Effects of length of stay and language proficiency on health care experiences among Immigrants in Canada and the United States

Social Science & Medicine 74 (2012) 1062e1072

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Effects of length of stay and language proficiency on health care experiences among Immigrants in Canada and the United States Lydie A. Lebrun Johns Hopkins University, Primary Care Policy Center, 624 North Broadway, Baltimore, MD 21205, United States

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 25 January 2012

This study sought to examine the influence of length of stay and language proficiency on immigrants’ access to and utilization of care in Canada and the United States (US). Data came from the 2007e2008 Canadian Community Health Survey and the National Health Interview Survey. Analyses were limited to foreign-born, non-elderly adults in each country (n ¼ 12,870 in Canada and n ¼ 7440 in the US). Health care indicators included having a usual source of care; annual consultation with a health professional, dentist, and eye doctor; flu shot in the past year; and Pap test in the past 3 years. Logistic regression models were employed to estimate the relative odds of access or use of care, adjusting for need, demographic factors, socioeconomic status, and insurance coverage. In general, rates of health care access and utilization were higher in Canada than the US among all immigrant groups. In both countries, adjusted analyses indicated that immigrants with shorter length of stay (less than 10 years) and limited language proficiency generally had lower rates of access/use compared with those with longer length of stay (10 years or more) and proficiency in each country’s official language(s), respectively. There was one exception to this pattern in the US: immigrants with limited English had higher odds of having a recent Pap test relative to English-proficient immigrants. The persistence of disparities in health care experiences based on length of stay and language proficiency in Canada suggests that universal health insurance coverage may not be sufficient for ensuring access to and utilization of primary and preventive care for this population. Ó 2012 Elsevier Ltd. All rights reserved.

Keywords: Access to health care Primary care Immigrants Language Length of stay Acculturation Canada USA

Introduction In the context of increasing migration flows, it is important to understand the health care needs of foreign-born populations (Larsen, 2004; Statistics Canada, 2007). While immigrants may arrive in their new country of residence healthier than the nativeborn in that new country, this health advantage appears to decline over time (Cunningham, Ruben, & Narayan, 2008; McDonald & Kennedy, 2004; Newbold, 2005). Various hypotheses have been suggested to explain this phenomenon. For instance, one theory suggests that the healthiest and most motivated individuals are self-selected to undergo migration to a new country, leaving behind sicker and frailer individuals (Bentham, 1988; Morales, Lara, Kington, Valdez, & Escarce, 2002; Palloni & Ewbank, 2004). Medical examinations by immigration authorities may also further screen out less healthy individuals desiring entry into the country (Citizenship and Immigration Canada, 2009; U.S. Citizenship and Immigration Services, 2010). Acculturation theories propose that

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immigrants are protected by sociocultural factors, such as healthy behaviors, but these protective factors are lost over time and exposure to environmental risks and detrimental lifestyle habits increase, leading to deteriorations in health (Abraido-Lanza, Chao, & Florez, 2005; Morales et al., 2002). Structural theories of immigrant adaptation and health, on the other hand, focus on the historical, political, and economic contexts of immigration and suggest that the stresses of resettlement, discrimination, and “othering” may be potential pathways through which immigrants’ health worsens over time (Grove & Zwi, 2006; Kirkman, 2003; Viruell-Fuentes, 2007). Of particular relevance to this study, another school of thought suggests that ensuring access to quality health care services, particularly primary and preventive care, can reduce mortality and morbidity by enabling early detection and treatment of disease (Macinko, Starfield, & Shi, 2003; Starfield, Shi, & Macinko, 2005). There is growing recognition among primary migrant destinations, such as Canada and the United States (US), that foreign-born individuals form a particularly vulnerable population whose access to health care is generally worse than that of the native population. Formulating policy changes and interventions to improve

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immigrants’ access to and utilization of health care first requires a thorough understanding of the specific determinants of health care experiences for this population. Previous research has drawn attention to a range of factors which influence access to and use of health care services among immigrant populations (Derose, Bahney, Lurie, & Escarce, 2009). Andersen and Aday’s foundational framework of access to care is a useful tool for understanding these factors, organizing them into broad categories such as predisposing factors, enabling factors, and need for services (Aday & Andersen, 1981; Andersen, 1995). Predisposing factors include demographic and social structure characteristics that influence individuals’ propensity to utilize health services, and may include age, sex, marital status, or race/ethnicity, among others. Enabling factors refer to the individual-level and community-level resources available to facilitate access to services, such as income, education, and health insurance coverage. Need factors pertain to the specific disease profile or underlying health needs that motivate individuals to access medical services. Additional factors specifically relevant to foreign-born populations may also be included in a modified version of the model. For instance, enabling factors might also include acculturation-related factors such as length of stay and language proficiency. Acculturation is a rather vague term referring to the process whereby individuals adapt to and resettle in a new country (Hunt, Schneider, & Comer, 2004). The new living environment upholds the dominant group’s values and culture as a norm, to which newcomers are expected to adapt. No consensus or standardized method exists to measure this construct, but researchers typically operationalize it through proxy factors, such as length (or proportion) of time spent in the country of resettlement; age at immigration; language proficiency, use, and preference; citizenship status; ethnic self-identification; adherence to traditions and values; and various behavioral habits (e.g., diet, media usage, social interactions) (Lara, Gamboa, Kahramanian, Morales, & Bautista, 2005; Messias & Rubio, 2004; Salant & Lauderdale, 2003). Acculturation scales have also been devised for specific immigrant subpopulations, based on these proxy factors (Barry, 2005; Marin, Sabogal, Marin, Otero-Sabogal, & Perez-Stable, 1987; Suinn, Rickard-Figueroa, Lew, & Vigil, 1987). The assumption underlying these measures is that the longer an individual resides in their new country and is exposed to the dominant culture, the more they adapt to the sociocultural environment through various economic, linguistic, cultural, social, and psychological transitions. Increased duration of residence, in particular, has been welldocumented to be associated with improved access to primary and preventive health care among immigrants in the US as well as Canada. Compared with more established immigrants, recent immigrants are less likely to have a regular medical doctor (Kao, 2009; Nandi et al., 2008; Talbot, Fuller-Thomson, Tudiver, Habib, & McIsaac, 2001), have a routine medical check-up (Xu & Borders, 2008), receive immunizations (Pylypchuk & Hudson, 2009; Wallace, Gutierrez, & Castaneda, 2007; Xu & Borders, 2008), receive cancer screenings (Brown, Consedine, & Magai, 2006; Kandula, Wen, Jacobs, & Lauderdale, 2006; Latif, 2010; Lofters, Glazier, Agha, Creatore, & Moineddin, 2007; Maxwell et al., 2008), obtain mental health consultations (Chen, Kazanjian, & Wong, 2008), and use dental services (Newbold & Patel, 2006; Pylypchuk & Hudson, 2009; Wallace et al., 2007) or vision services (Xu & Borders, 2008). Longer length of stay appears to be associated with an increase in material goods and human capital which facilitate access to the health care system. These resources include proficiency in the country’s official language(s), documented immigrant or naturalized citizen status, insurance coverage, and knowledge and beliefs about health and health care, among others.

