Examining Health Literacy and Health Outcomes Among United States Immigrants and Non-Immigrants

Jason L. McLeod1*‡, Muna M. Ahmed1*‡, Darin M. Chhing1*‡, Sami R. Hasan1*‡, Teresa N. James1*‡ , and Yashoda T. Khatiwoda1*‡

¹Geisinger Commonwealth School of Medicine, Scranton, PA 18509 *Master of Biomedical Sciences Program ‡Authors contributed equally Correspondence: jmcleod@som.geisinger.edu

Abstract

Background: Research on immigrant health is essential toward addressing the implications and needs of one of the largest growing demographics of the United States (U.S.) population. Immigrants face several challenges, including health literacy and access to health care. Many studies have shown that low health literacy is often associated with poor health outcomes. The goal of this study is to examine health literacy and health outcomes among immigrants who came to the U.S. between 1930 and 2011.

Methods: A secondary analysis was completed using data from the Health Information National Trends Survey (HINTS) collected from 2011 to 2012. Several health literacy questions from the survey were used to score health literacy in our sample of 502 immigrants, composed of different races, who immigrated to the U.S. between 1930 and 2011. The health literacy questions included comprehension of the following topics: over the counter and prescription drugs, nutrition, and medical devices. To assess health outcomes in our samples, two questions about overall health and confidence in caring for oneself were used.

Results: No statistically significant difference present between the health literacy score means of non-immigrant sample (n=1,646) and immigrant sample (n=203). A statistically significant difference was identified between the health literacy score means of Black/African American non-immigrants (n=274) and Black/African American immigrants (n=24) (t[25] = 2.493, p = 0.020). For both immigrant and non-immigrant samples, mean health literacy scores in association with results of health outcome assessments were relatively similar.

Conclusion: Overall, high health literacy scores were noted among survey respondents. High health literacy was associated with high health rating and high health confidence among both immigrant and non-immigrant sample populations. NonImmigrant and immigrant health literacy score means were found to be relatively similar. Black/African American nonimmigrants had higher health literacy score means than Black/ African American immigrants. Additional analyses via collection of primary data and randomized surveys can emphasize and further elucidate the findings within this study. These strategies, combined with examination of poor health literacy, are anticipated to further reveal the influence of health literacy and socioeconomics on immigrant and non-immigrant populations.

Introduction

Health literacy is the ability to comprehend and make decisions upon information regarding one’s overall health and/or the health of close friends and family members (1). It is a critical factor that represents the degree to which individuals have the capacity to obtain, process, and comprehend basic health information and utilize the services needed to make appropriate and informed health decisions (2). Health literacy remains one of the major contributors to health disparities in the United States (U.S.), as approximately 80 million adults have limited or low health literacy (3). Factors that contribute to health literacy in the U.S. include, among others, a person’s level of education and their proficiency in the English language, along with one’s cultural background and environment (4). The U.S. is unique, in that it is composed of approximately 46 million immigrants, more than any other country in the world (5). The health of U.S. immigrants, and their access to health care services, features wide variability by aspects such as race, ethnicity, legal status, and citizenship (6, 7). Longstanding challenges faced by immigrant populations include difficulty navigating the U.S. health care system and accessing health information in their preferred language (8). In recent years, intensifying rhetoric discouraging immigrant-use of public health insurance programs, paired with aggressive enforcement of immigration practices and rescission of protections for those at risk for deportation, have worsened access and utilization of health care services among immigrants in the U.S. (9). Comprehensive understanding of the interrelation between health literacy and the health outcomes of immigrants to the U.S. may provide key insight into the development of strategies that seek to improve the health status of this growing demographic (10). Researchers have demonstrated findings indicating immigrants with both low health literacy and limited English proficiency as being more likely to exhibit poor health outcomes (2). Limited English proficiency can be a significant barrier between health care providers and immigrant patients, as these patients may experience difficulty in expressing their concerns, voicing questions, or following health care instructions (2, 11).

