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Solved by verified expert:Please answer each question with four sentences. I have attached the reading assignment.Why are sociocultural factors important in determining Asian Americans access to care? How will this impact your social work with Asian American clients? (Nguyen)
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Journal of Gerontological Social Work
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The Effects of Sociocultural Factors on
Older Asian Americans’ Access to Care
Duy Nguyen
a
a
Silver School of Social Work , New York University , New York , New
York , USA
Published online: 05 Jan 2012.
To cite this article: Duy Nguyen (2012) The Effects of Sociocultural Factors on Older
Asian Americans’ Access to Care, Journal of Gerontological Social Work, 55:1, 55-71, DOI:
10.1080/01634372.2011.618525
To link to this article: http://dx.doi.org/10.1080/01634372.2011.618525
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Journal of Gerontological Social Work, 55:55–71, 2012
Copyright © Taylor & Francis Group, LLC
ISSN: 0163-4372 print/1540-4048 online
DOI: 10.1080/01634372.2011.618525
The Effects of Sociocultural Factors on Older
Asian Americans’ Access to Care
DUY NGUYEN
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Silver School of Social Work, New York University, New York, New York, USA
Most Asian American elders are immigrants to the United States,
and sociocultural factors such as English proficiency and immigration status are prominent factors in their lives. Using data
from the California Health Interview Surveys to focus on Asian
Americans over age 50, this study seeks to identify interethnic
differences, and the effects of English proficiency and immigration status in the way older Asian Americans access healthcare.
The results indicated that Asian ethnicity, English proficiency, and
immigration status have significant independent effects on older
Asian Americans’ access to care. Implications for social work’s role
in addressing access disparities are discussed.
KEYWORDS ethnicity and multicultural issues, older adults,
Asian Americans, service use
INTRODUCTION
Background
The rapid growth of racial/ethnic minority groups is changing the United
States’ population demographic characteristics. Particularly, the Asian segments of the population will increase the fastest due to increasing longevity
and new immigration. Seeking economic and social opportunities, Asian
ethnic groups have had a long history of immigration to the United States
(Kitano & Nakaoka, 2001). Since the immigration reforms of the 1960s, the
Asian population has grown exponentially. According to census counts, the
Received 20 July 2010; accepted 25 August 2011.
This study was supported by the Research Challenge Fund at New York University.
Address correspondence to Duy Nguyen, Silver School of Social Work, New York
University, 1 Washington Square North, New York, NY 10003, USA. E-mail: duy.nguyen@
nyu.edu
55
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D. Nguyen
proportion of Americans who identify themselves as Asians has doubled at
each census since 1970 (Kitano & Nakaoka, 2001). In 2000, 801,000 Asians
over 65 constituted 2.3% of older adults in the United States (He, Sengupta,
Velkoff, & DeBarros, 2005). Both the Asian and Hispanic American population are projected to double in size by 2050, outpacing the population
changes for African Americans and non-Hispanic Whites (US Census Bureau,
2008). However, the Asian population in the United States is unique in that
trends predict rapid growth of the middle-aged population, which points to
large increases in the future proportion of older Asians. The growth of the
Asian American population will be spurred by older adults; the number of
Asian Americans over 65 will grow five-fold by 2050 (US Census Bureau,
2008).
Despite the changing demographics of the American adult and older
population, little physical and mental health research has been conducted on
Asian groups (Dilworth-Anderson, Williams, & Gibson, 2002; LaVeist, 1995;
Tanjasiri, Wallace, & Shibata, 1995). The lack of empirical research limits
the ability of practitioners and policymakers to respond to the changing
population. Further, bundling together the various Asian ethnic subgroups
into one broad category masks the multiethnic heritage of immigrants from
Asian countries. Researchers and service providers will be better able to
respond to the physical/mental health needs of racial/ethnic minority adults
and older adults by using empirical information on the way adults from
immigrant backgrounds use healthcare services now.
Most Asian American older adults are immigrants to the United States
(US Census Bureau, 2004). The Asian immigrant experience in the United
States is shaped by the pushes and pulls that spur migration (Portes &
Rumbaut, 2006). Refugees and asylum-seekers are seen as having little
choice but to flee social or political persecution in their country of origin
as they are pushed toward life in the United States. Meanwhile, voluntary
immigrants, especially among the skilled labor force, choose to come to the
United States to seek economic opportunities. US immigration policy facilitates family reunification, and many immigrants and refugees are able to
sponsor their immediate and extended families to immigrate.
Portes and Rumbaut (2006) argued that immigrant or refugees’ social
positions in their country of origin influence their subsequent adaption to
life in the United States. This is clearly exemplified by the experience of
Vietnamese, who constitute, the largest group of Asian refugees. Although
the first wave of refugees was involuntarily resettled, they shared common
traits from their life in Vietnam that facilitated adjustment to their new life
in the United States; they were proficient in English and highly educated.