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Government policies also play a role in the relationship between length of stay and access to care. For instance, US legislation, such as the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) and the 1996 Illegal Immigration Reform and Immigrant Responsibility Act, make most legal immigrants ineligible for federally funded benefits, such as Medicaid, for the first 5 years after their arrival (Derose, Escarce, & Lurie, 2007). In addition, among immigrants who are eligible for federal benefits, PRWORA extends the length of time that a sponsor’s income is considered as income for means-tested programs, making access to services more difficult, even for well-established immigrants. Such restrictive health policies may also create fear and uncertainty among other immigrant groups; as a result, even eligible immigrants are discouraged from applying to public programs, thus increasing the chances that they will delay or forgo needed care (Asch, Leake, & Gelberg, 1994; Capps et al., 2002; Kaushal & Kaestner, 2005). Even in Canada, newcomers to some provinces (i.e., British Columbia, New Brunswick, Ontario, Québec) must complete a 3-month waiting period before being covered by a provincial health plan, forcing them to either purchase costly private insurance, pay for health care out-of-pocket, or forgo needed services altogether (Asanin & Wilson, 2008; Citizenship and Immigration Canada, 2005). Language proficiency is another well-documented predictor of access to care and utilization of services in both countries, which is often examined separately from length of stay. In the US, 4.2% of the population does not speak English well or does not speak it at all (Shin & Bruno, 2003). In Canada, 1.5% of the population speaks neither English nor French, the country’s two official languages (Statistics Canada, 2001). Among the foreign-born population, especially recent arrivals, the proportion of individuals who are linguistically isolated is even greater (around 10% in each country). Language and communication problems are well-documented barriers to health care, including physician visits (Fiscella, Franks, Doescher, & Saver, 2002; Ku & Waidmann, 2003; Yu, Huang, Schwalberg, & Nyman, 2006), vaccinations (Ayers, Juon, Lee, & Park, 2009; Fiscella et al., 2002), cancer screening (De Alba & Sweningson, 2006; Jacobs, Karavolos, Rathouz, Ferris, & Powell, 2005; Kandula et al., 2006; Latif, 2010), mental health care (Fiscella et al., 2002; Li & Browne, 2000), and sexual health services (Maticka-Tyndale, Shirpak, & Chinichian, 2007). While there is an abundance of research examining the effects of individual immigration-related factors on health care patterns, a relatively small proportion of the literature has simultaneously included two or more of these determinants in analyses. The current study contributes to the body of research by examining the effects of both length of stay and language proficiency on access to and utilization of primary and preventive care among immigrants. In addition, while previous studies have documented the roles of acculturation-related factors on immigrants’ health care experiences separately in the US and Canada, cross-national comparisons have been nonexistent to date. This study provides side-by-side analyses for both countries in order to shed light on how these variables influence access to care, and utilization of primary and preventive services, in two primary migrant destinations with similar geographic, social, and cultural characteristics (while remaining mindful of the important differences across these countries, most notably regarding health insurance coverage). Measuring acculturation among immigrants is complex, and there is no consensus among researchers about the best approach for doing so (Norman, Castro, Albright, & King, 2004). In the absence of such consensus, this study draws upon a combination of theory and previous research to inform how this construct is operationalized. Specifically, length of time since immigration is chosen as a unidimensional temporal measurement, which

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assumes a linear continuum of individuals’ acculturation, where time spent in new country is a proxy for exposure and adjustment to new culture, increased social interactions, improved communication, and increased ability to navigate through society (Gordon, 1967; Lara et al., 2005; Salant & Lauderdale, 2003). Thus, the purpose of this study was to apply a conceptual model of health care access and utilization to assess the effects of length of stay and language proficiency on health care access and utilization among immigrants in Canada and the US. The following analysis examines both potential access to care as well as health care utilization, and assumes that service use indicates realized access to the health care system and to appropriate primary and preventive services. Conversely, lack of service use is assumed to indicate a lack of access to care (although it is conceivable that patients may have access to certain services but prefer not to utilize them or not perceive a need for them). Methods Data sources Data came from the 2007e2008 Canadian Community Health Survey (CCHS) and the National Health Interview Survey (NHIS) (National Center for Health Statistics, 2008, 2009a,b; Statistics Canada, 2009). Sampling design, data collection methods, and survey questionnaire content were similar across surveys. Both data sources were nationally representative, cross-sectional surveys with annual datafile releases. Information was collected from respondents regarding health status, health care utilization, and health determinants. Data collection was conducted by Statistics Canada for the CCHS, and by the National Center for Health Statistics for the NHIS. Interviews in both countries were conducted in a range of languages. CCHS data were released in a single file including both 2007 and 2008, therefore separate 2007 and 2008 NHIS files were combined into one file in order to increase comparability across countries. The research proposal was reviewed and approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board. Study sample The CCHS and NHIS sampled civilian, noninstitutionalized individuals living in Canada and the US, respectively. The complex design of both surveys consisted of a multistage, stratified cluster design, in order to produce reliable nationally representative estimates. The CCHS was stratified by provinces and various geographic regions, clusters of households were then selected within strata through random sampling, and households were selected within clusters. The NHIS was stratified by states, clusters of smaller geographic regions and households were sampled within strata, and individual households were selected within clusters. Within each household, one individual was selected for interview. Survey weights in both datasets were modified to account for out-of-scope sampling units, non-response, and other adjustments in order to make the sample representative of the target population. Post-stratification techniques ensured comparability of final weights with other population estimates. The overall response rate was 76.4% for all respondents in the 2007e2008 CCHS, 67.8% for adult respondents in the 2007 NHIS, and 62.6% for adult respondents in the 2008 NHIS. For the current study, analyses were limited to foreign-born non-elderly adults, ages 18e64 years (n ¼ 12,870 in Canada; n ¼ 7440 in the US). The

