unplanned migration was significantly associated with poorer physical health for all Latina women respondents. CONCLUSIONS The context of both pre- and postmigration has an impact on immigrant health. Those involved in public health research, policy, and practice should consider variation in immigrant health by migration circumstances, including the context of exit and other immigration-related stressors.

Concepts of Burden in Giving Care to Older Relatives: A Study of Female Caregivers in a Mexico City Neighborhood

This study examined how women in a Mexico City suburb conceptualized the construct of burden within the context of giving care to older relatives. Data were collected on 41 women through semi-structured interviews regarding their caregiving experiences to elderly relatives. Phenomenological principles were used to analyze meanings and understandings of caregiving experiences. Burden was a multi-dimensional construct that referred to specific situations that made caregivers feel emotionally or physical “heavy.” Burden also referred to “being a burden” by being in the way, making things difficult, or being a ‘weight’ on caregivers’ shoulders. However, women in this study also viewed burden as a positive sacrifice that involved love, initiative, and good will. This study is an important first step in defining the ways in which caregiving is positively and negatively meaningful for Mexican caregivers and their families. Our findings offer an additional dimension of caregiver burden to broaden our understanding and measurement of the construct. The development of culturally appropriate instruments to measure caregiving burden in Mexico is necessary to provide an empirical foundation for policy recommendations that address the growing need for institutional support of caregivers. Moreover, our findings suggest that researchers studying caregiving in Mexico should think about how burden is measured on existing instruments before adapting them for widespread use.

Perceptions of health and use of ambulatory care: Differences between Korean and White elderly.

This study identifies whether culturally based differences in perceptions of health resulted in differences in ambulatory care use among the elderly. Methods:The authors conducted stratified Poisson regressions on data from a 1992 survey of older Koreans and Whites in Los Angeles County. The models included measures of demographics, health, functioning, income, insurance, social support, and culture (perceptions of health or other beliefs). Results:Descriptive findings showed older Koreans had more ambulatory physician visits, poorer functioning, and poorer perceptions of their health than Whites. Multivariate findings showed that positive perceptions of health independently reduced office visits for bothKoreans and Whites, but the effect was significantly smaller for Koreans. Other cultural differences also affected use. Discussion:The findings highlight differences between older Koreans and Whites’ responses to physical and socioeconomic conditions and the importance of cultural sensitivity in the health care delivery system.

Hispanic Baby Boomers: Health Inequities Likely to Persist in Old Age

PURPOSE As the Baby-Boom generation enters the ranks of the elderly adults over the next 4 decades, the United States will witness an unprecedented growth in racial/ethnic diversity among the older adult population. Hispanics will comprise 20% of the next generation of older adults, representing the largest minority population aged 65 years and older, with those of Mexican-origin comprising the majority of Hispanics. Little is known about the health status of this population. DATA/METHODS: Data are for Baby Boomers born between 1946 and 1964 (ages 43-61) in the 2007 California Health Interview Survey. Logistic regression estimates the odds of diabetes, hypertension, obesity, fair/poor self-rated health (SRH), and functional difficulties among U.S.-born non-Hispanic Whites (NHW), U.S.-born Mexicans, naturalized Mexican immigrants, and noncitizen Mexican immigrants. RESULTS The Mexican-origin populations are disadvantaged relative to NHW for all socioeconomic status (SES) and several health outcomes. The Mexican origin disadvantage in health attenuates when controlling for SES and demographics, but the disadvantage remains for diabetes, obesity, and fair/poor SRH. IMPLICATIONS Baby Boomers of Mexican origin do not share the advantages of health, income, and educational attainment enjoyed by U.S.-born NHW. As this cohort moves into old age, the cumulative disadvantage of existing disparities are likely to result in continued or worse health disparities. Reductions in federal entitlement programs for the elderly adults that delay eligibility, scale back programs and services, or increase costs to consumers may exacerbate those inequities.