Disparities in routine physical examinations among in-school adolescents of differing Latino origins

JOURNAL OF ADOLESCENT HEALTH 2004;35:310 –320

ORIGINAL ARTICLE

Disparities in Routine Physical Examinations Among In-School Adolescents of Differing Latino Origins OLGA L. SARMIENTO, M.D., M.P.H., Ph.D., WILLIAM C. MILLER, M.D., Ph.D., M.P.H., CAROL A. FORD, M.D., VICTOR J. SCHOENBACH, Ph.D., CLAIRE I. VIADRO, Ph.D., M.P.H., ADAORA A. ADIMORA, M.D., M.P.H., AND CHIRAYATH M. SUCHINDRAN, Ph.D.

Purpose: To estimate the prevalence of routine physical examination among in-school adolescents of differing national Latino origins and to assess associations with gender, age, immigrant generational status, language spoken at home, parental education, poverty level, family structure, and insurance status. Methods: Cross-sectional analysis of Wave I of the National Longitudinal Study of Adolescent Health conducted during 1995. Our sample was limited to adolescents in grades 7 through 12 of Mexican (n ⴝ 1657), Cuban (n ⴝ 490), Puerto Rican (n ⴝ 555), and Central/ South American or Dominican (C/S American or DR) (n ⴝ 427) origins. We used multivariate logistic regression for survey data to conduct the data analyses. Results: Mexican-origin adolescents were less likely to report a routine physical examination in the previous year, compared with other Latino populations [prevalence (95% confidence interval)]: Mexicans, 47.7 % (42.0% –53.6%], Cubans 67.6% (57.4%–76.4%), Puerto Ricans 65.2% (58.4%–71.4%), and C/S American or DR (57.0% [47.3– 66.2]). Among Mexican-origin adolescents, having a college-educated parent or insurance was associated with receiving care (adjusted prevalence odds ratio [95% confidence interval]), 2.12 (1.37–3.30) and 1.80 (1.31–2.47), respectively. For Cuban-origin adolescents, first-generation immigrants were less likely to receive care (0.31 [0.14 – 0.70]), and those living in a single-parent home From the Departments of Epidemiology (O.L.S., W.C.M., V.J.S., A.A.A.), Health Behavior and Health Education (C.I.V.), and Biostatistics (C.M.S.), School of Public Health, and the Departments of Medicine (W.C.M., C.A.F., A.A.A.) and Pediatrics (C.A.F.), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Address correspondence to: William C. Miller, M.D., Ph.D., M.P.H., Department of Epidemiology, CB#7435, 2105F McGavran, Greenberg Hall, Chapel Hill, North Carolina 27599-7435. Manuscript accepted September 26, 2003. 1054-139X/04/$–see front matter doi:10.1016/j.jadohealth.2003.09.020

were more likely to receive care (2.83 [1.52–5.25]). Having a routine physical examination among adolescents of C/S American or DR origins was associated with incomes above the poverty level (2.29 [1.10 – 4.77] and insurance (2.33 [1.10 – 4.91]). Conclusions: Reflecting the heterogeneity of Latino adolescents, the prevalence of routine physical examination and factors associated with it varied by national origin subgroup. These differences should be considered when developing strategies to better address the health needs of Latino youth. © Society for Adolescent Medicine, 2004 KEY WORDS:

Adolescence Disparities Health care utilization Hispanic

National and regional surveys have found that Latino adolescents report fewer annual visits for general health care than non-Latino Whites and Blacks [1–3]. In a previous analysis of the National Longitudinal Study of Adolescent Health (Add Health), Latino adolescents (62%) were less likely to have a physical examination in the previous year than non-Latino Whites (68%) or non-Latino Blacks (70%) [2]. Latino youth who do not receive routine health care do not receive screening for risk-associated behaviors and health problems or risk-reduction and prevention counseling from health care providers. These missed opportunities may increase the risk of preventable health problems that disproportionately affect U.S. Latinos, including sexually © Society for Adolescent Medicine, 2004 Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010

October 2004

transmitted diseases [4], unintended pregnancy [5], tuberculosis [6], substance use [7], depression [7], attempted suicide [8], and unintentional injuries [9]. The use of routine care by Latinos may differ according to national origin subgroup owing to the heterogeneity that characterizes these rapidly growing populations [10]. The population of Latino youth grew by 26% between 1994 and 2000, and it is expected to grow by 60% from 2000 to 2016 [11]. Among U.S. Latino adolescents aged 12–19 years in the year 2000, approximately two-thirds (69%) are of Mexican origin, 12.5% are Central and South American, 9.6% are Puerto Rican, and 3% are of Cuban origin (11). Latinos also vary in patterns of geographic distribution [12], socioeconomic status [12], family structure [12], and insurance coverage [9,13,14]. Although heterogeneity among Latino populations likely influences the effectiveness of health care policy initiatives addressing racial and ethnic disparities, Latino adolescent populations are often grouped in a single category in health care utilization research [2,15–17]. As a result, the extent of differences in use of routine health care among different populations of Latino adolescents, as defined by national origin subgroup, is unknown. This study begins to address this gap and is designed to increase our understanding of disparities in use of routine health care among Latino adolescents of different national origin subgroups. Within in-school Latino adolescents of Mexican, Cuban, Puerto Rican, and Central/South American or Dominican Republic (C/S American or DR) origins, our objectives were: (a) to estimate the prevalence of having had a routine physical examination within the past year, and (b) to identify predisposing (gender, age, immigrant generational status, and language spoken at home) and enabling (parental education, poverty level, family structure, and insurance status) factors associated with having had a routine physical examination.