focus on this age group was in keeping with much of the health services research literature, which separately examines children, non-elderly adults, and elderly adults. These groups have different access to care profiles, especially in the US where government-sponsored health insurance programs target children and the elderly. Future examinations of other age groups are warranted, but this analysis concentrated on non-elderly immigrants, which make up the largest proportion of the foreign-born population in both countries (Larsen, 2004; Statistics Canada, 2010). Analytical variables Every attempt was made to select dependent and independent variables that were comparable across the Canadian and US datasets, and to categorize variables as similarly as possible. However in a few instances some differences remained, and these are discussed in greater detail below. The dependent variables of interest included six commonly used measures of access to and utilization of primary and preventive health care: (a) usual source of care when sick or in need of advice, (b) consultation with a health professional in the past year, (c) consultation with a dentist in the past year, (d) consultation with an eye doctor in the past year, (e) flu shot in the past year, and (f) Pap test in the past 3 years (Kasper, 1998; Shi & Singh, 2008). These measures indicate entry into the health care system and utilization of appropriate primary and preventive care services that may prevent future health declines. Outcomes were selected because of their reasonable reliability and validity, their agreement with national health care recommendation guidelines, and/or their availability in national datasets (Agency for Healthcare Research and Quality, 2005; Cleary & Jette, 1984; Gilbert, Rose, & Shelton, 2002; Gordon, Hiatt, & Lampert, 1993; Health Canada, 2006; McPhee et al., 2002; Paskett et al., 1996; Raina, Torrance-Rynard, Wong, & Woodward, 2002; Ritter et al., 2001; Roberts, Bergstrahl, Schmidt, & Jacobsen, 1996; U.S. Department of Health and Human Services, 2000). All measures were dichotomously coded into yes or no responses. Analyses were limited to foreign-born respondents, and among this group the main independent variables of interest were length of stay and language proficiency. In order to conduct analyses comparable with previous research, length of stay was dichotomized into two categories: less than 10 years versus 10 years or more. Language proficiency was determined using language of interview in the US, and possible categories included English, Spanish, English and Spanish, and some other language. In Canada, language proficiency was based on language in which respondents reported being able to conduct a conversation, and categories included English, French, English and French, and some other language. For analytical purposes, language information was dichotomized in both countries. In the US, the language-proficient category included respondents with English only language of interview and the limited-proficiency category included all other language categories. In Canada, the categorization was slightly different, due to policies of official bilingualism and prevalence of both English and French throughout the nation: the languageproficient category included respondents who reported being conversational in English and/or French and the limited-proficiency category included respondents who were conversational in some other language. Other covariates were included in analyses in order to account for the potential confounding effects of a variety of demographic and socioeconomic factors on health care access and utilization patterns among immigrants. The selection of these covariates was informed by Aday and Andersen’s framework for organizing

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the risk factors for poor access to care (Aday & Andersen, 1981). Predisposing factors included the following demographic characteristics: age, sex, and marital status. Race/ethnicity was also included as a predisposing factor, although it was coded differently in each country. In the US dataset, racial/ethnic categories included White, Black, Hispanic, Asian, and Other (including American Indian/Alaska Native, Other race, and multiple race). In the Canadian dataset, the variable was dichotomized into White versus nonWhite minority. Enabling factors were incorporated, specifically education, household income, and health insurance coverage (for US respondents). The household income categories were based on slightly different cutoffs in each country due to differences in data availability. In the US, low income was defined as less than $35,000 per year, middle income was $35,000e$74,999, and high income was $75,000 or higher. In Canada, low income was defined as less than $40,000 per year, middle income was $40,000e$79,999, and high income was $80,000 or higher. Need factors were captured using perceived general health status; this variable is a common survey item which has been shown to have high validity and reliability across cultures despite its subjective nature, and which appears to be predictive of subsequent morbidity and mortality (Ferraro, Farmer, & Wybraniec, 1997; Gold, Franks, & Erickson, 1996; Idler & Benyamini, 1997). Statistical analysis Cross-sectional, design-based descriptive and comparative analyses and regression models were employed to examine disparities in access to and utilization of care based on length of stay and language proficiency among immigrants in Canada and the US. Survey weights were applied to obtain estimates that were representative of the target population, and the Taylor linearization method was used for variance estimation in order to account for complex sampling methods and weighting. The weight variables available in the dataset accounted for out-of-scope sampling units, non-response, and post-stratification. Two-tailed p-values less than or equal to 0.05 were considered statistically significant. Stata software, version 10.0, was used for all analyses (StataCorp, 2007). The distributions of sociodemographic and acculturation characteristics among the foreign-born in both countries were examined, and comparisons of health care experiences based on length of stay and language proficiency were also conducted within each country. Prevalence rates were obtained for the outcomes of interest, and Pearson c2 tests were performed to assess statistically significant differences in distributions across immigrant groups. Logistic regression modeling was used to examine the association between the main independent variables of interest and dichotomous outcome measures. The effects of length of stay and language proficiency on immigrants’ access to and use of care in each country were assessed. For each outcome measure, simple logistic regressions were first conducted to obtain the unadjusted odds ratios for the total effect of the main independent variables on health care measures. Then multivariable models were built to estimate adjusted odds ratios, after accounting for potential confounding variables (i.e., age, sex, marital status, general health status, race/ethnicity, education, household income, health insurance). Results regarding the effect sizes and statistical significance of length of stay and language proficiency were very similar in both unadjusted and fully adjusted models, therefore only adjusted models are presented. Various sensitivity analyses were employed to assess the robustness of the study findings.

