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BACKGROUND: English proficiency may be important in explaining disparities in health and health care access among older adults.
SUBJECTS: Population-based representative sample (N=18,659) of adults age 55 and older from the 2001 California Health Interview Survey.
METHODS: We examined whether health care access and health status vary among older adults who have limited English proficiency (LEP), who are proficient in English but also speak another language at home (EP), and who speak English only (EO). Weighted bivariate and multivariate survey logit analyses were conducted to examine the role of language ability on 2 aspects of access to care (not having a usual source of care, delays in getting care) and 2 indicators of health status (self-rated general health and emotional health).
RESULTS: Limited-English proficient adults were significantly worse off (1.68 to 2.49 times higher risk) than EO older adults in 3 of our 4 measures of access to care and health status. Limited-English proficient older adults had significantly worse access to care and health status than EP older adults except delays in care. English proficient adults had 52% increased risk of reporting poorer emotional health compared with EO speakers.
CONCLUSIONS: Provision of language assistance services to patients and training of providers in cultural competence are 2 means by which health care systems could reduce linguistic barriers, improve access to care, and ultimately improve health status for these vulnerable populations.
Language problems are 1 of biggest challenges facing immigrants to the United States. Language barriers can impede access to health care,1–4 lower the quality of care,5–7 and result in dissatisfaction with care.8–10 However, most studies on language barriers focus on children and adults in their child-rearing years. Much less is known about older adults who may be especially vulnerable to adverse health outcomes resulting from language problems in health care access.
There is also a paucity of studies that distinguish the gradations of English proficiency and its effect on health status and health care access. If gaining proficiency in English is viewed as an enabling characteristic as conceptualized in the Andersen Behavioral Model of health care access,11 then older adults who speak English well and very well are likely to have better health care access and better health than those who speak English not well or not at all. Additionally, the degree of English proficiency has been shown to be a dominant component of acculturation into the U.S. society.12 And, although acculturation may bring about socioeconomic mobility and improved health care navigational skills, Berry et al.13 have hypothesized that acculturation may lead to stressors of feelings of marginality and alienation that result in the reduction of health status of individuals. Although acculturation with its complex qualitative dimensions is not the focus of our study on language barriers, it is clearly intertwined with conceptualizing the relationship of English language ability with access to health care and health status.
Our approach in identifying linguistic disparities is to study language usage among individuals who speak another language at home and differentiate between those who are limited-English proficient (LEP) from those who are English proficient (EP) speakers; we then compare these 2 groups with English only (EO) speakers. If EP adults fare comparably with EO adults and appreciably better than LEP adults in health care access and health, then linguistic barriers are a major driver of disparities that need to be enabled by system changes to improve access for LEP adults.11 However, if another source of disparity is acculturative stress, then EP individuals could very well face similar barriers experienced by LEP individuals that cannot be addressed solely by language access efforts. This distinction is important in guiding providers to better understand the role of English proficiency in the well-being of their older adult patients so that they can direct the linguistic and cultural bridging resources needed to deliver care.
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Our findings indicate the language disadvantage of LEP older adults that need to be prioritized, specifically in ensuring the regularity of care. This is particularly important for LEP older adults, given that they report poorer general and emotional health. This finding adheres to Andersen's conceptualization that system enablers in health care could address the barriers faced by LEP older adults.
We further hypothesized that older adults that were proficient in English and at least 1 other language merit a separate examination as a language group distinct from LEP older adults and those who speak EO. Conventional analyses that dichotomize LEP from EP older adults may highlight only language-based disparities resulting in overlooked barriers that may be faced by immigrants who are EP. Indeed, our study revealed that EP older adults experienced a 53% elevated risk of poor emotional health compared with EO speakers. Although their English language ability attenuated this risk compared with their counterparts who speak no or limited English, it did not erase the disparity in emotional health.
Poorer emotional health reported by both LEP and EP older adults is consistent with Berry's acculturative stress hypothesis and supported by empirical studies that have linked depression among immigrants to the difficulty they experience in adapting to American society.13,32 Recent studies focusing on Asian elderly suggest that they may actually be at higher risk for depression than previously reported.33,34 Our finding is also consistent with a study on older Mexican-American adults that found that immigrant and bicultural Mexican Americans, had greater rates of depressive symptoms than U.S.-born Mexicans.35
It is interesting that EP individuals reported worse emotional health than EO speakers but did not report worse general health. Traumatic political and persecution events that have led to influxes of refugees and immigrants to the United States may profoundly affect the immigrant emotionally. Chronic worries over legal status among undocumented immigrants may also manifest in reports of poor emotional health. In addition, some researchers have posited that the acculturation process increases an adult's awareness of their emotions and life stressors so that worse self-reports of health may shift from a physical component to an emotional one.36,37 Increased awareness of emotional well-being may also be manifested by the EP whites in our sample, who comprised over 40% of the EP group with a considerable segment who were born in the United States and its territories. Thus, EP whites may drive the significant EP effects we found for emotional health. However, in comparing predicted rates of feeling sad all or most of the time by racial/ethnic group among EP adults, we found that the rates for whites (5%) did not statistically differ from the rates for Latinos (4%) and Asians (5%) (analysis not shown). Others have attributed the unique difficulties from being in situations that straddle 2 cultures, for example EP older adults may live in neighborhoods with less concentrated new immigrant communities so that they are less connected to these communities' social networks that may bestow supportive environments.38 Another possible distinguishing characteristic of EP adults is that they may have had a higher socioeconomic status (SES) in their home countries and then experienced a decline in social class and occupational status after immigrating to the United States. Hence, the immigration experience may have deflated their individual self-worth, resulting in an increase in depressive symptoms. Investigations that focus on the mental health of immigrant older adults should consider the unique experiences of EP adults that have typically been absent in past investigations on language. The fact that a large number of EP adults consisted of whites with European heritage also suggests that such investigations should consider other cultures in addition to Asian and Latino.
The study had several limitations. Foremost is that our measure of language ability are self-reports and thus may not fully capture language-related effectiveness in assimilating consumer information, navigating a health care system or communicating with a physician. However, as we focused on access to health care and self-rated health status, which presumably are not directly governed by a health care provider interaction, the conventional assessments on self-reported English proficiency and primary language may be sufficient. Although the survey was conducted in English, Spanish, Cantonese, Mandarin, Vietnamese, Khmer, and Korean, LEP individuals who do not speak these languages were excluded from the survey; but in total, these languages, were spoken by over 90% of California's population.39 Few studies have used and advocated for a single item measure of self-rated emotional health similar to the single-item measure of general health,40,41 but greater confidence in the findings would be possible if multiple item measures yielded similar results. Moreover, there has been no direct validation of the use of our single-item emotional health measure across different levels of English proficiency. However, there have been several relevant validation studies of the SF-36, which contains the emotional health item, among low-income nonEnglish speaking Mexican Americans and Chinese Americans.20,21 Finally, CHIS 2001 was a telephone survey, systematically excluding households without telephones, but the bias is minimal because fewer than 2% of California's occupied households were without telephone service in 2000.42 Limited-English Proficient older adults, however, may be overrepresented in the telephone exclusion, as well as in the overall refusal rates. Nonetheless, inclusion of these left-out groups, were it possible, is likely to increase the magnitude or precision of our disparate findings by English fluency because immigrants without phones are more likely to report worse access and health status.
Health systems must be poised to address the current and future language needs of a growing population of older adult immigrants.43 Provision of language assistance services to patients and training of providers in cultural competence are 2 means by which health care systems could reduce linguistic barriers, improve access to care, and ultimately improve health status for these vulnerable populations.