Methods Sample Design We conducted a cross-sectional analysis of data from Wave I of Add Health, collected in 1995 from adolescents in grades 7 through 12. Add Health used a multistage, stratified, school-based cluster sampling design that has been described in detail elsewhere [18]. Briefly, a sample of 80 high schools and their feeder middle or junior high schools stratified by region, urbanicity, school type (public, private, and

ROUTINE HEALTH CARE AMONG LATINOS

311

parochial), racial composition, and size was selected with probability proportional to enrollment size. Using school rosters, a random sample of adolescents stratified by grade and gender (with oversampling of Puerto Ricans and Cubans) was selected for an in-home interview. Interviews were conducted in English using computer-assisted personal interview and audio computer-assisted self-interview technology. In addition, interviews using a paper questionnaire were conducted with a parent or guardian. A Spanish-language version of the parental questionnaire was chosen by 25% of parents of Latino origin. All protocols were approved by the University of North Carolina Institutional Review Board on Research Involving Human Subjects. Study Populations The study population for our analyses consisted of adolescents who self-identified as being of Latino background or who had a parent or guardian who self-identified as being of Latino background. Latino background was measured by responses to the following questions: “Are you of Hispanic/Latino origin?” and “What is your Hispanic or Latino background? You may give more than one answer (Mexican, Chicano, Cuban, Puerto Rican, Central/ South American, other).” Of the 18,924 adolescents interviewed 3331 were Latino. However, 6% (n ⫽ 202) of these were excluded from the analyses because their specific Latino background could not be ascertained, resulting in a final sample size of 3129. For analyses by Latino national origin subgroup, we categorized adolescents as follows: (a) Mexican (n ⫽ 1657), (b) Cuban (n ⫽ 490), (c) Puerto Rican (n ⫽ 555), and (d) C/S American or DR (n ⫽ 427). Chicanos were classified as Mexican. We grouped youth whose family origin was Dominican or Central or South American into a single category because the sample sizes for each group were insufficient for separate analysis. Analyses excluding adolescents of DR origin from this category did not change results (11% of foreign born C/S American or DR Latino adolescents were Dominicans). Adolescents who marked the “other” category for Latino origin, reported multiple Latino origins, or did not know their Latino origin were classified according to their country of birth, if foreign born, or according to the background of the parent or guardian who answered the parental questionnaire. Our analysis focuses on Latino national origin subgroup (referring to the country or region in which the adolescent or the adolescent’s parent or ancestors were born) because

312

SARMIENTO ET AL

Latinos have shown a preference for identifying themselves with a national origin– based term [19]. Outcome Measure The outcome, routine physical examination, was measured by the question: “In the past year have you had a routine physical examination?” Independent Variables To guide our analysis, we used the Andersen Behavioral Model of Health Care [20,21]. According to this conceptual model, having a routine physical examination is determined in part by predisposing and enabling factors. Predisposing factors. We included four predisposing factors: gender, age, primary language spoken at home, and immigrant generational status. Gender, age (computed from date of birth), and primary language spoken at home (“What language is usually spoken at home?”[English vs. Spanish/other]) were determined from adolescents’ interviews. Age was grouped into two categories (ⱕ15 years vs. ⬎15 years). Immigrant generational status was coded as “firstgeneration” if the adolescent reported being born outside the United States and had at least one foreign-born parent. Adolescents who had at least one foreign-born parent but who were born in the United States were considered “second-generation immigrants,” and adolescents were classified as “third-generation immigrants” if they and their parent(s) were United States born. Owing to the small sample size of the third-generation category among Cubans and C/S American or DR adolescents, immigrant generational status was recoded as a dichotomous variable (“first-generation” vs. “second- or third-generation”) to permit comparisons across populations. Puerto Rican– origin adolescents are not immigrants but U.S. citizens born in either Puerto Rico or on the U.S. mainland. We could not classify Puerto Rican– origin adolescents according to place of birth because they were not asked specifically whether they were born in Puerto Rico but only whether they were born in the United States. Because many Puerto Ricans may have responded affirmatively to this question even if born on the island [22], no measure of immigrant status was available for this group. Enabling factors. We included three enabling factors from the parent questionnaire: parental educa-

JOURNAL OF ADOLESCENT HEALTH Vol. 35, No. 4

tional attainment, poverty level, and insurance status. The highest level of education of parents in the household was coded into three categories (“less than high school,” “high school,” and “more than high school”). Household income was coded as being above poverty level or not, based on household size and the 1994 federal poverty threshold. Insurance status was coded as “private” if the adolescent had individual or group private coverage (Blue Cross or Cigna) or had a prepaid health plan coverage (health maintenance organization or the Civilian Health or Medical Program of the Uniformed Services). Insurance was coded as “public” if the adolescent had Medicare or Medicaid and as “other insurance” if the parent reported “other” without specifying the type. In bivariate analysis insurance was coded into three categories (“private” vs. “public” vs. “none”). In multivariate analysis, we used a dichotomous variable (“insured” vs. “uninsured”). Family structure was coded in two categories (“single parent” vs. “two parents/guardians”).

Statistical Analysis Our analytic strategy involved several steps. First, we described the prevalence of routine physical examination and predisposing and enabling characteristics within each national origin subgroup and assessed differences in these prevalences across subgroups, with the design-based Pearson Chi-square statistic. Second, we conducted multivariate analyses to assess the independent association between national origin subgroup and having a routine physical examination after adjusting for predisposing and enabling characteristics. Third, we used interaction terms and the Cochran’s Q test of homogeneity [23] to compare factors associated with having an examination across all four subgroups. Analyses were conducted using Stata [23], with appropriate weighting and adjustment for the sampling design. We assessed multicollinearity by examining regression diagnostics. Language spoken at home was strongly correlated with immigrant generational status among the populations of Mexicans and Latinos of C/S American or DR origins. Therefore, only immigrant status was assessed in final multivariate subgroup analyses including Mexicans, Cubans, and Latinos of C/S American or DR origins. In multivariate models that included Puerto Ricans (for whom we did not have measures of immigrant status), we used language spoken at home as a measure of cultural factors.