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Results Descriptive and comparative statistics Sociodemographic and acculturation characteristics Table 1 presents the distribution of sociodemographic and acculturation-related characteristics for foreign-born residents in Canada and the US. Differences across countries could not be assessed for statistical significance because data came from two separate datasets, however a few general trends across countries were highlighted. Immigrants in Canada tended to be older than those in the US. The majority of immigrants in both countries were racial/ethnic minorities (although the proportion was higher in the

Table 1 Distribution of sociodemographic and acculturation characteristics of the foreignborn population by country of residence, 2007e2008.

Sociodemographic factors Age category 50e64 years 40e49 years 30e39 years 18e29 years Sex Female Male Marital status Single, never married Widowed/divorced/separated Married/common-law/partnered General health status Excellent Very good Good Fair Poor Race/Ethnicity Non-White minority Hispanic Asian Black Other White Educational attainment College degree or higher Some college/university High school or GED Less than high school Household incomea High Middle Low Missing Has health insurance coverage Acculturation factors Length of stay Less than 10 years 10 years or more Language proficiencyb Other language French (Canada)/Spanish (US) English & French (Canada)/English & Spanish (US) English a

Canada (N ¼ 12,870)

US (N ¼ 7440)

n (%)

n (%)

4978 2893 3044 1955

(31.82) (26.22) (23.02) (18.94)

1606 1796 2188 1850

(22.81) (24.17) (27.40) (25.61)

6936 (51.05) 5934 (48.95)

3934 (48.45) 3506 (51.55)

2633 (20.22) 1706 (9.33) 8489 (70.45)

1685 (19.75) 1163 (10.33) 4563 (69.92)

2934 4532 4020 1017 351

(22.77) (34.95) (31.69) (7.63) (2.96)

2347 2252 2105 589 142

(32.44) (30.34) (27.81) (7.56) (1.85)

6322 (62.01) . . . . 6287 (37.99)

. 4245 1622 602 24 947

(51.81) (21.78) (8.05) (0.53) (17.84)

8608 845 1973 1321

(66.22) (7.07) (16.24) (10.47)

1912 1396 1558 2466

(27.74) (19.89) (21.95) (30.42)

3729 3965 3290 1886 .

(30.47) (31.54) (23.54) (14.45)

1354 2215 3251 620 4659

(23.71) (32.49) (34.61) (9.18) (63.87)

3162 (31.82) 8634 (68.18)

2433 (32.60) 4828 (67.40)

560 (5.92) 393 (4.11) 1766 (14.17)

123 (1.81) 1724 (19.49) 875 (10.99)

10,063 (75.80)

4717 (67.71)

Income was categorized using slightly different cutoffs in each country, based on data availability. Canada: High ($80,000 or higher), Middle ($40,000e$79,999), Low (less than $40,000). US: High ($75,000 or higher), Middle ($35,000e$74,999), Low (less than $35,000). b In US, language proficiency based on language of interview; in Canada, based on language in which respondent can conduct conversation.

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US). In the US, the largest racial/ethnic groups of immigrants were Hispanics, followed by Asians. Immigrants in Canada had higher education and income levels than those in the US. About two-thirds of immigrants in the US had health insurance (virtually all immigrants to Canada are assumed to have health insurance due to universal health coverage). In both countries, about one-third of the foreign-born immigrated less than 10 years ago, and over two-thirds had resided in either country for 10 years or more. In Canada, most immigrants reported being conversational in English only or in both English and French. A small proportion reported speaking French (but not English) or some other language. In the US, two-thirds of immigrants were conversational in English (i.e., were interviewed in English only); another 20% spoke Spanish (i.e., were interviewed in Spanish only). A smaller proportion spoke both English and Spanish, or some other language during the interview. In subsequent analyses, language variables were dichotomized into language-proficient versus limited-proficient, in order to increase power to reflect language-based differences. Access to and utilization of primary and preventive care Table 2 shows unadjusted percentages of the health care access and utilization indicators among foreign-born adults in Canada and the US, according to length of stay and language proficiency. In both countries, a smaller proportion of immigrants with shorter length of stay (less than 10 years) reported access to care and service use compared with those with longer length of stay (10 years or more). Access and utilization among both short-stay and long-stay immigrants were higher in Canada than the US, except for Pap tests which occurred at higher rates among immigrants in the US. In Canada, reports of dentist consultations, eye doctor consultations, and Pap tests were lower among immigrants with limited language proficiency, compared with language-proficient immigrants. In the US, limited-English immigrants had lower access to and use of care than English-proficient immigrants for all indicators. Logistic regression analyses Table 3 presents partial regression results for models examining immigrants’ health care experiences in Canada and the US. Each model includes the full set of explanatory variables previously described, but the table shows only odds ratios and 95% confidence intervals for length of stay and language proficiency variables. Effect of length of stay on health care access and utilization in Canada and the US In Canada, after accounting for potential confounding from other sociodemographic factors, immigrants with less than 10 years’ stay had lower odds of having a usual source of care when sick (OR ¼ 0.28, 95% CI: 0.20e0.39), a consultation with a health

