The Use of Preventive Health Care in Asian Americans: The Cross-Level Interactions between Individual and Neighborhood Factors in the United States

Background: The benefits of preventive health care in health promotion, disease prevention and management, and reduction in health care costs are widely known. Despite the expansion of preventive health care benefits under the Affordable Care Act, however, uptake of many preventive services still remains low, and there are persistent racial/ethnic disparities in their use. Asian Americans, for example, in previous research not only had disproportionately low utilization rates of preventive health care services compared with non-Hispanic Whites but also had the lowest utilization of cancer screenings among diverse racial/ethnic groups. The present study explored how individual- and neighborhood-level factors contribute to predicting the use of preventive health care in a sample of Asian Americans. The cross-level interaction between individual- and neighborhood-level factors was also examined.

Methods: Survey data were drawn from 2016 Asian American Quality of Life Study funded by the City of Austin, TX (n=1,898). Due to the nested nature of the data (i.e., individuals within the census tracts) and a dichotomous outcome variable, we used multilevel logistic models using Mplus 8 that enabled us to parse out the individual effects from contextual factors. First, the main effects model tested the effects of individual (e. g., age, gender, marital status, education, health insurance coverage, length of stay in the U.S., and self-rated health) and neighborhood-level factors (e.g., poverty level, ethnic density, and healthcare providers availability). Next, the cross-level interactions between individual and neighborhood-level factors were introduced.

Results: At the individual-level, the findings from the main effects model suggest that older individuals (OR = 1.03, p < .001, 95% CI = 1.02-1.04), women (OR = 1.65, p < .001, 95% CI =1.32-2.05), and Filipinos (OR = 1.62, p < .05, 95% CI = 1.02-2.58) were more likely than their counterparts, including younger individuals, men, and Chinese, to use preventative health care services. Among neighborhood-level factors, the census-tract poverty level was positively associated with the use of preventive health care services (OR = 3.82, p < .01, 95% CI = 1.39-10.46). In the multiplicative model, only the cross-level interaction between health insurance coverage at the individual-level and availability of health care providers at the neighborhood-level was significant (OR = 2.83, p < .05, 95% CI = 1.11-7.18). Those who were uninsured and living in areas with limited availability of health care providers were at the greatest disadvantage.

Conclusions: This study expands understanding of the use of preventive health care services by identifying individual and neighborhood-level factors as possible determinants and sources of disparities. Our results show that barriers to health services include the interaction of inadequate or no insurance coverage and lack of availability of health care services. The results of this study strongly suggest that increased availability of health care providers to more uninsured people will improve their use and access to preventive health care. To diminish the demonstrated disparity in health care access, health care planning should consider both health insurance coverage at the individual level and the availability of health care providers at the neighborhood level.