October 2004

ROUTINE HEALTH CARE AMONG LATINOS

313

Table 1. Prevalence of Predisposing, Enabling Characteristics and Routine Care of Adolescents of Mexican, Cuban, Puerto Rican, and C/S America or DR Origin* Mexican N ⫽ 1657 Factor

na

Predisposing factors Gender Male 834 Female 822 Mean age, yr 1653 Immigrant generational status First generation 286 Second generation 724 Third generation 612 Language spoken at home Spanish/other 764 English 889 Enabling factors Parental education Less than high school 769 High school graduate 364 Some college 305 College or more 171 Poverty level At or below 358 Above 701 Family structure Mother only 296 Father only 46 Two biological parents 956 Stepparents 242 Other formse 117 Insurance status None 404 Private continuous 593 Private interrupted 48 Public continuous 124 Public interrupted 28 Routine physical examination Yes 798 No 847

P

95% CIb

Cuban N ⫽ 490

Puerto Rican N ⫽ 555

C/S American or DR N ⫽ 427

P

95% CI

n

P

95% CI

n

241 249 339

46.9 53.1 16.1

(41.1–52.8) (47.3–58.9) (14.5–17.6)

280 275 554

53.0 47.1 15.8

(45.8 – 60.0) (40.0 –54.2) (15.1–16.5)

213 214 427

50.0 (43.0 –57.0) 50.1 (43.1–57.1) 16.4 (15.6 –17.2)

20.9 (16.1–26.7) 220 36.2 (29.8 – 43.1) 239 43.0 (33.2–53.3) 25

29.2 60.9 9.9

(17.7– 44.3) (45.7–74.2) (3.4 –25.3)

238 124 40

61.1 (48.1–72.7) 38.9 (20.0 –35.8) 11.8 (6.4 –20.8)

⬍.001

43.9 (36.4 –51.8) 366 56.1 (48.2– 63.6) 122

61.9 38.1

(45.1–76.3) (23.7–55.0)

106 449

21.1 78.9

(14.0 –30.7) (69.3– 86.0)

273 153

67.4 (52.0 –79.8) 32.6 (20.2– 48.0)

⬍.001

45.8 (37.1–54.8) 22.9 (18.4 –28.2) 20.2 (16.7–24.3) 11.0 (8.1–14.8)

152 132 103 95

31.3 (23.2– 40.7) 116 27.6 (23.1–32.6) 180 20.5 (18.0 –23.2) 157 20.7 (12.1–33.0) 98

23.1 35.5 26.1 15.4

(16.9 –30.7) (29.9 – 41.5) (18.5–35.4) (12.3–19.0)

135 82 98 103

33.4 15.6 26.2 24.7

⬍.001

(33.3– 44.5) 130 (55.5– 66.7) 236

43.5 (30.4 –56.5) 120 56.5 (43.5– 69.6) 311

30.1 69.9

(21.3–38.9) (61.1–78.7)

118 192

45.0 (33.5–56.4) 55.0 (43.6 – 66.5)

.15

18.8 (15.0 –23.3) 125 3.4 (2.3–5.0) 14 55.0 (47.9 – 61.9) 243 15.5 (11.9 –19.9) 76 7.3 (5.8 –9.1) 32

27.7 (22.2–34.0) 161 2.4 (0.9 – 6.4) 11 49.2 (36.4 – 62.1) 230 14.6 (7.4 –26.8) 120 6.1 (2.4 –14.5) 33

34.4 1.7 36.5 22.0 5.5

(27.8 – 41.5) (0.7–1.8) (29.8 – 43.7) (16.7–28.3) (3.7– 8.1)

110 6 198 87 26

24.5 (19.0 –31.1) 1.4 (0.4,4.8) 49.2 (42.0,56.3) 19.7 (16.0,24.0) 5.3 (3.3,8.4)

.005

36.3 44.8 3.4 12.7 2.8

24.7 (14.8 –38.0) 65 52.7 (41.9 – 63.2) 274 3.7 (1.8 –7.5) 20 15.7 (6.0 –35.2) 93 3.2 (2.2– 4.6) 10

13.7 54.5 4.1 25.1 2.6

(9.6 –19.3) (44.9 – 63.8) (1.7–9.6) (17.5–34.5) (1.1– 6.3)

129 163 13 33 12

38.9 (27.4 –51.9) 42.0 (30.9 –53.9) 5.8 (3.5–9.4) 9.6 (4.8 –18.3) 3.8 (1.8 – 8.0)

.01

67.6 (57.4 –76.4) 378 32.4 (23.6 – 42.7) 176

65.2 34.8

(58.4 –71.4) (28.6 – 41.6)

258 164

57.0 (47.3– 66.2) 43.0 (33.8 –52.7)

.001

51.7 (48.1–55.3) 48.3 (44.7–51.9) 16.0 (15.4 –16.5)

38.9 61.1

(29.7– 43.4) 108 (38.3–51.5) 221 (2.2–5.3) 23 (8.7–18.2) 51 (1.5–5.1) 12

47.7 (42.0 –53.6) 52.3 (46.4 –58.0)

306 181

NAd

P

95% CI

pc

n

(26.1– 41.7) (11.9 –20.3) (21.2–31.9) (17.6 –33.6)

.69 .71

a

Unweighted sample size. Sample sizes may not sum to total N owing to missing data. Weighted percentage (p) and 95% confidence intervals (CI). The p value of test of homogeneity to assess differences of prevalence estimates across the four populations. d NA, Adolescents of Puerto Rican origin were not classified according to immigrant generational status. e Other forms include grandparents, other relatives, group home. b c

Sensitivity Analysis of Missing Data We conducted sensitivity analyses to assess the effect of missing data for insurance status (range 12% to 20% among subgroups) and poverty level (range 22% to 36% among subgroups) (Table 1). We created 10 imputed data sets using the Markov Chain Monte Carlo method in SAS [24]. The imputation model included all the predisposing and enabling factors analyzed in the final multivariate models and other correlated variables (mother’s employment status, parental receipt of Aid to Families with Dependent

Children, food stamps, or Supplemental Security Income). The multiple imputation procedure provided more precise estimates for poverty level but not insurance status. Poverty level was imputed in our final analyses.