professional in the past year (OR ¼ 0.58, 95% CI: 0.44e0.77), a dentist consultation in the past year (OR ¼ 0.62, 95% CI: 0.53e0.73), and a Pap test in the past 3 years (OR ¼ 0.52, 95% CI: 0.37e0.72), relative to those who immigrated 10 years ago or more. In the US, recent immigrants also had lower odds of having a usual source of care when sick (OR ¼ 0.63, 95% CI: 0.53e0.76), a consultation with a health professional in the past year (OR ¼ 0.77, 95% CI: 0.65e0.92), a dentist consultation in the past year (OR ¼ 0.66, 95% CI: 0.56e0.79), and a Pap test in the past 3 years (OR ¼ 0.62, 95% CI: 0.45e0.85), as well as an eye doctor consultation in the past year (OR ¼ 0.75, 95% CI: 0.61e0.91), compared with more established immigrants. There were no effects of length of stay on flu shots in the past year in either country. Effect of language proficiency on health care access and utilization in Canada and the US In Canada, after adjusting for covariates, immigrants with limited language proficiency had lower odds of having an eye doctor consultation (OR ¼ 0.64, 95% CI: 0.46e0.87) and a flu shot (OR ¼ 0.68, 95% CI: 0.48e0.96) in the past year relative to those who were language-proficient. There were no other differences based on language proficiency. In the US, immigrants with limited English had lower odds of having a consultation with a health professional in the past year (OR ¼ 0.75, 95% CI: 0.61e0.92), consultation with an eye doctor in the past year (OR ¼ 0.78, 95% CI: 0.63e0.98), and a flu shot in the past year (OR ¼ 0.63, 95% CI: 0.51e0.77), compared with Englishproficient immigrants. On the other hand, limited-English immigrants had higher odds of having a Pap test in the past 3 years relative to English-proficient immigrants (OR ¼ 1.57, 95% CI: 1.02e2.43). There were no language-based disparities for having a usual source of care and dentist consultations. Effect of other sociodemographic factors on health care access and utilization in Canada and the US Other variables were associated with immigrants’ access to care and use of services in both countries (see electronic Appendices, available with online version of the paper). In Canada, female sex was associated with higher odds of access and utilization among immigrants, as was higher income for most indicators. Single marital status was associated with lower odds of a usual source of care and Pap tests, and being widowed/divorced/ separated was associated with lower odds of a flu shot. Older age was generally associated with higher odds of access and utilization. Higher education was also associated with higher odds of dentist and eye doctor consultations. Finally, minority race was associated with lower odds of a dentist consultation and Pap test, and higher odds of a flu shot. In the US, female sex, older age, higher education, higher income, and insurance coverage were generally associated with

Table 2 Percentage of foreign-born adults reporting health care access and use, by length of stay and language proficiency in Canada and the US. Canada (N ¼ 12,870) Length of stay

Usual source of care Health professional consult, past year Dentist consult, past year Eye doctor consult, past year Flu shot, past year Pap test, past 3 years

US (N ¼ 7440) Language proficiency

Length of stay

Language proficiency

<10 years

10þ years

Limited

Proficient

<10 years

10þ years

Limited

Proficient

90.86% 87.25 52.31 26.14 24.53 62.18

97.71% **** 94.03 **** 68.74 **** 35.02 **** 30.41 *** 75.57 ****

94.89% 89.13 49.55 21.77 25.63 57.78

95.49% 91.99 64.33 **** 32.78 *** 28.51 72.20 *

57.83% 59.67 40.92 15.86 13.36 67.37

79.00% **** 74.24 **** 58.50 **** 27.60 **** 21.24 **** 78.49 ****

59.59% 57.45 37.87 15.00 11.26 76.44

84.07% **** 81.81 **** 63.13 **** 34.55 **** 25.06 **** 80.79 *

*p < .05, **p < .01, ***p < .001, ****p < .0001, based on c2 test for categorical variables.

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Table 3 Associations between length of stay, language proficiency, and health care access and use, among foreign-born adults in Canada and the US. Adjusted odds ratios (95% confidence intervals)

Canada Length of stay Less than 10 years 10 years or more Language proficiency Limited Proficient US Length of stay Less than 10 years 10 years or more Language proficiency Limited Proficient

Usual source of care

Consultation with health professional, past year

Dentist consult, past year

Eye doctor consult, past year

Flu shot, past year

Pap test, past 3 years

(n ¼ 11,393)

(n ¼ 11,379)

(n ¼ 11,396)

(n ¼ 11,393)

(n ¼ 11,128)

(n ¼ 3075)

0.28 (0.20e0.39)**** 1.00

0.58 (0.44e0.77)**** 1.00

0.62 (0.53e0.73)**** 1.00

0.91 (0.77e1.07) 1.00

0.95 (0.79e1.13) 1.00

0.52 (0.37e0.72)**** 1.00

1.04 (0.50e2.14) 1.00 (n ¼ 7059)

0.79 (0.49e1.28) 1.00 (n ¼ 7002)

0.77 (0.57e1.05) 1.00 (n ¼ 7006)

0.64 (0.46e0.87)** 1.00 (n ¼ 7031)

0.68 (0.48e0.96)* 1.00 (n ¼ 7002)

0.63 (0.35e1.14) 1.00 (n ¼ 1685)

0.63 (0.53e0.76)**** 1.00

0.77 (0.65e0.92)** 1.00

0.66 (0.56e0.79)**** 1.00

0.75 (0.61e0.91)** 1.00

0.90 (0.73e1.10) 1.00

0.62 (0.45e0.85)** 1.00

1.01 (0.80e1.29) 1.00

0.75 (0.61e0.92)** 1.00

0.92 (0.77e1.09) 1.00

0.78 (0.63e0.98)* 1.00

0.63 (0.51e0.77)**** 1.00

1.57 (1.02e2.43)* 1.00

Multiple logistic regressions adjusted for age, sex, marital status, general health status, race/ethnicity, education, household income, and health insurance coverage (in the US). (Full table with all covariates not shown.) *p < .05, **p < .01, ***p < .001, ****p < .0001.

