Health Status and Health Services Access and Utilization Among ...

RESEARCH AND PRACTICE

Health Status and Health Services Access and Utilization Among Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese Children in California Stella M. Yu, ScD, MPH, Zhihuan Jennifer Huang, PhD, MPH, and Gopal K. Singh, PhD

It has been widely documented that ethnic minority children in the United States have less access to health care than do non-Hispanic White children.1,2 Most studies on health care access have focused on Hispanic and African American children.3,4 Although estimates derived from the US Census Bureau’s 2006 American Community Survey indicate that people of Asian descent represent only 4.9% of the US population, there has been an almost 50% increase in the Asian American population since 1990.5 Despite the substantial increase in the Asian American population, information on health care access and health services utilization among Asian American children is lacking. Chinese, Filipino, and Asian Indians are the 3 largest Asian American subgroups in the United States, comprising 23.6%, 18.9%, and 17.8%, respectively, of the total Asian population, followed by the Vietnamese (11.3%), Korean (10.2%), and Japanese (6.3%) subgroups. Of the US population younger than age 18 years in 2006, nearly 3 million (3.9%) were Asian and 150 000 (0.2%) were Native Hawaiian or Pacific Islander. An estimated 1.2 million children aged 5 to 17 years speak an Asian or Pacific Island language at home. The 2005 Current Population Survey data indicated that 1 in 5 children lived with a foreign-born individual, although most of these children were US born. Children living with foreign-born individuals were younger and more likely to live in poverty than those living with USborn individuals.6 Health care access, health insurance coverage, and the use of preventive health services are among the most challenging health issues facing today’s immigrants and ethnic minorities7–10 even though immigrants have lower mortality and morbidity risks than do US-born infants, children, and adults, as reported.11–16 Additionally, child and parental birthplace have

Objectives. We examined health status and health services access and utilization of Chinese, Filipino, Japanese, Korean, South Asian, Vietnamese, and non-Hispanic White children in California. Methods. We analyzed aggregated data from the 2003 and 2005 California Health Interview Survey (648 Chinese, 523 Filipino, 235 Japanese, 308 Korean, 314 South Asian, 264 Vietnamese, and 8468 non-Hispanic White children aged younger than 12 years), examining the relationship between Asian ethnicities and outcomes. Results. Compared with non-Hispanic White children, Korean children were 4 times more likely to lack health insurance; Filipino children were twice as likely to not have had recent contact with a doctor; Chinese, Korean, and Vietnamese children were less likely to have visited an emergency room in the past year; and Chinese, Korean, and Vietnamese children were more likely to be in fair or poor health. Age, gender, poverty, citizenship–nativity status, health insurance, and parental marital and child health statuses were related to most outcomes. Conclusions. Asian ethnicities have heterogeneous health care access and utilization patterns, suggesting the need for targeted outreach to different Asian ethnic groups. (Am J Public Health. 2010;100:823–830. doi:10.2105/AJPH.2009. 168948)

been found to affect insurance status and access to health services among Latino children in the United States.3 The joint effect of being foreign born and lacking health insurance among the poor has also been associated with a severe lack of a usual source of care.17 Health issues are compounded by the problem of adaptation to a new culture for Asian children, particularly those from families with limited English proficiency.18–20 Asian children have also been shown to have the lowest utilization of preventive care and to receive the lowest quality of primary care compared with other racial/ethnic groups.21,22 Moreover, Asian parents are often limited in their ability to act as advocates for their children in the health care setting.23,24 Passage of the 1996 Personal Responsibility and Work Opportunity Reconciliation Act has limited immigrants’ access to many public benefits (Public Law 104–193).8,25

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Undocumented immigrants and legal immigrants within 5 years of entry into the United States were barred from receiving services other than emergency care until the 2009 passage of the Children’s Health Insurance Program Reauthorization Act.26,27 The 1996 law has been shown to have the unintended consequence of deterring eligible immigrants from accessing benefits.28 There is a clear lack of studies on children’s health care access that focus on disaggregated Asian subgroups, especially populations that have arrived more recently. Studies on prenatal care utilization and the health of adult immigrants have demonstrated substantial heterogeneity among Asian ethnic groups.29,30 One study found that Chinese, Filipino, and Asian Indian children have more difficulty accessing health care than do non-Hispanic White children.31 Moreover, most recent national surveys on children and adolescents have not collected detailed data on Asian ethnicities.32–34 In