Results Study Populations Predisposing and enabling characteristics among Mexican, Cuban, Puerto Rican, and C/S American or

314

SARMIENTO ET AL

DR adolescents are shown in Table 1. Adolescents of C/S American or DR origins were predominantly first-generation immigrants (61.1%), whereas most Cuban-origin (70.8%) and Mexican-origin (79.2%) adolescents were second- or third-generation immigrants. Adolescents of Puerto Rican origin were more likely to report speaking English at home than were the other three populations. About half of the adolescents of Mexican origin (45.8%) had parents with less than a high school education, compared with less than one-third for the other three groups. Puerto Rican– origin youth were more likely than the other three groups to live in a single-parent home. Nearly 40% of Mexican and C/S American or DR origin adolescents were uninsured, compared with 25% and 14% of adolescents of Cuban and Puerto Rican origins, respectively. Gender, age, and poverty level did not differ meaningfully across Latino populations.

Prevalence of Routine Physical Examination Overall, 53% [95% confidence interval (CI), 47.7–57.9] of adolescents of Latino origin reported having had a routine physical examination in the past year, although the prevalence of routine examination differed by national origin subgroup (Table 1). Fewer than half (47.7%, 95% CI, 42.0 –53.6) of Mexicanorigin youth reported having had a routine examination in the previous year, compared with approximately three-fifths (57%, 95% CI, 47.3– 66.2) of adolescents of C/S American or DR origins and about two-thirds of Cuban (67.6%, 95% CI, 57.4 –76.4) and Puerto Rican (65.2%, 95% CI, 58.4 –71.4) adolescents. After adjusting for all enabling and predisposing factors, adolescents of Cuban, Puerto Rican, and C/S American or DR origins continued to be significantly more likely to have had a routine physical examination in the past year than adolescents of Mexican origin (Table 2).

Factors Associated With Routine Examination Within Each Latino National Origin Subgroup Adolescents of Mexican origin. Mexican-origin adolescents who reported speaking English at home were more likely to have received a routine physical examination than those who reported speaking Spanish or another language (52.0% vs. 42.3%; p ⫽ .004) (Table 3). Mexican-origin youth whose parent(s) had more than high school education were

JOURNAL OF ADOLESCENT HEALTH Vol. 35, No. 4

Table 2. Adjusted Prevalence Odds Ratios for Having a Routine Physical Examination in the Past Year Among Latino Adolescents Factor Latino national origin subgroup Mexican Cuban Puerto Rican C/S American or DR Predisposing Gender Male Female Age, yr 11–15 16 –21 Language spoken at homeb Spanish/other English Enabling Parental education Less than high school High school Some college or more Poverty level At or below Above Family structure Single parent/guardian Two parent/guardian Insurance status Yes None

POR

95% CI

1.00a 2.15 1.68 1.62

(1.16 – 4.00) (1.11–2.55) (1.06 –2.47)

0.97 1.00

(0.79 –1.20)

0.86 1.00

(0.66 –1.10)

0.98 1.00

(0.76 –1.27)

1.00 1.08 1.60

(0.74 –1.58) (1.09 –2.35)

1.00 1.14

(0.83–1.56)

1.44 1.00

(1.07–1.93)

1.85 1.00

(1.43–2.39)

a

Reference group. An analysis including immigrant generational status instead of language spoken at home, but excluding Puerto Rican origin youth, lead to similar results. POR ⫽ prevalence odds ratio; CI ⫽ confidence interval. b

more likely to have received a routine physical examination, as were insured Mexican-origin adolescents [private (52.4%) vs. public [54.1%] vs. none (36.7%); p ⬍ .001]. In multivariate analyses (Table 4), insurance status and parental education remained associated with receiving a routine physical examination. Adolescents of Cuban origin. Younger Cuban-origin adolescents (ⱕ15 years) were more likely to have received a routine physical examination than those older than 15 years (75.2% vs. 58.9%; p ⫽ .02) (Table 3), as were second- or third-generation immigrants, compared with first-generation immigrants (71.6% vs. 58.3%; p ⱖ .05). Living with a single parent (79.9% vs. 62.4%; p ⫽ .01) and having public insurance [public (93.3%) vs. private [64.1%] vs. none (56.9%); p ⬍ .001] also were associated with having received a routine physical examination. In multivariate anal-

October 2004

ROUTINE HEALTH CARE AMONG LATINOS

315

Table 3. Estimated Prevalence of Routine Physical Examination and Unadjusted Prevalence Odds Ratios for Report of Routine Health Care Within the Past Year Among Adolescents of Mexican, Cuban, Puerto Rican, and C/S American or DR Origin by Predisposing and Enabling Factors Mexican Factor

P

Predisposing factors Gender Male 47.8 Female 47.7 Age, yr 11–15 46.9 16 –21 48.6 Immigrant generational First generation 42.2 Second/Third 48.9 generation Language spoken at home Spanish/other 42.3 English 52.0 Enabling factors Parental education Less than high 39.2 school High school 48.0 graduate Some college 55.7 College or 64.3 more Poverty level At or below 44.7 Above 49.7 Family structure Single parent 53.6 Two parent 46.1 Insurance status None 36.7 Private 52.4 Public 54.1

(SE) POR (95% CI)

Cuban P

(SE) POR

Puerto Rican (95% CI)

P

C/S America or DR

(SE) POR (95% CI)

P

(SE) POR (95% CI)

(3.7) 1.00 (0.76 –1.32) 70.6 (4.1) 65.0 (10.5) (3.1) 1.00a

1.29 (0.40 – 4.20) 64.2 (4.3) 0.91 (0.53–1.56) 56.8 1.00 66.4 (4.7) 1.00 57.3

(6.3) 0.98 (0.58 –1.65) (5.3) 1.00

(3.3) 0.93 (0.67–1.31) 75.2 (3.9) 1.00 58.9 status (5.8) 0.76 (0.50 –1.10) 58.3 (2.7) 1.00 71.6

(3.6) (4.5)

2.11 (1.16 –3.84) 1.00

(5.2) 1.16 (0.69 –1.94) (6.1) 1.00

(7.0) (4.8)