higher odds of access or utilization among immigrants. Single marital status was associated with lower odds of having a usual source of care, health professional consultation, and Pap test. Better health status was associated with lower odds of a health professional consultation and eye doctor consultation but higher odds of a dentist consultation. Relative to White immigrants, Asian immigrants had lower odds of a health professional consultation, Black immigrants had lower odds of a flu shot, and all racial/ethnic groups except Hispanics had lower odds of a dental consultation. Sensitivity analyses There was a considerable portion of missing data for household income (9.2% for US immigrants, 14.5% for Canadian immigrants), therefore a “missing” category was included in all analyses in order to preserve sample sizes. Sensitivity analyses were also conducted to determine the effect of (a) dropping observations with missing income information, (b) assigning high income to all missing datapoints, or (c) assigning low income to all missing datapoints. Effect sizes and significance of the main variables of interest (i.e., length of stay, language proficiency) were virtually unchanged regardless of the treatment of income. Only results from the models including a “missing” income category are presented. Other covariates had sufficiently low rates of missing information (cumulative missing information of 1.56% for NHIS and 4.73% for CCHS), therefore imputation was not performed for other variables. Analyses were also repeated for the US population, this time limiting the US sample to insured immigrants only, in order to produce a US sample that was more comparable to the universally insured Canadian sample. Results after stratifying by insurance status did not differ significantly from the models presented in Table 3, where insurance was used as a covariate. Effect sizes and statistical significance for the associations between length of stay and language proficiency and outcome measures were similar using both approaches, with a few exceptions where the variables of interest lost significance due to smaller sample sizes in the stratified models (see electronic Appendices, available with online version of the paper). Other sensitivity analyses were also conducted regarding length of stay in the US (data unavailable for Canadian sample). Specifically, the NHIS dataset included more detailed information concerning length of stay, therefore additional analyses were conducted using more refined length of stay categories: less than 5

years, 5e10 years, 10e15 years, and 15 years or more. For most indicators, there was a dose-response relationship between length of stay and access or use, with shortest-stay immigrants (less than 5 years) having the lowest odds relative to longest-stay immigrants (15 years or more), and intermediate-stay immigrants (5e10 years) falling somewhere in between. There were few significant differences in health care experiences between immigrants with 10e15 years of stay versus those with 15 years or more. Replacing the dichotomized length of stay variable with the specific length of stay variable in regression models did not significantly change results regarding the effect of language proficiency (see electronic Appendices, available with online version of the paper). Discussion Unadjusted analyses showed that longer-stay immigrants in both countries had higher access to care and utilization rates across all indicators, compared with shorter-stay immigrants. In addition, language-proficient immigrants had better health care experiences than immigrants with limited-proficiency, although the association between English language ability and use of health care was stronger in the US than in Canada. After adjusting for potential confounding from differences in age, sex, marital status, general health status, race/ethnicity, education, income, and insurance coverage, immigrants in both countries with shorter length of stay (less than 10 years) continued to report worse access to care and lower service use for most indicators. Limited English or French proficiency was associated with lower odds of a consultation with an eye doctor and flu shot in the past year among immigrants to Canada. Limited English proficiency was also associated with lower utilization of these services among immigrants to the US, as well as lower odds of a consultation with a health professional in the past year. However, limited English proficiency was also associated with higher odds of a recent Pap test among the foreign-born in the US. The results of this study indicate that, overall, recent immigration and limited language proficiency independently contribute to reduced potential and realized access to care in both Canada and the US. These results largely concur with those of previous studies which have examined the influence of these variables on immigrants’ health care patterns. The finding that receipt of Pap tests was greater among limited-English immigrants than Englishproficient immigrants in the US may seem counterintuitive at first, given that limited language proficiency typically poses

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a barrier to care. However, this may be explained by the demographic composition of the immigrant population in the US. A large proportion of the foreign-born population originates from Mexico, Central America, and South America, and this group is also limited in English proficiency. Latina women also have higher fertility rates, bringing them into contact with the health care system more frequently, and potentially accounting for the higher rates of Pap tests among limited-English immigrants (Gonzales, 2008; Passel & Suro, 2005; Terrazas, Batalova, & Fan, 2007). Comparing unadjusted rates of health care measures across countries revealed that access and service use was better in Canada than the US among both short-stay and long-stay immigrants (with the exception of Pap tests). Similarly, access and use was generally better in Canada than the US among both limited-proficiency and language-proficient immigrants. The statistical significance of these differences could not be directly assessed due to the separate data sources for each country, but the magnitude of these differences was large. For instance, over 90% of shorter-stay immigrants in Canada reported having a usual source of care, compared with less than 60% in the US. These disparities may be partly explained by socioeconomic differences among the foreign-born across the two countries. Most obvious is the difference in health insurance coverage, which is near-universal in Canada and fragmented in the US. In addition, Canadian immigrants typically have higher education levels and higher incomes compared with US immigrants, factors which are known to enable access to care. The proportion of immigrants who are undocumented is also much higher in the US than in Canada. However, the persistent presence of barriers to care in Canada based on length of stay, and to a lesser extent language proficiency, suggests that universal health coverage and higher socioeconomic status does not necessarily ensure access to care or utilization of services, and that other barriers prevent immigrants’ full participation in the health care system. There were several limitations with this study. First, two separate surveys were used to make cross-country comparisons, introducing the possibility of systematic bias across countries. Although variables were selected and coded in order to maximize comparability across the Canadian and US datasets, a few differences remained, namely regarding language proficiency, race/ ethnicity, and income. Language proficiency was based on language of interview in the US and self-reported conversational language in Canada; while these are different operationalizations, they both reflect individuals’ preferred spoken language and self-perceived language proficiency, and represent two of the more common approaches to measuring language proficiency in the health services research literature (Brotanek, Halterman, Auinger, & Weitzman, 2005; Fiscella et al., 2002; Weech-Maldonado et al., 2003). In addition, research suggests that self-assessed language ability is a reliable indicator of actual language ability (Marian, Blumenfeld, & Kaushanskaya, 2007). Measuring language ability through validated scales would provide more accurate information about actual comprehension and communication skills, but this rarely occurs in national surveys due to a lack of practical, standardized assessment tools. Race/ethnicity was coded using specific categories in the US and a dichotomous variable, White vs. Non-White, in Canada. The aggregated race variable in the CCHS stems from concerns about limitations in sample sizes, privacy and confidentiality, and an overarching national commitment to multiculturalism (Rodney & Copeland, 2009). National data collected in Canada are generally not available for specific racial/ethnic groups so this is not a limitation unique to the CCHS. Finally, household income categories were created using slightly different cut-off points for low, middle, and high income groups in each country. This was unavoidable

