ORIGINAL PAPER Health Disparities Among Immigrant and Non-immigrant Elders: The Association of Acculturation and Education Terry Y. Lum �� Julianne P. Vanderaa Published online: 31 January 2009 �� Springer Science+Business Media, LLC 2009 Abstract Guided by the theories of human capital and acculturation, this study investigated the association of immigrant status among older people with their physical and mental health outcomes, health services utilization, and health insurance coverage. Specifically, it examined the interactive effects of immigrant status, education, accul- turation, race, and ethnicity on these dependent variables. The study used a national representation sample of 7,345 older Americans from the first wave of the Asset and Health Dynamic of the Oldest Old study (AHEAD) survey. We used both logistic regression and ordered logit regression for our multivariate analyses. The findings are as follows: (1) immigrant status was negatively associated with level of depression, number of IADL difficulties, and on types of health insurance coverage. Immigrant status had a significant relationship only with the utilization of outpatient surgery, but not on other health services utili- zation. (2) There were significant interactive effects of race and ethnicity and immigrant status on these dependent variables. The findings support the existence of double jeopardy among those who are simultaneously an immi- grant and a member of a racial and ethnic minority group in the United States. (3) Acculturation has strong associations with health insurance coverage and with number of diffi- culties with IADL. Keywords Old immigrants Health disparity Acculturation Education Race and ethnicity Most of the people living in the United States are either descendants of immigrants or themselves immigrants. In 2002, the U.S. Census Bureau estimated that 33 million people in the United States (or 12% of the total U.S. population) were foreign-born [39]. The immigrant popu- lation is growing faster than the U.S.-born population. Between 1970 and 2000, the number of foreign-born in the United States increased by 3.4 times. In contrast, the total U.S. population increased by only 1.4 times [38]. In 2000, one in five residents in the United States was either foreign- born or had at least one foreign-born parent [38]. It is projected that the nation���s foreign-born population will increase from 36 million in 2005 to 81 million in 2050 [29]. Additionally, the immigrant population is aging. In July 2003, 35.9 million people, or 12 percent of the U.S. population, were aged 65 years and older [13]. The older population is expected to double in 2030 from its size in 2000, increasing from 35 million to 70 million people and representing almost 20 percent of the US population in 2030 [13]. In 2005, almost four million of those over 65 years of age were foreign-born [30]. Immigrating is a stressful life event that begins when foreign-born individuals leave their native countries to move to the United States. Once in the U.S., many immi- grants face a lifetime of adjustment and acculturation. Immigrants not only have to adjust to a new culture, lan- guage, and social and economic systems that may be very different from their countries of origin, they also have to overcome many obvious and not-so-obvious obstacles [12]. As immigrants age, they are likely to have experienced T. Y. Lum (&) School of Social Work, University of Minnesota, 105 Peters Hall, 1404 Gortner Avenue, St. Paul, MN 55108, USA e-mail: tlum@umn.edu J. P. Vanderaa Mental Health Resources, Inc., 1821 University Avenue, Suite N-464, St. Paul, MN 55104, USA e-mail: jvanderaa@mhresources.com 123 J Immigrant Minority Health (2010) 12:743���753 DOI 10.1007/s10903-008-9225-4

various levels of stress throughout their lives. An accumulation of stressful life experiences may lead to poor physical and mental health in old age. Although the amount of information available on the physical and mental health of immigrants has been slowly growing over the past few decades, many of the studies are based on data collected from small convenience samples that focused on a specific ethnic group in a specific geographical area [7���9, 15, 17, 19, 20, 23, 24, 26, 32, 37]. The findings of these studies have enriched our understanding of the struggles experi- enced by immigrant groups, yet failed to provide a more general profile of the physical and mental health of older immigrants living in the United States. Even though health service utilization and insurance coverage are important indicators of health care system, research on these topics among older immigrants is sparse. Given the significant size of the elderly immigrant population and the lack of understanding of that population, it is necessary to examine their physical and mental health status, health insurance coverage, and health services utilization using a large nationally representative sample. Relying on data from the first wave of the Asset and Health Dynamic of the Oldest Old study (AHEAD), we investigated the differences in physical health, mental health, health insurance coverage, and health services uti- lization between foreign-born and native-born elderly people. This data includes elderly immigrants whether they are newly arrived immigrants or immigrants who have aged in the United States. Furthermore, we examined how levels of acculturation and education mediated the rela- tionship of immigration with these variables. Finally, we analyzed the independent and interactive effects of race/ ethnicity and immigration on older immigrants��� physical and mental health status and on their utilization of four health services, including physician visit, hospital stay, outpatient surgery, and dentist visit. Literature Review Many studies that focused on mental health of immigrants assumed that a stressful life trajectory and the social iso- lation apparent after immigration harm an immigrant���s mental health. With few exceptions (e.g. [16]), there is growing evidence from both qualitative and quantitative sources to indicate that immigration is related to higher levels of depression among elderly immigrants [5, 23, 24, 32, 34]. Research on the association between acculturation and the mental health status of immigrants has been inconclu- sive. Acculturation is generally referred to as the psychological adjustment and adaptation to a new culture by an individual from another culture [11]. There is evidence that a higher level of acculturation is associated with enhanced mental health among refugees [22, 27, 28, 40]. However, for non-refugee immigrants, the relationship between acculturation and emotional well-being remains uncertain. Some studies found a negative association between levels of acculturation and mental health out- comes [17, 18, 21, 25, 41]. Others discovered a positive association between levels of acculturation and emotional well-being [3, 26]. A few studies failed to find any sig- nificant association between them [4, 6, 20, 35]. Some research discerned indirect connections between levels of acculturation and depression. A higher level of accultura- tion corresponded to a higher level of stress that in turn contributed to a higher level of depression. Conversely, an association existed between a higher level of acculturation and a higher socioeconomic status, which in turn contrib- uted to a lower level of depression [31]. With regard to social isolation, studies consistently found that better social support is associated with lower levels of depression [7, 23, 24, 31, 32]. Additionally, a more recent study found that the relationship between immigration-related factors, such as status and language proficiency, and mental illnesses were different for men and women [36]. Some of these inconsistencies could be due to the utilization of varied data collection techniques, sampling strategies, and mea- sures for determining depression or other mental disorders [36]. A few recent studies addressed the physical health of elderly immigrants. One investigated the health status of elderly Asian Pacific Islanders within the home health care system [19]. Another study looked at the impact of social integration on health status [7]. Others examined elderly immigrants��� health-related social service utilization [8, 15, 33]. These studies consistently concluded that the physical health of elderly immigrants is poorer than the health of native-born elders. Additionally, elderly immigrants faced more challenges in accessing high quality health care services. Although these studies provide some useful information about the physical and mental health status of older immigrants, they display some major deficiencies. First, most of the research centered on a specific ethnic group, such as Hispanic and Latino [3, 6, 7, 18, 21], Asian Indian [7] and Chinese [15, 17, 23, 24, 31, 34]. Most of them also lacked a comparison group of native-born elderly people possessing the same racial and ethnic background. Conse- quently, this earlier research failed to separate the effects of racial and ethnic minority status from the effects of immigrant status on physical and mental health, health services utilization and health insurance coverage as many of the immigrant elders are also people of color. Further- more, recently, there is an increase in the number of refugees and immigrant coming to the United States from 744 J Immigrant Minority Health (2010) 12:743���753 123