1. The Relationship between Nativity Status, Satisfaction with and Confidence in Health Care Florence J. Dallo, PhD MPH Academy Health Meeting 9 June 2008 Washington, DC

2. Acknowledgements Robert Wood Johnson New Connections Program Robert Wood Johnson New Connections Program Debra Perez, PhD MPA MA Debra Perez, PhD MPA MA Catherine West Catherine West Luisa N. Borrell, DDS PhD Luisa N. Borrell, DDS PhD Stacey L. Williams, PhD Stacey L. Williams, PhD Margarita Alegria, PhD Margarita Alegria, PhD

3. Outline Problem Problem Objective Objective Background Background Methods Methods Results Results Discussion Discussion

4. Problem We know very little about certain domains of quality of health care, especially by nativity status We know very little about certain domains of quality of health care, especially by nativity status

5. Objective Examine the association between nativity status and both satisfaction and confidence in quality health care Examine the association between nativity status and both satisfaction and confidence in quality health care

6. Background Institute of Medicine defines good quality health care as: Institute of Medicine defines good quality health care as: “providing patients with “providing patients with appropriate services in a technically competent manner, with appropriate services in a technically competent manner, with good communication, good communication, shared decision making, and shared decision making, and cultural sensitivity.” cultural sensitivity.” IOM. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academy Press; 2001

7. What Do We Know? Reporting being very satisfied with their health care Reporting being very satisfied with their health care 65.3% of whites 65.3% of whites 57.0% of Hispanics 57.0% of Hispanics 43.8% of Asians 43.8% of Asians Saha S, Arbelaez JJ, Cooper LA. Patient-physician relationships and racial disparities in the quality of health care. American journal of public health 2003;93(10):1713-9.

8. How About Foreign-Born? 40.2% of Hispanics and 68.9% of Asians are foreign- born 40.2% of Hispanics and 68.9% of Asians are foreign- born What do we know about the quality of health care among foreign-born individuals? What do we know about the quality of health care among foreign-born individuals? Very little Very little Malone N, Baluja KF, Costanzo JM, Davis CJ. The Foreign-Born Population: 2000; 2003.

9. Health Care by Nativity Status Foreign-Born (%) US-Born (%) No Health Insurance All All Whites Whites Blacks Blacks Hispanics Hispanics Asians Asians25.712.822.536.814.810.69.414.715.86.0 No doctor visits (past 12 mos) 29.017.6 No usual source of care 23.612.3 Dey AN, Lucas JW. Physical and mental health characteristics of U.S.- and foreign-born adults: United States, 1998-2003. Advance data 2006(369):1-19.

10. Methods Study Design Study Design Commonwealth Fund 2001 Survey on Disparities in Quality of Health Care Commonwealth Fund 2001 Survey on Disparities in Quality of Health Care Cross-sectional Cross-sectional 25 minute telephone interviews 25 minute telephone interviews

11. Methods Sample Sample N = 6,772 (> 18 years of age) N = 6,772 (> 18 years of age) Race/Ethnicity Race/Ethnicity 3,961 non-Hispanic whites 3,961 non-Hispanic whites 1,037 non-Hispanic blacks 1,037 non-Hispanic blacks 1,153 Hispanics 1,153 Hispanics 621 Asians 621 Asians Nativity Status Nativity Status 1,518 foreign-born 1,518 foreign-born 5,156 US-born 5,156 US-born

12. Satisfaction and Confidence: Two Common Quality of Health Constructs Questions posed to patients are: Questions posed to patients are: “Overall, how satisfied or dissatisfied are you with the quality of health care you received during the last 2 years?” “Overall, how satisfied or dissatisfied are you with the quality of health care you received during the last 2 years?” Very satisfied Very satisfied Somewhat satisfied Somewhat satisfied Somewhat dissatisfied Somewhat dissatisfied Very dissatisfied Very dissatisfied

13. Questions posed to patients are: Questions posed to patients are: “Now thinking about the future, how confident are you that you can easily get good medical care when you need it?” “Now thinking about the future, how confident are you that you can easily get good medical care when you need it?” Very confident Very confident Somewhat confident Somewhat confident Not too confident Not too confident Not confident at all Not confident at all Satisfaction and Confidence: Two Common Quality of Health Constructs