given the manner in which the raw income variables were coded in each dataset, but efforts were made to select cut-off points that were as similar as possible and categories never differed by more than $5000 across countries. Due to the use of separate datasets and slight differences in variables across datasets, the reader should refrain from comparing odds ratios across countries. However, the sampling design, survey interview methods, and questionnaire formats for selected variables were sufficiently similar to make general observations of health care trends in both countries. Second, the study measured acculturation through simplified indicators, namely length of stay and language proficiency. Both variables were coded dichotomously, due to the lack of availability of more refined categories in the datasets. The 10-year cutpoint for length of stay precluded any examination of health care patterns among very recent immigrants. In addition, the more appropriate comparisons for assessing Pap tests in the past 3 years would be between immigrants with length of stay 3e10 years versus 10 or more years. Since Pap tests are only recommended every 3 years, immigrants in Canada or the US for less than 3 years would not have had the same opportunity to be tested. Failure to obtain a Pap test within 3 years of immigration does not necessarily indicate inadequate use of preventive care. Due to data limitations, it was also not possible to consider other dimensions, such as generational cohort (e.g., foreign-born, first-generation, second-generation), age at immigration, or proportion of lifetime in new country. In contrast with the linear model of acculturation assumed in this study, the literature suggests that using multidimensional scales may better capture the independent nature of acculturation to a new culture and the adherence to a culture of origin (Abraido-Lanza, Armbrister, Florez, & Aguirre, 2006; Al-Omari & Pallikkathayil, 2008; Berry, 1997; Messias & Rubio, 2004; Ryder, Alden, & Paulhus, 2000). These scales are able to measure biculturalism as well as varying degrees of acculturation in different domains (e.g., language, ethnic identity, dietary preferences, values). However, these scales are not without their own limitations (Thomson & Hoffman-Goetz, 2009). First, they are usually designed for specific immigrant subpopulations (e.g., Asians, Hispanics) and therefore cannot be used across different immigrant groups. In addition, they depend heavily on language proficiency items, which fail to distinguish bicultural individuals and which diminish the important role of other domains of acculturation (Alvidrez, Azocar, & Miranda, 1996; Betancourt & Lopez, 1993; Lara et al., 2005). Finally, there is a lack of standardization, reliability, and validity of many acculturation measures (Matsudaira, 2006; Messias & Rubio, 2004; Ponterotto, Baluch, & Carielli, 1998). Although unidimensional, single-item proxy measures like length of stay may be imperfect oversimplifications, they are conveniently available in national surveys, are concise and practical to manipulate and quantify, and correspond to acculturation measures commonly used in other health studies of immigrant populations (Flannery, Reise, & Yu, 2001; Lara et al., 2005). Temporal measures of acculturation have also been found to be positively associated with immigrants’ integration and assimilation in their new country, including increased language proficiency (Arcia, Skinner, Bailey, & Correa, 2001; Barry, 2001; Dela Cruz, Padilla, & Agustin, 2000). Another limitation of the study was that, due to the secondary nature of the analyses, it was not possible to consider other contextual factors that might play a role in immigrants’ adaptation and health care experiences, including community availability of resources such as language-concordant health care providers or translation/interpretation services (Green, Freund, Posner, & David, 2005; Karliner, Jacobs, Chen, & Mutha, 2007; Ngo-Metzger et al., 2003; Wilson, Chen, Grumbach, Wang, & Fernandez, 2005),

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experiences with discrimination (Arcia et al., 2001; Shah, Ayash, Pharaon, & Gany, 2008; Viruell-Fuentes, 2007), size and geographic distribution of immigrant group (Gresenz, Rogowski, & Escarce, 2009), and so on. Health and health care beliefs and knowledge were also not considered in the current analyses, although they may serve as mediators in the path linking duration of stay and access to and utilization of care (Brotto, Chou, Singh, & Woo, 2008; Johnson, Mues, Mayne, & Kiblawi, 2008). Region or country of origin, which may serve as a proxy for cultural differences in health and health care knowledge and behaviors, was also unavailable in the datasets, although this may have been partly captured by the race/ethnicity variables. For example, some cultural groups may embrace fatalistic notions, or the acceptance of inevitable and unalterable fate, which can be a barrier to use of preventive care services (Chavez, Hubbell, Mishra, & Valdez, 1997; Shah et al., 2008). Immigrants are also more likely to report unmet health care needs if they lack knowledge about where and how to access services (Kandula et al., 2006; Li & Browne, 2000; Wu, Penning, & Schimmele, 2005). Additionally, individuals who have a stigmatized or embarrassing health condition (Foley, 2005; Li & Browne, 2000; Maticka-Tyndale et al., 2007), distrust health care providers (Foley, 2005; Garces, Scarinci, & Harrison, 2006; Lai & Chau, 2007; Ma, 2000), rely on alternate sources of care (e.g., traditional healers, holistic approaches to care) (Garces et al., 2006; Ma, 2000), or are uncomfortable or dissatisfied with the biomedical model of the health care system (Asanin & Wilson, 2008; Foley, 2005; Lai & Chau, 2007; Li & Browne, 2000) may be less likely to access care. In addition, although both surveys were nationally representative, foreign-born populations may have been underrepresented in the sample. The CCHS and NHIS were conducted in numerous languages, but linguistically isolated immigrants may still have been less likely to participate in the surveys. Immigrants with shorter duration of stay or undocumented immigrants may have also been more reluctant to participate. Since limited language proficiency, shorter length of stay, and lack of citizenship or legal status are all barriers to care, any under representation of immigrants would likely result in underestimates of the true barriers to care among the foreign-born. In other words, the estimates of access to care and utilization of care in the current study may conceal more severe barriers to care among the most vulnerable segments of foreign-born populations. Finally, this study used cross-sectional data, limiting any conclusions about longitudinal effects among generations of immigrants. Specifically, these results compared differences in health care experiences across two immigrant cohorts (shorter length of stay vs. longer length of stay) at one point in time. Findings do not, however, provide any insights about the trajectories of individual immigrants over time. These limitations notwithstanding, the study has several notable strengths. It is among a limited number of studies attempting to simultaneously examine the effects of multiple immigration-related factors (i.e., length of stay, language proficiency) on access to and use of care. In addition, it provides nationally representative estimates of immigrants’ health care in two countries which are primary migration destinations. While such studies have been conducted in the past in the US and in Canada separately, no study has yet attempted to conduct comparable analyses across countries in order to facilitate cross-national comparisons. Several policy implications can be gathered from these findings. First, the analyses serve to identify specific groups of vulnerable foreign-born individuals who have the lowest access to and use of primary and preventive care in both Canada and the US, namely immigrants with shorter duration of stay and limited language

