Graduation Date

Spring 5-7-2016

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Programs

Health Services Research, Administration, and Policy

First Advisor

Li-Wu Chen

Abstract

The number of immigrants in the United States has recently been increasing significantly. Immigrants may experience some worse health outcomes than natives, due to substantial legal and socioeconomic barriers. Many immigration-related disparities in health behavior and health care utilization still remain unexplored. This dissertation comprises of 3 independent studies examining such disparities across immigration status, including (1) E-cigarette use and acculturation effects; (2) Cancer-related office-based medical provider visits among cancer patients; and (3) Potentially preventable emergency department visits.

Two nationally representative data sources included National Health Interview Survey and Medical Expenditure Panel Survey. We categorized the respondents into three immigration groups based on their place of birth and citizenship, including US native, naturalized citizen, and noncitizen. Univariate analyses described the distributions of outcome variables and covariates by immigration status, with t-test and Pearson test to identify statistically significant differences. Multivariate regressions, including logistic and generalized linear models, were performed to adjust for demographic characteristics, socioeconomic status, health care need, and health behavior etc. Nonlinear Fairlie decomposition and propensity score matching method were further adopted to measure covariates’ contributions to the disparities, and reduce potential selection bias, respectively. Stata 14.0 SE was used to adjust for the complex survey design, and we considered a p-value of less than 0.05 as statistical significance.

We found (1) Noncitizens had about 55% lower odds of ever or current use of e-cigarettes than US natives, and highly acculturated immigrants were more likely to try e-cigarettes; (2) Among cancer patients, noncitizens had significantly fewer cancer-related office-based medical provider visits than US natives, however, there was no difference in annual expenditures; (3) Noncitizens were significantly less likely than US natives to have preventable ED visits, and more than 50% of the difference was attributable to race/ethnicity, lack of insurance, and usual source of care; the disparity between naturalized citizens and natives was smaller. Our research suggests that culturally-sensitive health education intervention programs and community health workers may be needed to reduce immigration-related disparities in health behavior and health care utilization.

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