14. Methods Dependent variables Dependent variables Satisfaction with care Satisfaction with care Confidence in health care Confidence in health care Independent variable Independent variable Nativity status Nativity status Covariates Covariates Demographics, SES, health care, chronic conditions, and acculturation Demographics, SES, health care, chronic conditions, and acculturation

15. Methods Analytic approach Analytic approach Descriptive statistics Descriptive statistics Bivariate analyses Bivariate analyses Logistic regression Logistic regression SAS and SUDAAN SAS and SUDAAN

16. Descriptive Results Compared to US-born, foreign-born were: Compared to US-born, foreign-born were: More likely to be young, married, and Hispanic More likely to be young, married, and Hispanic Less likely to have insurance, have a regular doctor, and have a chronic condition Less likely to have insurance, have a regular doctor, and have a chronic condition

17. Bivariate Results Table 1. Comparisons of US- versus Foreign-Born on Dissatisfaction with and Lack of Confidence in Care US-BornForeign-BornP-value Dissatisfied with care Total Total Hispanic Hispanic Asian Asian 35.9 (1.00) 39.6 (3.50) 35.0 (7.46) 45.1 (2.25) 47.0 (3.53) 60.8 (3.82) <.001 NS <.05 Lack of confidence Total Total Hispanic Hispanic Asian Asian 48.6 (1.00) 60.8 (3.23) 60.0 (7.02) 58.2 (2.08) 57.5 (3.19) 63.7 (3.46) <.001 NSNS

18. Dissatisfied with Care Crude Model 1 Model 1 ‡ Model 2 ¶ Model 3 † Model 4 ‡ Total Sample 1.47 (1.21,1.79) 1.41 (1.15, 1.72) 1.35 (1.07,1.70) 1.22 (0.97,1.55) 1.37 (1.03,1.82) Hispanic Hispanic 1.35 (0.90, 2.02) 1.46 (0.96,2.20) 1.43 (0.88,2.33) 1.18 (0.72,1.93) 1.20 (0.65,2.21) Asian Asian 2.88 (1.40,5.90) 2.63 (1.23,5.59) 3.25 (1.37,7.75) 2.81 (1.19, 6.64) ___ € Referent group is US born. ‡ Model 1 adjusted for age, sex, and marital status. The model for the total population was additionally adjusted for race/ethnicity throughout. ¶ Model 2 additionally adjusted for education and income. † Model 3 additionally adjusted for insurance status, having a regular physician, and having any chronic disease ‡ Model 4 additionally adjusted for language of interview and length of stay in the. Table 2. Odds Ratios (95% Confidence Intervals) for Dissatisfaction with Care for Foreign-Born Individuals

19. Table 3. Odds Ratios (95% Confidence Intervals) for Lack of Confidence in Health Care for Foreign-Born Individuals Lack of Confidence in Health Care Crude Model 1 Model 1 ‡ Model 2 ¶ Model 3 † Model 4 ‡ Total Sample 1.47 (1.23,1.77) 1.43 (1.18, 1.73) 1.44 (1.16,1.80) 1.32 (1.05,1.65) 1.33 (1.01,1.74) Hispanic Hispanic 0.87 (0.60, 1.26) 0.87 (0.60,1.27) 0.67 (0.43,1.04) 0.53 (0.33,0.84) 0.48 (0.28,0.83) Asian Asian 1.17 (0.61,2.24) 0.95 (0.46,2.97) 1.40 (0.65,3.02) 1.33 (0.59, 2.97) ___ € Referent group is US born. ‡ Model 1 adjusted for age, sex, and marital status. The model for the total population was additionally adjusted for race/ethnicity throughout. ¶ Model 2 additionally adjusted for education and income. † Model 3 additionally adjusted for insurance status, having a regular physician, and having any chronic disease ‡ Model 4 additionally adjusted for language of interview and length of stay in the.

20. Discussion Reasons for our findings may be due to cultural, language, or social barriers Reasons for our findings may be due to cultural, language, or social barriers Future studies should include more qualitative research to better understand concepts of satisfaction and confidence both from the patient’s and physician’s perspectives. Future studies should include more qualitative research to better understand concepts of satisfaction and confidence both from the patient’s and physician’s perspectives.