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proficiency. To the extent that these nations wish to reduce health care inequalities and improve health care for underserved communities, interventions may be specifically targeted towards these subpopulations. For instance, insurance coverage eligibility could be expanded among the foreign-born in the US by repealing the 5-year minimum waiting period for low income legal immigrants to be eligible for public insurance programs such as Medicaid. Certain provinces in Canada (i.e., British Columbia, New Brunswick, Ontario, Québec) could also eliminate the 3-month waiting period before allowing newcomers to enroll in provincial health plans. In addition, provincial government recommendations determine whether certain services such as dental care, vision care, and cervical cancer screening are available, whether individuals are deemed eligible for the services, and whether they are covered by the provincial medical plan. The finding that rates of dentist consultations, eye doctor consultations, and Pap tests were lower among shorter-stay and limited-proficiency immigrants to Canada suggests that these policies may have a negative impact on newer immigrants. However, this study found that disparities in health care access and utilization remained among immigrants to Canada with less than 10 years of stay, compared with their longer-stay counterparts, suggesting that insurance coverage may not be the only solution, and that other barriers should also be addressed. For example, more language-concordant health care providers are needed to reduce language barriers to care; promotion of gender concordance and culturally sensitive health messages may also help to increase the rates of Pap tests in both countries. Encouraging medical training of a more diverse workforce, as well as accelerating the process by which foreign-trained health professionals are recertified to practice in the US and Canada, could increase the supply of workers with cultural and linguistic competency to meet the needs of immigrants. Functional knowledge of a second language and/or periodic cultural sensitivity training could also be required of health care providers. Translation and interpretation services could be encouraged by mandating implementation and providing more reimbursement. Community organizations catering to newcomers could also use additional funding to increase outreach in order to enroll eligible immigrants into insurance plans, promote primary and preventive care, and provide referrals to culturally and linguistically competent health care providers. Health care reform is under way in the US, but provisions for the foreign-born are limited and millions of immigrants will remain uninsured (Correal, 2010; National Immigration Law Center, 2010). For instance, the 5-year waiting period for Medicaid will still apply for low-income foreign-born adults. Since April 2009, states have been given the option to expand Medicaid and Children’s Health Insurance Program (CHIP) benefits to legal immigrant children and pregnant women before the waiting period elapses, but most states have not elected to do so (National Immigration Law Center, 2009). And of course, no health care benefits (besides emergency care) are or will be available for undocumented immigrants, a group which has proven to be a political third rail in the US. Given the current economic climate and anti-immigrant sentiments in the US, such policy changes are unlikely to occur at the federal level. However, expansions at the state level may be more feasible, especially among states with growing proportions of foreign-born populations. In fact, since the 2009 CHIP reauthorization was passed, three statesdColorado, Connecticut, and Minnesotadhave succeeded in extending health care to legally residing newcomer pregnant women and children. Another option might be to expand insurance options for undocumented parents of legal immigrant or native-born children, since research has

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indicated that providing insurance to parents increases the odds of coverage and access to care for their children (Davidoff, Dubay, Kenney, & Yemane, 2003; Dubay & Kenney, 2003). Expanding health insurance coverage in the short term improves access to primary and preventive care, which may in turn reduce the future need for more costly acute care resulting from undiagnosed and untreated diseases. In the long term, increasing utilization of primary and preventive care may also lower the burden of providing health care benefits to elderly immigrants who become naturalized citizens and are thus eligible for public coverage (e.g., Medicare in the US) by preventing and slowing health declines among the aging foreign-born. In this study, over two-thirds of the immigrant population in each country had a duration of stay of at least 10 years or more; longer length of stay is associated with higher rates of eventual naturalization, suggesting that these nations will increasingly provide health care to older foreign-born citizens (He, 2002). Investing in preventive care today may help reduce the need for more expensive medical interventions in the future for naturalized citizens who are fully entitled to government-sponsored programs. While most immigration-related debates in the US are quick to focus on unauthorized immigrants (about 12 million people), they often fail to acknowledge the remaining 26 million people, or roughly 70% of the foreign-born population, who are legally residing in the US (Passel, 2006). Notwithstanding the challenges and controversy, there is a rationale for addressing the health care needs of immigrants. Migration flows which were initiated long ago have become self-perpetuating phenomena due to structural factors such as globalization and transnationalism, economic and labor factors, and migrant social networks (Castles & Miller, 2003; Massey et al., 1998). Despite their best attempts, governments have not had significant control over immigration because of their inability to recognize or address these structural causes. Efforts to increase the costs and reduce the benefits of migration to individuals have resulted in marginalization of immigrants, with minimal effects on actual migration flows. In the context of current globalization trends and changing demographics in primary migrant destinations like Canada and the US, policy makers should consider efforts to ensure that immigrants can access primary care and make use of preventive services. Absence of action may have eventual implications for ill health, increased medical costs, and economic well-being, not only for immigrants but for nations as a whole. Acknowledgments This analysis is based on Statistics Canada’s Canadian Community Health Survey Microdata File, which contains anonymized data collected in the 2007e2008 Canadian Community Health Survey, as well as the Centers for Disease Control and Prevention, National Center for Health Statistics’ National Health Interview Survey datasets from 2007 to 2008. All computations on these microdata were prepared by the author, and the responsibility for the use and interpretation of these data is entirely that of the author. This work was supported in part by a Doctoral Research Award from the Canadian Institutes of Health Research and a National Research Service Award training grant from the U.S. Agency for Healthcare Research and Quality. Appendix. Supplementary data Supplementary data related to this article can be found online at doi:10.1016/j.socscimed.2011.11.031.

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