Although many lost status when they sought employment in the United
States, their language skills and prior education enabled them to adapt to
the US workforce. This stands in contrast to later Vietnamese refugees, who
came with less education, had higher levels of health and mental health
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The Effects of Sociocultural Factors
57
needs, and encountered more challenges (Rumbaut, 2000). There were
fewer professionals in later waves, and later refugees experienced additional
challenges in securing employment.
Despite the general perception that the Asian American population
is a model minority, able to overcome obstacles, they have unmet psychosocial needs (Sue, Sue, Sue, & Takeuchi, 1995). Notably, high levels of
physical and mental health need have been observed among refugees from
Southeast Asia (Beiser, 1988) and among Japanese and Vietnamese older
adults (Mui & Kang, 2006). In the context of acculturation, the aging process
introduces new psychosocial challenges and exacerbates preexisting psychological distresses (Stoller & Gibson, 1999; Tran, 1992). Variations among
Asian Americans with respect to ethnic background, immigration status, and
language proficiency affect physical and mental health (Loo, Tong, & True,
1989). The distinction between voluntary and involuntary migration to the
United States has been reported to affect the mental health and life satisfaction of older Asian Americans (Mui & Shibusawa, 2008). Furthermore,
familiarity with and use of Western medical care in their country of origin
has been found to increase the likelihood of using formal medical service in
the United States (Chung & Lin, 1994).
Although the research base has established the relationship between
English language proficiency and health outcomes (Mui, Kang, Kang, &
Domanski, 2007), the construct has been overlooked in the access to care literature. Understanding how older Asian Americans come into the healthcare
system is important for social workers and other healthcare providers. The
healthcare system is a common point of entry into a broader range of health
and social services. Access to care has been defined broadly to encompass
having health insurance, seeing a physician, and having a usual source of
care. Having a usual source of care is also an indicator of access to preventive health services and screenings for chronic health conditions such as
diabetes, cardiovascular disease, and psychosocial well-being that are integral to the overall well-being of older adults (US Centers for Disease Control
and Prevention et al., 2009). Having a usual source of care is associated with
a decreased number of visits to emergency departments (Petterson, Rabin,
Phillips, Bazemore, & Dodoo, 2009), improved linkages with the healthcare
system, and more use of preventive services (Xu & Borders, 2008).
Conceptual Framework
Most access-to-care studies have applied Andersen’s behavioral model
(Andersen, 1995; Choi, 2006). The model seeks to predict healthcare service
use through the environment (healthcare system), population characteristics (predisposing characteristics, enabling resources, need factors), health
behavior (health practices, use of health services), and outcomes (perceived
health status, evaluated health status, consumer satisfaction). Predisposing
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D. Nguyen
characteristics include social demographic variables such as a person’s gender, age, racial and ethnic group membership, and health beliefs. Enabling
factors include aspects of the individual’s personal, family, or community
domains that facilitate access to and use of healthcare, including the person’s social support and his or her access to healthcare benefits. Need factors
include the individual’s health status and issues that may precipitate the use
of health services. Assessing outcomes of previous health service use and
the environmental dimensions is important for analyses of racial and ethnic
minority groups who may have negative experiences with the healthcare
system or have limited access to resources due to their minority status.
A challenge of using the behavioral model for immigrant populations is
conceptualization of cultural variables. Building on Bordieu’s original work,
Abel (2008) discussed the relative contributions of social, economic, and cultural capital in the development of social class and their subsequent effects
on healthcare access and overall health. Cultural capital refers to a group’s
resources to use and seek out information that enriches their lives. For Asian
Americans and other population segments with histories of recent immigration to the United States, the term group refers directly to a racial/cultural
entity. Within the context of the US healthcare system, however, the concept
of cultural capital can be extended to one’s ability to navigate and access
healthcare, as well as help-seeking behaviors. Therefore, to blend the behavioral model and Abel’s description of cultural capital, the enabling factors are
divided into economic and sociocultural factors.
Among enabling factors, economic resources have been found to be
associated with access to and use of healthcare. Having any insurance coverage and having supplemental insurance coverage are factors associated with
increased levels of medical service use (Fitzpatrick, Powe, Cooper, Ives, &
Robbins, 2004; M. Jang, Lee, & Woo, 1998).
Although the literature has established a connection between economic
factors and access to care, research with immigrant samples has also identified the impact of length of stay in the United States on health care access.
One study that compared newly arrived older immigrants with immigrants
with longer durations in the United States found that immigrants arriving
within the preceding 5 years were far more likely not to have insurance
and more likely not to have a usual source of care (Choi, 2006). In their
study using nationally representative data, Xu and Borders (2008) showed
that immigrants had fewer preventive and nonpreventive visits to physicians
than non-immigrants. In addition, more immigrants than nonimmigrants indicated they did not have a usual source of care. Having a usual source of care
increased the number of physician contacts for immigrants at a greater rate
than for nonimmigrants. Immigrants who had arrived within the preceding
10 years received the least preventative care. Previous research on Mexican
immigrants reported differences in access to preventive care by nativity
and length of stay in the United States (Wallace, Gutiérrez, & Castañeda
2008).