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addition to work predicated on vital statistics, very few studies that address individual Asian ethnicities and are founded on small numbers have identified vulnerabilities in specific Asian groups.35 However, these studies have addressed primarily psychosocial and mental health issues and have focused on adolescents. To our knowledge, no study has examined the health care access and utilization characteristics of children by specific Asian American subgroups on the basis of recent statewide health data. California is the state with the largest Asian American population. Using aggregated data from the 2003 and 2005 waves of the California Health Interview Survey (CHIS),36,37 we aimed to determine the social and demographic characteristics of Asian (Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese) children aged zero through 11 years, to describe the prevalence of selected health status and health care access and utilization characteristics among them, and to examine adjusted differentials in health and health care outcomes among children in Asian subgroups after controlling for selected social and demographic covariates.

parent proxies for child interviews completed in 2003 and 2005, respectively. Approximately 12% (2003) and 10% (2005) of the adult interviews were completed in a language other than English, as were 21% (2003) and 18% (2005) of all child (parent proxy) interviews.38 One criterion for the adolescent or child to be selected for the survey was ‘‘association’’ with the selected adult, which meant that in most cases the interviewed adult had to be either the child’s parent or guardian. Interviews were conducted in English, Spanish, Chinese (Mandarin and Cantonese dialects), Vietnamese, Korean, or Khmer.39 These languages were selected to include the largest possible number of non– English-speaking California residents. Finally, we aggregated the 2 waves of CHIS data to yield sufficient statistical power to examine the health status and health services characteristics among the specific Asian American subgroups.40 The comparison group was non-Hispanic White children surveyed during the same period. We weighted estimates to represent all non-Hispanic White and Asian children younger than age 18 years in California.

Measures

METHODS The data used in this study are derived from the 2003 and 2005 CHIS.36,37 The CHIS, the largest statewide health survey in the nation, collects data on multiple public health issues, including health status, health behaviors, access to health care, and health care utilization.

Data CHIS is a random-digit-dialed telephone survey of adults, adolescents, and children. Detailed methodological information is available elsewhere.37All California households with a telephone comprised the sampling frame. Each computer-generated telephone number was screened to determine participant eligibility (e.g., language fluency), and 1 adult per household was randomly selected to be interviewed. If the interviewed adult was the parent or guardian of a child residing in the household, the adult was asked to complete the child interview; if he or she was the parent or guardian of an adolescent residing in the household, he or she was asked to give verbal consent for the adolescent to be interviewed. There were 8526 and 11358

To classify race/ethnicity, the parent was first asked if the child was Latino; the parent was then asked to identify a race if a child was not Latino. If a parent identified the child as Asian, he or she was asked to identify a specific Asian ethnic group. Asian ethnicity consisted of 6 groups: Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese. We examined child health status; physical, behavioral, or mental limitations; and several measures of health care access and utilization as reported by the parent. We coded all measures into dichotomized outcomes. Parent-reported health status (excellent, very good, or good versus fair or poor) was derived from the question ‘‘In general, would you say (child)’s health is excellent, very good, good, fair, or poor?’’ Insurance status (uninsured versus some type of insurance) was derived from responses to the question about ‘‘type of current health coverage source.’’ The types of insurance included Medicaid, Children’s Health Insurance Program, Medicare, employment based, privately purchased, and other public insurance. The usual source of care was assessed from the question: ‘‘Is there a place

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that the child would go when he or she is sick or you need advice about his or her health?’’ Whether the child had had a physical checkup within the past year was determined with the question ‘‘During the past 12 months, did (child) get a physical exam or general checkup when (he or she) was not sick or hurt?’’ The number of visits to a doctor was determined on the basis of the question: ‘‘During the past 12 months, how many times has your child seen a medical doctor?’’ Emergency room visits were assessed on the basis of the question: ‘‘During the past 12 months, did (child) visit a hospital emergency room?’’ Delayed or forgone medical care was derived from the following question: ‘‘During the past 12 months, did you delay or not get any other medical care that you felt (child) needed—such as seeing a doctor, a specialist, or other health professional?’’ Delay filling a prescription was based on the question ‘‘During the past 12 months, did you delay or not get a medicine that a doctor prescribed for (child)?’’ The dental visit variable was derived from the question ‘‘About how long has it been since your child last visited a dentist or dental clinic? Include dental hygienists and all types of dental specialists.’’ The covariates included child’s age, gender, citizenship–nativity status, family poverty status, insurance status, household composition, and health status. Poverty status is a variable created from family income and family or household size that uses the US Census Bureau’s poverty thresholds.41 Children in families with income below the poverty threshold were coded as poor, children in families with income 100% to less than 200% of the poverty threshold as near poor, and children in families with income 200% and above the poverty threshold as not poor. Parental education was not included because of colinearity with income.