Few studies have analyzed more recently published datasets from national samples to further elucidate the connection between health literacy and health outcomes among immigrant and non-immigrant individuals in the U.S. (12). The purpose of our investigation was to perform a secondary data analysis on participant responses from the Health Information National Trends Survey (HINTS) to examine health literacy and health outcomes in non-immigrant populations in comparison to those who immigrated to the U.S. Discussion of the results obtained through statistical techniques may suggest how health literacy interventions can be an effective tool in improving health comprehension, combating health disparities, and generating

health benefits through broad implementation across diverse immigrant populations.

Methods

HINTS is sponsored by the Health Communication and Informatics Research Branch (HCIRB) of the Division of Cancer Control and Population Science. HINTS is leveraged to routinely accumulate nationwide data representative of the American public’s use of cancer-related information. The survey is also employed to monitor changes in the reception of health communications in individuals over the age of 18 by assessing usage of a variety of channels, including the internet, to obtain crucial health information for themselves and loved ones (13). Our study consisted of a secondary data analysis using data from the first cycle of the fourth edition of HINTS (HINTS 4 Cycle 1). The data to be analyzed was originally collected from October 25, 2011, through February 21, 2012. Only participants meeting specific sampling criteria were included in this study. Responses from survey question K6: “Were you born in the United States?” were used to determine inclusion of participant data. The resulting sample consisted of 3,310 participants who were born in the U.S. and 502 participants who were born abroad and immigrated to the U.S. between 1930 and 2011. There were no instances of U.S. citizens born abroad to report. All other respondents, including missing values, were excluded (n=147). The HINTS 4 Cycle 1 data was collected utilizing a survey that respondents received in the mail. In order to increase participation, the survey was translated into the Spanish language for households that were considered Spanishspeaking by the U.S. Census Bureau. A total of 12,385 addresses provided by Marketing Systems Group underwent a random sample method and were stratified such that census block groups with a population proportion of Hispanics or African Americans equaling or exceeding 40% were assigned to the high-minority stratum (n=6,730), while the remaining addresses were assigned to the low-minority stratum (n=5,475) (13). One-hundred and eighty addresses of the low minority group were from central Appalachia. The survey asked participants questions regarding topics such as: access to health information, health care opinions, current health status, health literacy, cancer, and demographics. Responses were in various formats, including dichotomous, non-Likert, and Likert scales. This information was highlighted in the HINTS 4 Cycle 1 methodology report (13). Our study employed secondary data analysis to better understand health literacy and health outcomes in our samples (Immigrant vs. Non-immigrant). Selected statements pertaining to health literacy and health outcomes from the HINTS 4 Cycle 1 survey instrument were identified for inclusion into this secondary analysis. A definition of health literacy from the National Library of Medicine, “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions,” was adopted to guide the selection of relevant statements from the survey, as well as to help indicate the qualities of health literacy (14). Twelve statements from the HINTS survey pertaining to health literacy were selected for inclusion in this study (Table 1), focusing primarily on over-the-counter drug consumption and nutrition. The responses “agree” or “disagree” were originally captured in the HINTS survey and were applied to operationalize a scale of health literacy for the secondary data analysis. The response “no opinion” has been excluded from the health literacy scale, as it does not add any benefit to the analysis. Any participants from either sample who had more than 16.67% missing data in the health literacy scale were excluded. Those participants with less than 16.67% missing data were included, and missing responses were imputed via the series mean method. Although the series mean method can potentially produce biased results, we mitigated this by imputing values only for participants with a very small amount of missing data. Two health outcome questions from the HINTS 4 Cycle 1 survey were selected for inclusion in this secondary analysis. Participants were asked, “In general, would you say your health is…,” (n=1,639) in addition to the question, “Overall, how confident are you about your ability to take good care of your health?” (n=1,638). Responses to these two questions were in Likert scale form in the original survey. Questions and responses are listed in Table 2. Any participants, from either sample, that had missing data from the two health outcomes questions were excluded (n=31). The Statistical Package for the Social Sciences (SPSS) software stored on a private hard drive both recorded and managed the resulting data to facilitate assessment of the health literacy and health outcomes in our samples. Personal identifiers were not provided in the HINTS 4 Cycle 1 dataset. An Institutional Review Board (IRB) committee determined that our research did not fall under human subjects research under the federal Common Rule, 45 CFR Part 46.102(d). Both descriptive and inferential statistics were employed to analyze the data and provide a statistical summary of immigrant (Figure 1) and non-immigrant (Figure 2) samples. The Kuder-Richardson Formula 20 test was performed to measure internal consistency of the 12-point health literacy scale. Independent samples t-tests were used to demonstrate if the mean health literacy score for each sample was different, and if this difference was statistically significant. In addition, independent samples t-tests were conducted to determine potential differences in mean health literacy scores when examining self-identified race between the non-immigrant and immigrant samples. Ultimately, the combined use of these tests helped characterize health literacy and health outcomes in our samples. Resulting data from the independent samples t-tests were reported on bar graphs.