0.56 (0.31–1.01) 1.00

(3.1) 0.68 (0.52– 0.88) 70.0 (3.3) 1.00 63.9

(4.1) (7.7)

62.7 (5.9) 0.77 (0.40 –1.49) 59.2 68.5 (3.8) 1.00 55.5 NAb

49.5 68.2

(5.8) 0.46 (0.22– 0.96) (7.0) 1.00

1.32 (0.78 –2.22) 1.00

64.0 (7.1) 0.94 (0.54 –1.62) 52.3 65.5 (3.0) 1.00 67.0

(5.1) 0.54 (0.29 –1.01) (6.8) 1.00

1.00

71.7 (7.4) 1.00

(7.0) 1.00

(4.0)

0.35 (0.06 –2.19)

55.3 (6.5) 0.49 (0.19 –1.23) 61.8

(8.7) 1.76 (0.75– 4.16)

(4.3) 1.95 (1.28 –2.96) 78.2 (5.1) (5.4) 2.79 (1.61– 4.84) 54.0 (10.5)

0.85 (0.28 –2.57) 0.28 (0.03–2.64)

69.1 (6.0) 0.88 (0.38 –2.05) 53.1 72.4 (6.6) 1.03 (0.34 –3.18) 72.0

(7.5) 1.23 (0.65–2.35) (5.9) 2.80 (1.32–5.95)

(4.2) 1.00 68.2 (3.2) 1.22 (0.86 –1.73) 67.2

(8.6) (4.2)

1.00 0.95 (0.43–2.11)

64.6 (7.3) 1.00 43.7 65.5 (3.7) 1.04 (0.50 –2.14) 67.8

(6.0) 1.00 (4.8) 2.72 (1.63– 4.54)

(4.9) 1.35 (0.93–1.96) 79.9 (2.9) 1.00 62.4

(6.6) (4.5)

2.39 (1.28 – 4.48) 70.5 (4.6) 1.45 (0.88 –2.40) 60.4 1.00 62.2 (4.1) 1.00 55.9

(6.5) 1.21 (0.72–2.03) (5.2) 1.00

(3.7) 1.00

80.8 (12.7)

(3.3) 1.43 (1.00 –2.06) 59.6

47.9

(3.8) 1.00 56.9 (13.1) 1.00 61.3 (8.5) 1.00 44.7 (5.4) 1.00 (3.1) 1.89 (1.35–2.65) 64.1 (5.2) 1.35 (0.33–5.46) 69.1 (4.2) 1.41 (0.57–3.48) 70.8 (4.9) 3.00 (1.58 –5.60) (5.0) 2.03 (1.26 –3.29) 93.3 (7.2) 10.57 (2.90 –38.50) 61.5 (7.3) 1.01 (0.36 –2.84) 65.1 (13.9) 2.30 (0.84 – 6.30)

a

Reference group. NA: Adolescents of Puerto Rican origin were not classified according to immigrant generational status. CI ⫽ confidence interval; P ⫽ weighted percentage; POR ⫽ prevalence odds ratio. b

ysis (Table 4), immigrant generational status and family structure remained associated with reports of having received a routine physical examination in the past year. Adolescents of Puerto Rican origin. For Puerto Rican adolescents, the association of predisposing and enabling factors with having a routine physical examination was weak in both bivariate (Table 3) and multivariate analyses (Table 4). Adolescents of CS American or DR origin. Second- or third-generation immigrants (68.2% vs. 49.5%; p ⫽ .04) were more likely to have received a routine

physical examination than were first-generation immigrants (Table 3). Adolescents whose parent(s) had completed college [college or more (72%) vs. less than high school [47.9%]; p ⫽ .01] and adolescents living in households above poverty level (67.8% vs. 43.7%; p ⬍ .001) also were more likely to have received a routine physical examination. Private insurance coverage was associated with having received a routine physical examination [private (70.8%) vs. public [65.1%] vs. none (44.7%); p ⫽ .001]. In multivariate analyses, poverty level and insurance coverage remained associated with having a routine physical examination (Table 4).

SARMIENTO ET AL

316

JOURNAL OF ADOLESCENT HEALTH Vol. 35, No. 4

Table 4. Adjusted Prevalence Odds Ratios for Report of Routine Physical Examination Within the Past Year Among Adolescents of Mexican, Cuban, Puerto Rican, and C/S America or DR Origin by Predisposing and Enabling Factors Mexican Factor Predisposing factors Gender Male Female Age, yr 11–15 16 –21 Immigrant generational status First generation Second/Third generation Enabling factors Parental education Less than high school High school Some college or more Poverty level At or below Above Family structure Single parent Two parent/guardian Insurance status Yes None

Cuban

Puerto Rican

C/S America or DR

POR

(95% CI)

POR

(95% CI)

POR

(95% CI)

POR

(95% CI)

pa

1.01 1.00b

(0.78 –1.31)

1.24 1.00

(0.38 – 4.04)

0.83 1.00

(0.48 –1.43)

0.94 1.00

(0.59 –1.49)

.89

0.83 1.00

(0.58 –1.19)

1.85 1.00

(0.90 –3.80)

0.78 1.00

(0.37–1.61)

0.87 1.00

(0.50 –1.49)

.05

1.35 1.00

(0.84 –2.17)

0.31 1.00

(0.14 – 0.70)

0.85c 1.00

(0.46 –1.56)

0.90 1.00

(0.34 –2.40)

.01d

1.00 1.36 2.12

(0.93–1.99) (1.37–3.30)

1.00 0.25 0.32

(0.04 –1.63) (0.06 –1.62)

1.00 0.54 0.96

(0.19 –1.52) (0.33–2.81)

1.00 1.25 1.19

(0.46 –3.40) (0.57–2.46)

.03

1.00 0.97

(0.65–1.46)

1.00 1.49

(0.85–2.60)

1.00 1.15

(0.47–2.83)

1.00 2.29

(1.10 – 4.77)

.045

1.36 1.00

(0.88 –2.12)