Statistical Analyses Sample weights, person-level weights, and population weights were employed. These weights accounted for, among other variables, nonresponse, multiple telephone lines, and within-household probability of selection, and adjusted for gender, age, race, ethnicity, urbanization, number of children, and number of adolescents in the household. Because the data were weighted on the basis of the 2000

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census data, our findings are generalizable to children in California. The c2 test was used to test for ethnic differences in the proportion of binary health status, health access, and utilization outcomes. Logistic regression models were used to examine the independent effects of Asian ethnicity on various outcomes. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were computed by using the regression beta coefficients and standard errors obtained from the logistic regression models. To account for the complex sample design involving stratification, clustering, and

multistage sampling of the CHIS, statistical analyses were conducted with SUDAAN version 9.0.1 (Research Triangle Institute, Research Triangle Park, NC).42 Jackknife replicate weights were applied for variance estimation as recommended.40

RESULTS Table 1 shows the demographic characteristics of the children by ethnicity. There were 648 Chinese, 523 Filipino, 235 Japanese, 308 Korean, 314 South Asian, and 264 Vietnamese children younger than age 12 years. The

comparison group consisted of 8468 nonHispanic White children. Statistically significant associations (by the c2 test) were found between ethnic groups and most sociodemographic characteristics examined (P< .05). Among Asian children, the highest percentage of noncitizens and foreign-born children were Korean or South Asian. South Asians had the highest percentage of children younger than age 5 years. One half of Vietnamese children live in poor or near poor households, as did nearly one quarter of Filipino and Korean children. Almost all Asian American children resided in metropolitan areas; 4.4% of

TABLE 1—Sociodemographic Characteristics of Asian American Children: California Health Interview Survey, 2003–2005 Non-Hispanic White (n = 8468), % (SE)

Chinese (n = 648), % (SE)

Filipino (n = 523), % (SE)

Japanese (n = 235), % (SE)

Korean (n = 308), % (SE)

South Asian (n = 314), % (SE)

Vietnamese (n = 264), % (SE)

0–4

38.2 (0.7)

43.6 (2.7)

39.5 (2.8)

33.5 (4.0)

44.3 (3.9)

55.3 (3.6)

34.8 (3.4)

5–11

61.8 (0.6)

56.4 (2.7)

60.5 (2.8)

66.5 (4.0)

55.7 (3.9)

44.8 (3.6)

65.2 (3.4)

Age, y

Gender Male Female Citizenship–nativity status US-born citizen

51.2 (0.0)

51.3 (2.7)

50.6 (2.7)

53.6 (4.9)

50.5 (3.8)

52.9 (3.2)

56.1 (3.7)

48.8 (0.0)

48.7 (2.7)

49.4 (2.7)

46.5 (4.9)

49.5 (3.8)

47.2 (3.2)

43.9 (3.7)

98.2 (0.2)

88.6 (1.8)

90.6 (2.0)

94.5 (1.8)

79.0 (2.9)

87.6 (2.3)

93.3 (1.7)

Naturalized citizen

1.0 (0.2)

4.5 (1.2)

2.9 (1.1)

3.2 (1.5)

3.3 (1.4)

0.8 (0.6)

1.8 (0.8)

Noncitizen

0.9 (0.2)

6.9 (1.3)

6.5 (1.5)

2.3 (1.5)

17.7 (2.6)

11.6 (2.3)

4.9 (1.7)

Family poverty status Poor

5.9 (0.4)

7.2 (1.4)

8.4 (1.7)

1.3 (1.3)

6.7 (2.2)

7.7 (2.7)

29.0 (4.0)

12.5 (0.6)

12.6 (1.8)

16.7 (2.2)

5.6 (1.5)

17.1 (2.8)

9.1 (2.0)

21.0 (3.1)

81.6 (0.6)

80.3 (2.1)

74.9 (2.5)

93.1 (2.0)

76.2 (3.4)

83.3 (3.1)

50.1 (3.7)

95.6 (0.1)

99.7 (0.2)

98.8 (0.3)

98.5 (0.6)

99.7 (0.3)

99.5 (0.3)

99.9 (0.1)

4.4 (0.1)

0.3 (0.2)

1.2 (0.3)

1.5 (0.6)

0.3 (0.3)

0.5 (0.3)

0.1 (0.1)

Married with children

81.9 (0.6)

90.8 (1.7)

82.1 (2.5)

88.9 (2.7)

86.7 (3.2)

93.3 (2.2)

82.9 (3.4)