Results

Descriptive statistics were used to understand the generalization of health literacy scores between both immigrant (Figure 1) and non-immigrant samples (Figure 2). The mean health literacy score for the immigrant and non-immigrant sample was 8.82 (SD=3.44) and 9.02 (SD=3.22), respectively. The Kuder-Richardson Formula 20 test applied on the 12-question health literacy scale (Table 1) resulted in α=.877. This finding is an indicator of “good” internal consistency. All

Table 1. Health Literacy Measurement Statements Selected from the Health Information National Trends Survey (HINTS 4 Cycle 1)

Table 2. Health Outcomes Measurement Questions Selected from the Health Information National Trends Survey (HINTS 4 Cycle 1)

Figure 1. Frequency of health literacy scores from overall immigrant sample.

questions used to determine the health literacy scale appeared to be meaningful in this test. Deletion of one or more questions from this analysis would cause a negligible change in alpha value.

An independent sample t-test was performed to determine if the means of the health literacy scale were significantly different between our samples, non-immigrant (n=1646) vs. immigrant (n=203) (Figure 3). The results of this test suggested acceptance of the null hypothesis, indicating that there was not a statistically significant difference in the health literacy scale means between our sample of non-immigrants and immigrants (t[1847] = .864, p = 0.388). Further independent samples t-tests were performed to determine if there were differences in health literacy means when examining self-identified race between the non-immigrant Figure 2. Frequency of health literacy scores from overall nonimmigrant sample.

and immigrant samples (Figure 4). Notably, the data suggested a statistically significant difference in health literacy means (mean difference=1.97) between Black/African American nonimmigrants (n=274) and Black/African American immigrants (n=24), (t[25] = 2.493, p = 0.020). All other races were determined to be not statistically significant.

The mean health literacy scores and standard deviations for immigrant and non-immigrant populations, in association with the health outcome question: “In general, would you say your health is…,” were calculated and reported in Table 3, and subsequently graphed in Figure 5. Likewise, the mean health literacy scores and standard deviations for non-immigrant and immigrant populations, in relation to the health outcome

Table 3. Health literacy score means for non-immigrant and immigrant populations in association with the health outcome question “In general, would you say your health is...”

Table 4. Health literacy score means for non-immigrant and immigrant populations in association with the health outcome question “Overall, how confident are you about your ability to take good care of your health?”

Figure 3. Overall health literacy score means for non-immigrant (n=1646) and immigrant (n=203) samples (t[1847] = .864, p = 0.388). Figure 4. Health literacy score means for Black/African American non-immigrants (n=274) and Black/African American immigrant (n=24) samples (t[25] = 2.493, p = 0.020).

question: “Overall, how confident are you about your ability to take good care of your health?” were calculated and reported in Table 4 and subsequently graphed in Figure 6.

Discussion

The HINTS survey is considered a robust survey tool used to gauge the health and health communication in communities and has helped the National Cancer Institute gather information since 2003 (15, 16). Our selection of 12 questions from the HINTS Survey (Table 1) was determined to have good internal consistency for the purposes of this study. The list of frequently Figure 5. Health literacy scores in relation to the health outcome question “In general, would you say your health is...” in non-immigrant and immigrant samples.

Figure 6. Health literacy scores in relation to the health outcome question “Overall, how confident are you about your ability to take good care of your health?” in non-immigrant and immigrant samples.

asked questions included with the cover letter for each survey was intended to put the voluntary participants at ease with the survey methodology (17). Among other aspects to the study, participants were made aware of efforts to ensure their privacy, including the manner in which resulting data would be used. Stated under the Privacy Act, responses to survey questions could not be associated with participant names. In addition, the completed surveys would be securely stored throughout the duration of data analysis, and all versions destroyed upon study completion. It was also made known that the data was intended solely for the purposes of improving public health (17).