2.83 1.00

(1.52–5.25)

1.22 1.00

(0.70 –2.15)

1.50 1.00

(0.95–2.37)

.19

1.80 1.00

(1.31–2.47)

1.37 1.00

(0.51–3.70)

1.26 1.00

(0.50 –3.13)

2.33 1.00

(1.10 – 4.91)

.73

a

p value of test of homogeneity to test equality in prevalence odds ratios estimates across the populations. Reference group. Adolescents of Puerto Rican origin were not classified according to immigrant generational status. In this model we used language spoken at home. d Comparing Mexican, Cuban, and C/S American or DR populations. POR ⫽ prevalence odds ratio; CI ⫽ confidence interval. b c

Across-Group Comparison of Factors Associated With Having a Routine Physical Examination Patterns of association between predisposing/enabling factors and routine physical examination in the past year showed significant differences across subgroups (final column of Table 4). In particular, the associations of recent routine physical examinations with immigrant generational status, parental education, and poverty level were different across groups. First-generation immigrants of Cuban origin were less likely to have received a routine physical examination than second- or third- generation immigrants, whereas an opposite but not significant association was observed among Mexicans. Higher parental education increased the likelihood of receiving a routine physical examination among Mexican-origin adolescents, whereas an opposite but not significant association was observed among Cuban-origin adolescents. Adolescents of C/S American or DR origins living above the poverty level were more

likely to have received a routine physical examination, whereas poverty did not have an association among adolescents of Mexican national origin. The strength of the positive association between insurance status and having a routine physical examination did not differ significantly across Latino populations.

Discussion Our results suggest that 53% of adolescents, who represent 1.2 million in-school English-speaking Latino adolescents of Mexican, Cuban, Puerto Rican, and C/S American or DR origins, do not receive an annual routine physical examination as recommended by the American Academy of Pediatrics [25]. Reflecting the heterogeneity of Latino populations in the United States, significant disparities in the prevalence of recent routine health care visits were evident among adolescents of differing national

October 2004

origin subgroups. Whereas only about one in two (48%) adolescents of Mexican origin reported having had a routine physical examination in the previous year, about two in three adolescents of Cuban (68%) and Puerto Rican (65%) origins and three of five (57%) adolescents of C/S American or DR origin reported having received a routine physical examination. To place these prevalence disparities in context, the prevalence of having had an annual physical examination among in-school non-Latino Whites and non-Latino Blacks has been reported to be 68% and 70%, respectively [2]. These proportions are similar to the prevalences found among Puerto Rican– and Cuban-origin youth in our study. The low prevalence of recent routine physical examinations among our sample of in-school Latino adolescents mostly appears to be accounted for by the lower reports of routine health care use among Mexican-origin adolescents and, to a lesser extent, C/S American– or DR-origin adolescents. However, even among our high-use Latino adolescents (Cubans, Puerto Ricans), the prevalence of having had a routine physical examination was still substantially lower than national estimates of annual health care for Latino children aged 0 to 17 years of Mexican (74%), Cuban (87%), and Puerto Rican (78%) origins [26]. Our finding that the annual prevalence of having a routine physical examination is lower among Mexican-origin adolescents than among Cuban-origin and Puerto Rican– origin adolescents is consistent with other studies of general health care use among children of all ages [26] and adults [13,22,27]. However, in addition to documenting that disparities persisted in use of health care by Mexican-origin adolescents as compared with other Latino populations, even after adjusting for predisposing and enabling factors, our study assessed the influence of these factors within each Latino population. We detected important differences between patterns and predictors of health care utilization among adolescents of Mexican, Cuban, Puerto Rican, and C/S American or DR origins. These differences would have been missed if our analyses had treated Latinos as a single homogenous group or if national origin subgroup had been simply included as a categorical variable in multivariate analyses. We therefore concur with recommendations for taking into consideration the heterogeneity of U.S. Latino populations when designing studies and policies related to improving Latino health care [10,26,28]. Our treatment of ethnicity as an external factor not only allowed us to assess differences among popu-

ROUTINE HEALTH CARE AMONG LATINOS

317

lations but also advances understanding of health care utilization within each Latino population. For example, for Mexican-origin adolescents, the factors most strongly associated with having received a recent physical examination were insurance coverage and parental education. Insurance coverage and poverty index were the most influential variables for C/S American or DR adolescents. For adolescents of Cuban origin, the main factor associated with having received a routine physical examination was immigrant generational status. These different associations have implications for the design of policies, interventions, and research aimed at improving health care and health among in-school Latino populations. The importance of expanding insurance coverage as an approach to decrease racial and ethnic disparities in use of preventive health care has been widely documented [17,28 –30] and is supported by our study. However, even among insured adolescents of Mexican origin, the prevalence of having had a routine physical examination was only 53%. Furthermore, after adjusting for insurance status the disparity between Mexican-origin adolescents and the three other Latino populations persisted. Together, these findings suggest that insurance coverage alone will not ensure that Latino adolescents receive routine health care. Among Puerto Rican– origin adolescents, the associations between predisposing and enabling factors and having a routine physical examination were not significant. Other studies have suggested that Puerto Rican– origin children may be less affected by financial factors than children of Mexican or Cuban origin [28]. A study, in which one-third (36%) of the sample consisted of Puerto Rico– born Latino adolescents, found that variables such as alcohol use and feeling connected to friends at school were associated with having had a physical examination within the past 2 years [31]. Both the higher prevalence of routine care as well as the lesser influence of financial factors could, in part, reflect familiarity with the health care system and access privileges that accrue to Puerto Rican– origin adolescents as U.S. citizens. Add Heath provides more precise estimates of health care utilization patterns of Latino subgroups than other national [26] or regional school surveys [31] that have analyzed Latino subgroups to date because of the large sample size and the oversampling of Cubans and Puerto Ricans. In addition, compared with other national surveys [26] with high representation of Latino children, Add Health may provide more accurate estimates of adolescent health