Single with children

18.1 (0.6)

9.2 (1.7)

17.9 (2.5)

11.1 (2.7)

13.3 (3.2)

6.7 (2.2)

17.1 (3.4)

< High school High school graduate

3.5 (0.3) 18.9 (0.6)

8.2 (1.5) 15.0 (2.0)

4.0 (1.3) 14.7 (2.0)

0.2 (0.2) 12.6 (3.0)

4.1 (2.1) 15.5 (2.7)

0.9 (0.5) 4.0 (1.9)

22.9 (3.3) 27.2 (4.0)

Some college

28.1 (0.8)

13.2 (1.8)

28.2 (3.0)

19.3 (3.5)

10.3 (2.7)

10.4 (2.7)

19.3 (3.2)

College graduate

49.5 (0.8)

63.7 (2.5)

53.1 (3.1)

67.8 (4.2)

70.1 (3.8)

84.7 (3.2)

30.7 (3.8)

Near poor Not poor Place of residence MSA Non-MSA Household type

Respondent’s education

Other parental characteristics Both parents foreign born

5.2 (0.4)

66.8 (2.5)

53.2 (2.8)

14.8 (3.5)

82.8 (3.0)

88.24 (2.1)

86.1 (2.7)

MKA speaks English less than well

1.8 (0.4)

34.8 (3.1)

9.1 (2.1)

8.0 (3.4)

45.9 (4.3)

1.13 (0.5)

57.7 (4.2)

Mother not US citizen

4.2 (0.3)

29.9 (2.6)

22.2 (2.6)

27.1 (3.9)

55.4 (3.8)

53.3 (3.9)

30.8 (3.8)

Father not US citizen

4.0 (0.3)

25.7 (2.5)

16.6 (2.4)

12.4 (3.1)

47.9 (4.0)

51.5 (4.0)

17.9 (3.4)

Note. MKA = most knowledgeable adult; MSA = metropolitan statistical area. Sample sizes are unweighted. All percentages are weighted.

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non-Hispanic White children lived in nonmetropolitan areas. Parental education attainment varied substantially among the ethnic groups. Eighty-five percent of South Asian parents were college graduates, whereas only 31% of Vietnamese parents were. More than two thirds of Chinese, Japanese, and Korean parents also had at least a college degree. Nearly 60% of Vietnamese and nearly half of Korean parents did not speak English ‘‘very well’’ or were considered of limited English proficiency. More than 80% of Koreans, South Asians, and Vietnamese children had 2 foreign-born parents. About one half of Korean and South Asian children had noncitizen parents. Approximately one sixth of Filipino and Vietnamese children came from single-parent households. Table 2 shows children’s health status and health care access and utilization characteristics by ethnicity. In general, Asian American children (except for Japanese children) had

a lower prevalence of physical, behavioral, or mental limitations compared with non-Hispanic White children. Japanese and Filipino children had similar rates of asthma compared with non-Hispanic White children, whereas children in all other Asian subgroups had lower rates of asthma. Ethnic patterns in attention deficit hyperactivity disorder were similar to those for asthma. Rates for ever having been breastfed (aged 1 to 3 years) for all Asian groups were similar to those for non-Hispanic Whites, except for Vietnamese children, 34% of whom were never breastfed. Except for Japanese children, children in all Asian subgroups were more likely to be in fair or poor health compared with non-Hispanic White children. In particular, one quarter of Vietnamese children were reported by their parents to be in fair or poor health. With respect to health care access, Korean, Filipino, and Vietnamese children were more

likely to be without health insurance at the time of the interview than were non-Hispanic White children. Nearly 13% of Korean children were uninsured. Approximately 11% of Korean children and 13% of Filipino children did not have contact with a health professional within the past 12 months. Korean and Vietnamese children were more likely to be without a usual place for health care and to have had no contact with a health professional within the past 12 months than were non-Hispanic White children. Filipino, Korean, and Vietnamese children were more likely to not have had a well-child visit within the past 12 months than were non-Hispanic White children. Except for South Asians, children in all Asian groups were less likely to have had an emergency room visit within the past year than were non-Hispanic White children. More than one third of South Asian children aged 3 years and older had never seen a dentist.

TABLE 2—Health Status and Health Services Access and Utilization Characteristics of Asian American Children: California Health Interview Survey, 2003–2005 Non-Hispanic White, % (SE) Health status Parent-assessed fair or poor health

Chinese, % (SE)

Filipino, % (SE)

Japanese, % (SE)

Korean, % (SE)

South Asian, % (SE)

Vietnamese, % (SE)

Pa