Contextual factors on health and mental health service use among immigrants in the United States: moderation of citizenship status and race/ethnicity

After the welfare reform in 1996, immigrants’ access to social service programs and health services has been largely limited, particularly for non-citizens. Latino and Asian immigrants in the United States as the major growing immigrant populations have been found to under use health and mental health services compared to U.S.-born citizens. While prior literature identifies various individual barriers, contextual influence, such as state and community factors have not been widely examined. Adapted from Andersen’s Behavior Model of Health Service Use, this study aims to examine the associations between contextual factors (community cohesion, state funded-programs, and state concentration of immigrants) and immigrants’ preventive and mental health service use after controlling for individual-level (predisposing, enabling and needs factors) factors. This study further examines whether the associations of service use and state factors are moderated by immigrants’ citizenship statuses and their race and ethnicity. Data were obtained from the public and restricted data set of the National Latino and Asian American Survey (NLAAS), which consists of a sample of 4,254 Latino and Asian immigrant adults from 18 to 64 years of age living in the U.S. household across 50 states during 2002 and 2003. Binary logistic regression models were estimated to address the questions above. Sampling weights, strata and cluster variables were applied due to the multistage sampling design of this data set and oversampling of higher density areas with immigrant origin groups of interest. Findings from the study with regard to health care use indicated that immigrants who were female, not in the labor force, being older, had medical insurance or had better English proficiency were more likely to have physical checkups in the previous year. Immigrants who lived in states with the highest immigrant concentration (more than 20%, such as California, New York and New Jersey) were 60% less likely to have physical checkups than those who lived in non-traditional immigrant states (states that are composed of less than 5% of immigrants). Community cohesion and living in states that offered state-funded health programs to immigrants had no effect on immigrants’ preventive health care use and mental health care use year after controlling for individual-level factors. With regard to mental health care use, being a younger immigrant (18-30 years old), being male, married, or living in poverty were more likely to receive counseling or therapy after adjusting for individual-level factors. Those who were employed, Asian immigrants or naturalized citizens as well as those who perceived to have excellent health and mental health condition had greater odds of seeking mental health professionals’ help. Immigrants who lived in states with moderate immigrant concentration (10-14.9%) had 3.64 times greater odds for receiving mental health care than those who lived in non-traditional immigrant states. In the analyses for the interactions between citizenship status and state immigrant concentration, non-citizens who lived in states with a moderately high concentration of immigrants (e.g. 10% and above) or above had a lot less odds for having physical checkups. On the other hand, naturalized citizens who lived in states with 15-19% of immigrants were nearly 20 times more likely to receive counseling than their US-born counterparts. In the analyses for the interactions between race/ethnicity and state concentration of immigrants, Asian immigrants had 8-11 times greater odds for having physical checkups than Latino immigrants when they both lived in highly immigrant-concentrated states (e.g. 15% and above). However, this protective factor does not continue to hold true for Asian immigrants in their mental health care use in moderately immigrant-concentrated states. Compared to Latino immigrants, Asian immigrants’ odds for going to counselors or therapists decreased by 90% when they lived in states such as Illinois, Arizona, Virginia, Connecticut, Rhode Island, Maryland, Washington, and DC (10-14.9% of immigrants). Neither of the interactions, between citizenship status and state generosity or race/ethnicity and state generosity, were significant. This indicates that living in a more generous state does not affect immigrants differently than US-born counterparts, nor does it differently affect Latino or Asian immigrants in terms of their utilization of health and mental health care. Based on the findings, the current study suggests that practice, policy and research on the preventive care and mental health care for Latino and Asian immigrants should have more understandings of sociocultural and contextual factors at community and state levels, and how these utilizations differ across different citizenship statuses and racial and ethnic groups in state contexts. By untangling the various effects in research and responding to them through practice, legislation and policy implementation, we can more likely reduce health disparities among immigrant and minority groups and thus enhance better health and mental health well-beings for all in the United States