318

SARMIENTO ET AL

care utilization because adolescents rather than their parents reported their health care utilization patterns. Despite the advantages of Add Health to assess health care utilization among Latino adolescents, the sampling frame is limited because it was schoolbased, and non–English-speaking adolescents were excluded. Out-of-school youth as well as adolescents in limited English proficient programs are more likely to be first-generation immigrants, poor and undocumented, and of Mexican origin [32]. As a result, our prevalence results are likely to have overestimated the prevalence of receiving a routine physical examination, particularly among first-generation Mexican immigrants. Furthermore, Puerto Ricans in our sample did not have significantly higher poverty rates than Cubans or Mexicans. This finding differs from results of the National Health Interview (NHI) Survey including monolingual Spanish speakers and out-of-school children [26]. These differentials in poverty level between our study and the NHI survey could also be related to differences in the sampling frame of Add Health. It is likely that Add Health excluded the poorest population of Puerto Ricans and Mexicans (out of school and linguistically isolated youth), which contributes to the lack of differences in poverty level between Latino populations found in our study. Additionally, it is important to note that in Add Health the proportion of third-generation Cuban adolescents is small (9%). As a result, our population of Cubans is mainly represented of those who arrived in the 1980s, a population that is less educated and poorer and has required more federal assistance than did earlier Cuban immigrants who arrived in 1960 [27] To have a better representation of the patterns of health care utilization of the general population of Latino adolescents, we recommend that in future surveys sampling frames represent in-school, out-of-school, and monolingual Spanish adolescents. Additionally, future studies should also explore our counterintuitive finding that living in a singleparent family increases the likelihood of receiving a routine physical examination, which is consistent with previous studies among children of all ages [33], Puerto Rican children [28], and children of parents with less than 15 years of education [34]. Research to determine the reasons for disparities between Mexicans and other Latino populations also is needed. Finally, the potential influences of normative cultural values [35,36], discrimination [22,37],

JOURNAL OF ADOLESCENT HEALTH Vol. 35, No. 4

familiarity with accessing the health care system, and contextual factors should be assessed.

Limitations Because Wave I of Add Health was conducted in 1995, our results do not reflect the impact of subsequent Medicaid restrictions and the establishment of state-funded non-Medicaid children’s health insurance program [38]. Nonetheless, our study provides a useful baseline from which to evaluate the impact of these and other health care reforms, including the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, which reduced benefits to immigrant children [39]. Our study is also limited because adolescents in the C/S American or DR origin category could not be analyzed by national origin subgroup. Another limitation is that our measure of routine health care did not capture the content or quality of care received. The heterogeneity of the Mexican, Cuban, Puerto Rican, CS American and DR origin populations included in our study highlight the diversity of the United States’ growing Latino population. In some respects, our findings pose challenges for the planning and delivery of preventive health care services because the findings suggest potential problems with a one-size-fits-all approach. Nonetheless, by documenting differences between, and within, Latino populations and developing culturally competent programs that respond to those differences, we will likely increase Latino adolescents’ use of routine health care and improve their health. Implementation of programs should be linked to mechanisms to accurately monitor progress and setbacks in addressing racial and ethnic health care disparities. We thank Drs. Krista Perreira, Eliseo Pe´ rez-Stable, Andrea Weathers, and Claire Newbern who provided valuable comments on earlier drafts of this manuscript. Support was provided in part by the University of North Carolina STD Clinical Research Center (National Institute of Allergy and Infectious Diseases UO131496) (to W.C.M., O.L.S., C.A.F., V.J.S.), The Robert Wood Johnson Foundation Generalist Physician Faculty Scholar Award program (to C.A.F.), the Clinical Associate Physician Program of the General Clinical Research Center (RR00046), Division of Research Resources, National Institutes of Health (to W.C.M.), and the Carolina Population Center at the University of North Carolina-Chapel Hill (to C.A.F.). The Add Health project is a program project designed by J. Richard Udry (PI) and Peter Bearman, and funded by grant P01-HD31921 from the National Institute of Child Health and Human Development to the Carolina Population Center, University of North Carolina at Chapel Hill, with cooperative funding participation by the National Cancer Institute; the National Institute of Alcohol Abuse and Alcoholism; the National Institute on Deafness and Other Communication Disorders; the National Institute on Drug Abuse; the National Institute of General Medical

October 2004

Sciences; the National Institute of Mental Health; the National Institute of Nursing Research; the Office of AIDS Research, National Institutes of Health (NIH); the Office of Behavior and Social Science Research, NIH; the Office of the Director, NIH; the Office of Research on Women’s Health, NIH; the Office of Population Affairs, Department of Health and Human Services (DHHS); the National Center for Health Statistics, Centers for Disease Control and Prevention (CDC), DHHS; the Office of Minority Health, CDC, DHHS; the Office of Minority Health, Office of Public Health and Science, DHHS; the Office of the Assistant Secretary for Planning and Evaluation, DHHS; and the National Science Foundation.