In both the immigrant sample and non-immigrant sample, most participants appeared to have relatively high health literacy scores (refer to Figure 1 and Figure 2, respectively). This was expected, as participants in the voluntary survey may tend to have higher levels of health literacy (18). Although no relationship was identified for the health literacy score means between non-immigrants and immigrants, it is of value to note that the health literacy score mean was only slightly higher

for non-immigrants (9.02) than for immigrants (8.82), with the mean values differing only by 0.20. Observing a relatively similar mean health literacy score for immigrants and non-immigrants in our study may be attributed to the phenomenon known as the “Healthy Immigrant Effect.” In the Healthy Immigrant Effect, it is proposed that immigrants arrive with a health status above that of the country of destination. After 10 to 20 years of being in the destination country, immigrant health status resembles that of native residents (19). Economic stability, education, health care, one’s neighborhood, community, and environment are examples of determinants of health that may promote or hinder health literacy (20). These determinants of health are intimately influenced by the country of residence. Longer time spent in the U.S. can cause immigrants to have a similar health literacy score to non-immigrants, reflective of health care access, but also the amount of cultural assimilation (21). Though length of time in the country was not explored in our study, researchers may benefit from including time of residence as an element of future studies. African Americans have been found to have among the lowest health literacy in the U.S. (4). We report that a statistically significant difference was identified between the health literacy score means of Black/African American immigrants and Black/African American non-immigrants in our samples. In this study, the mean health literacy score of Black/African American non-immigrants (9.60) was higher than that of Black/ African American immigrants (7.60). The lower health literacy with Black immigrant populations can potentially be attributed to less exposure to the U.S. health care system and language barriers (22). There is diversity among Black immigrants to the U.S. that is also to be considered, with 54% and 34% being from the Caribbean and Africa respectively (23). The findings in our study are supportive of the knowledge that Black immigrants to the U.S. have been noted to face barriers to overall health, such as accent-based and race-based discrimination, physician inexperience with African and Caribbean cultural attitudes in regard to health, and not having health insurance or adequate access to language interpreters (23). Capturing the country of origin, along with the level of proficiency with the English language, could help provide more insight on the impact of these factors on low health literacy.

Overall, for the immigrant and non-immigrant sample groups, the more health-literate the participants, the higher they rated the quality of their health, describing a possible correlation between health literacy and self-evaluated health quality between the two sample groups. It has been established that low health literacy is linked to poor rating of one’s health, poor self-management skills, and poor health outcomes (24). Our finding coincides with high health literacy correlating with high self-evaluated health quality. Health literacy is again affirmed as a fundamental and critical tool in construing health and health outcomes (24). Mean health literacy scores in association with results of the health outcome question, “In general, would you say your health is…” for both immigrant and non-immigrant samples were relatively comparable (Table 3). While non-immigrant health literacy ranged from 7.66 (“Poor” health rating) to 9.87 (“Excellent” health rating), immigrant health literacy had a more pronounced range of 5.39 (“Poor” health rating) to 10.62 (“Excellent” health rating). The non-immigrant mean health literacy scores were greater than those of the immigrant group in all categories, with the exception of the mean health literacy score related to “Excellent” health status.