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The Effects of Sociocultural Factors
59
Research on Asian American samples has focused on the multiple barriers to service utilization, including language access issues, a fragmented
healthcare system, lack of insurance, and lack of knowledge about existing resources (M. Jang et al., 1998; Y. Jang, Kim, Hansen, & Chiriboga,
2007; Loo et al., 1989) . In general, limited English proficiency restricts
access to care (Ponce, Hays, & Cunningham, 2006). In Ma’s (2000) study
of Chinese Americans living in Houston, persons with limited English proficiency encountered more barriers to accessing the healthcare system than
those with higher levels of English ability. Ma (2000) also reported that
facility with the Western healthcare system enabled Chinese Americans to
overcome some barriers to care.
Furthering the understanding of English proficiency, M. Jang and his
colleagues (1998) found that persons who spoke only Chinese were less
likely than English speakers to have health insurance. Among Southeast
Asian refugees from Vietnam, Cambodia, and Laos, those with higher levels
of English proficiency were more likely to use Western medical services than
traditional medical care (Chung & Lin, 1994).
Although researchers have studied minorities’ access to care, past
research has focused on broad racial and ethnic comparisons. By aggregating Asian Americans into a single racial categorization, previous studies
have overlooked the rich diversity within the racial group. The Asian race
encompasses more than 30 distinct ethnic groups. However the majority
of Asian Americans represent one of six ethnic groups: Chinese, Filipino,
Asian Indian, Japanese, Korean, or Vietnamese (US Census Bureau, 2002).
To extend the knowledge base on Asian American access to care, this
study looks at Asian Americans over age 50 from different ethnic groups.
Specifically, this study addresses two specific research questions. First, are
there interethnic differences in the way older Asian Americans access healthcare? Second, how do English proficiency and immigration status affect their
access to care?
METHODS
This study used publicly available data derived from the 2003 and
2005 versions of the California Health Interview Survey (CHIS; 2005, 2008).
Conducted by the Center for Health Policy Research at the University of
California–Los Angeles, the CHIS is a cross-sectional study of California residents’ health and access to care; it is a random-digit-dial telephone survey
that uses a two-stage sampling procedure. More Asian Americans live in
California than any other state, and combining two CHIS years enables this
study to have the statistical power to focus on interethnic differences among
older Asian American adults.
A total of 42,044 adults responded to the 2003 CHIS, and
43,020 responded to the 2005 CHIS. Supplemental sampling strategies were
60
D. Nguyen
used during both survey years to increase the number of Korean and
Vietnamese respondents. The survey instrument was translated into a number of Asian languages, including Cantonese, Mandarin, Korean, Vietnamese,
and Khmer. The overall response rates for the survey years remained low;
they ranged from 33.5% in 2003 to 26.9% in 2005, which were consistent
with other health surveys (CHIS, 2005, 2008). The local Institutional Review
Board approved the protocols for this study.
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Study Sample
The study’s sample consisted of Asian Americans over age 50. Respondents
were included in this study if they identified with the Asian race only and
if they were non-Hispanic. This resulted in an unweighted sample size of
3,011. Respondents ranged in age from 50 to 85. To account for the complex
sampling methods used in CHIS, jackknife replication methods applying the
survey-supplied replicate weights were used to obtain accurate, weighted
variance estimates (Rust & Rao, 1996; SAS Institute, 2008).
Measurement of Variables
The dependent variable for this study was whether or not the respondent
had a usual source of care. To identify those at risk, not having a usual
source of care was coded 1 and having a usual source of care was used as
the reference category.
Independent Variables
Anderson’s (1995) behavioral model was used to organize the independent
variables. Abel’s (2008) conceptualization of social class was integrated into
enabling factors, which were divided between economic and sociocultural
variables. Figure 1 shows the conceptual model.
Predisposing characteristics. To control for differences in work status
qualification for government-sponsored insurance, age was used as a continuous measure and as a means of categorizing the preretirement age cohort
(50–64) versus those age 65 and older. The sample was subdivided by Asian
ethnicity: Chinese, Filipino, Korean, Vietnamese, or Other Asian. The Other
Asian category included ethnic groups that were not well represented in the
survey, such as Japanese, Cambodian, and South Asian. Marital status was
used as a predisposing characteristic. Given the high rate of marriage among
older Asian Americans, the sample was divided between the married and the
unmarried (widowed, divorced, separated, and never married).
Enabling resources. The enabling resources in this study were divided
between economic and sociocultural factors. Economic factors included
The Effects of Sociocultural Factors
Independent Variables
61
Dependent Variable
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Predisposing characteristics
• Age
• Ethnicity
• Gender
• Marital status
Enabling resources
Economic
• Educational attainment
• Insurance status
• Usual Source of Care
Sociocultural
• English proficiency
• Length of stay in U.S.
Need factor
• Self-rated health
FIGURE 1 Blended conceptual framework for health service use.
educational attainment (less than high school, high school graduate, and
some college) and insurance status. Poverty …
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