References 1. Ziv A, Boulet JR, Slap GB. Utilization of physician offices by adolescents in the United States. Pediatrics 1999;104:35–42. 2. Ford CA, Bearman PS, Moody J. Foregone health care among adolescents. JAMA 1999;282:2227–34. 3. Zimmer-Gembeck M, Alexander T, Nytstrom R. Adolescents report their need for and use of health care services. J Adolesc Health 1997;21:388 –99. 4. Centers for Disease Control and Prevention. Tracking The Hidden Epidemics: Trends in STDs in the United States, 2000. Atlanta, GA: Centers for Disease Control and Prevention, 2000. 5. Mayden B, Castro W, Annito M. First talk: A Teen Pregnancy Prevention Dialogue Among Latinos. Washington, DC: CWLA Press [imprint of the Child Welfare League of America], 1999. 6. De La Rosa JM, Escobedo M. Tuberculosis and other infectious diseases in the adolescent immigrant. Adolesc Med 2000;11: 453–66. 7. Flores G, Zambrana RE. The early years: The health of children and youth. In: Aguirre-Molina M, Molina C, Zambrana RE (eds). Health Issues in the Latino Community. San Francisco, CA: Jossey-Bass, 2001:77–106. 8. Borowsky IW, Ireland M, Resnick MD. Adolescent suicide attempts: Risks and protectors. Pediatrics 2001;107:485–93. 9. Mendoza FS. The health of Latino children in the United States. Future Child 1994;4:43–72. 10. Flores G, Fuentes-Afflick E, Barbot O, et al. The health of Latino children: Urgent priorities, unanswered questions and a research agenda. JAMA 2002;288:82–90. 11. U.S. Census Bureau Current Population Survey. Population by Sex, Age, Hispanic Origin and Race: March 2000. Available at: http://www.census.gov/population/socdemo/hispanic/ p20-535/tab01-1.txt. (Accessed August 15, 2002.). 12. Therrien M, Ramirez R. The Hispanic Population in the United States: March 2000, Current Population Reports. Washington, DC: U.S. Census Bureau, 2000:20 –535. 13. Solis JM, Marks G, Garcia M, et al. Acculturation, access to care, and use of preventive services by Hispanics: Findings from HHANES 1982–1984. Am J Public Health 1990;80(suppl):11–9. 14. Doty MM, Ives BL. Quality of Health Care for Hispanic Populations. Findings from the Commonwealth Fund 2001 Health Care Quality Survey. New York: The Commonwealth Fund, 2002:526. 15. Rietmeijer CA, Bull SS, Ortiz CG, et al. Patterns of general health care and STD services use among high-risk youth in Denver participating in community-based urine chlamydia screening. Sex Transm Dis 1998;25:457–63. 16. Newacheck PW, Brindis CD, Cart CU, et al. Adolescent health insurance coverage recent changes and access to care. Pediatrics 1999;104:195–202.

ROUTINE HEALTH CARE AMONG LATINOS

319

17. Lieu TA, Newacheck PW, McManus MA. Race, ethnicity, and access to ambulatory care among U.S. adolescents. Am J Public Health 1993;83:960 –5. 18. Add Health Research Design. Available at: http://www. cpc.unc.edu/projects/addhealth /design.html. (Accessed January 2003.). 19. Brodie M, Steffenson A, Valdez J, et al. 2002 National Survey of Latinos. PEW Hispanic Center/ Kaiser Family Foundation. Available at: http://www.pewhispanic.org/site/ docs/pdf/ LatinoReportExecSumandSectionOne.pdf. (Accessed January 2003.). 20. Andersen RM. Revisiting the behavioral model and access to medical care: Does it matter? J Health Soc Behav 1995;36:1–10. 21. Rew L. Access to health care for Latina adolescents: A critical review. J Adolesc Health 1998;23:194 –204. 22. Wagner TH, Guendelman S. Healthcare utilization among Hispanics: Findings from the 1994 Minority Health Survey. Am J Manag Care 2000;6:355–64. 23. Stata Corp. Stata Statistical Software, Release 7.0. College Station, TX: Stata Corp, 2001. 24. SAS Institute Inc. SAS/STAT user’s guide version 8.2. Cary, NC: SAS, 2001. 25. Elster A. The American Medical Association Guidelines for Adolescent Preventive Services. Arch Pediatr Adolesc Med. 1997;15:19:958 –9. 26. Flores G, Bauchner H, Feinstein AR, et al. The impact of ethnicity, family income, and parental education on children’s health and use of health services. Am J Public Health 1999;89: 1066 –71. 27. Hajat A, Lucas JB, Kington R. Health outcomes among Hispanic subgroups: United States, 1992–1995. Advances data from vital and health statistics. No. 310. Hyattsville, MD: National Center for Health Statistics, 2000:1–16. 28. Guendelman S, Schwalbe J. Medical care utilization by Hispanic children. How does it differ from black and white peers? Med Care 1986;24:925–40. 29. Weinick RM, Krauss NA. Racial/ethnic differences in children’s access to care. Am J Public Health 2000;90:1771–4. 30. Brown ER, Wyn R, Yu H, et al. Access to health insurance and health care for children in immigrant families. In: Hernandez DJ (ed). Children of Immigrants: Health, Adjustment and Public Assistance. Washington, DC: National Academy Press, 1999:126 –86. 31. Rew L, Resnick M, Beuhring T. Usual sources, patterns of utilization, and foregone health care among Hispanic adolescents. J Adolesc Health 1999;25:407–13. 32. Hirschman C. The educational enrollment of immigrant youth: A test of the segmented-assimilation hypothesis. Demography 2001;38:317–36. 33. Moreno CA. Utilization of medical services by single-parent and two parent families. J Fam Pract 1989;28:194 –99. 34. Heck KE, Parker JD. Family structure, socioeconomic status, and access to health care for children. Health Serv Res 2003;37:173–86. 35. Flores G. Culture and the patient-physician relationship: Achieving cultural competency in health care. J Pediatr 2000; 136:14 –23. 36. Flores G, Abreu M, Olivar MA, et al. Access barriers to health care for Latino children. Arch Pediatr Adolesc Med 1998;152: 1119 –25. 37. Racial and Ethnic Discrimination in Health Care Settings. Public Health—Seattle and King County: Public Health Special Report. 2001. Available at: http://www.metrokc.gov/

320

SARMIENTO ET AL

health/phnr/ eapd/reports/discriminationinhealthcare.pdf. (Accessed September 1, 2002.). 38. Brindis CD, VanLandeghem K, Kirkpatrick R, et al. Adolescents and the State Children’s Health Insurance Program (CHIP): Healthy Options for Meeting the Needs of Adolescents. Association of Maternal and Child Health Programs,

JOURNAL OF ADOLESCENT HEALTH Vol. 35, No. 4

Washington, DC and the University of California, San Francisco, Policy Information and Analysis Center for Middle Childhood and Adolescence and National Adolescent Health Information Center, San Francisco, CA, 1999. 39. Lessard G, Ku L, Reidy M. Gaps in coverage for children in immigrant families. Future Child 2003;13:101–15.