The similar health literacy scores between both immigrant and non-immigrant samples for the health outcome question asking respondents to rate their general health may also potentially be ascribed to facets of the Healthy Immigrant Effect (19). As previously discussed, after some time in the country of destination, immigrants become similar in their health behaviors to their non-immigrant counterparts (19). Furthermore, since it is more common that healthier individuals would migrate, this period of assimilation is preceded by a period of time immediately following their migration in which immigrants have better health behaviors than non-immigrants (10). Barriers such as segregation, poor quality of health care, incompatibility with the new culture, lack of access to health care, insurance or familiarity with the health care system, and lack of English language fluency can lead to immigrants reporting lower health quality than non-immigrants (10). Conversely, the healthier individuals that migrate may tend to have higher education and greater economic stability than non-immigrants and may consequently report higher health ratings (10). This duality provides rationale behind the polarity in the health literacy scores among the immigrant sample, with immigrants having lower health literacy score means than non-immigrants for “Poor” health rating and higher health literacy score means than non-immigrants for “Excellent” health rating. Mean health literacy scores in association with results of the health outcome question “Overall, how confident are you about your ability to take good care of your health?” for both immigrant and non-immigrant samples were also relatively comparable (Table 4). Non-immigrant health literacy ranged from 7.05 (“A little confident”) to 9.88 (“Completely confident”), whereas immigrant health literacy exhibited a relatively similar range of 6.99 (“A little confident”) to 9.83 (“Completely confident”). The greatest difference in mean health literacy scores among the two samples was for the response “Somewhat confident,” with the non-immigrant sample exhibiting a mean (8.36) that was 0.75 higher than the immigrant sample mean (7.61). The interplay between health literacy scores and health confidence levels as seen in our data between immigrants and non-immigrants was as expected (25, 26, 27). Higher health literacy was associated with higher health confidence levels in both sample populations. In regard to the immigrant sample group, our findings may also be attributed to the Healthy Immigrant Effect (19). The results of both groups emphasized the important role that health literacy can play in contributing to health outcomes. Health confidence levels are impacted by the significance of health literacy, made evident as patients attempt to meet the stipulations of carrying out self-care, planning for care coordination, and navigating the intricacies of the health care system (25). Health literacy scores between immigrants and non-immigrants were found to be relatively similar within this study. In addition, it is important to note that for both immigrants and non-immigrants, the health literacy scores for all health confidence levels were above 50%, meaning that health literacy was relatively good for both sample populations. Aside from the Healthy Immigrant Effect explanation for our

findings among the immigrant sample, several factors may have contributed to health literacy in both sample groups, particularly socioeconomic factors (19, 10). Linking health literacy with additional elements assessed within the HINTS survey will require further exploration. Future analysis should investigate potential confounding factors that may falsely exhibit an apparent relationship between two variables or mask a true association. In addition, while HINTS does not include psychometric evaluation, this information would be relevant to collect with self-reported data in order to better address variation among the data sets, such as from small sample sizes. Furthermore, research might include examination of data for possible confounding effect or association between health literacy and the following factors, independently or in combination: length of time residing in a country, self-evaluation of overall health quality, level of confidence in caring for one’s personal health, age of immigrant and non-immigrant survey participants, mean age of sample, level of English fluency among immigrant and non-immigrant samples, education, and income.

Conclusion

Health literacy refers to the capability of individuals to achieve, process, and discern the essential information required to make applicable health decisions (2). Assessment of health literacy in our study was shown to be similar among both immigrant and non-immigrant U.S. samples. Through secondary data analysis, we obtained results characterizing how health literacy may impact the health outcomes of non-immigrant populations in juxtaposition to those who migrated to the U.S. Based on results of an independent samples t-test, the p value of 0.388 suggested acceptance of the null hypothesis, indicating no statistically significant differences in health literacy score means between immigrant and non-immigrant samples.

Independent samples t-tests indicated a statistically significant difference (p = 0.020) in health literacy means between Black/ African American immigrants (7.60) and Black/African American non-immigrants (9.60). While inconclusive for other races, future studies may consider expanding upon health literacy and its influence on health outcomes among American Indian/ Alaska Native, Asian, Native Hawaiian/other Pacific Islander, and white respondents in subsequent HINTS reports. The results of this secondary data analysis demonstrated that most of the individuals who participated in the survey possess high health literacy. There were no definitive relationships between immigrants and non-immigrants. Irrespective of immigrant or non-immigrant designation, those with higher health literacy tended to rate their health status as higher. Mean health literacy scores in association with results of two health outcome questions for both immigrant and non-immigrant samples were relatively similar. Healthy Immigrant Effect is a phenomenon that helps describe how migrants to the U.S. tend to take on a health status that is similar to non-immigrants after residing in the country for 10 to 20 years (16). Health literacy was generally good overall for both immigrants and non-immigrants, indicated by the confidence intervals of 50% and above.

Further research into the health of U.S. immigrants, who are deeply interwoven across a dynamic social and political landscape, is imperative for primary data analysis. The combination of primary data collection and randomized surveys should be pursued for more discrete results. Moreover, inspection of data and evaluation of the causal factors contributing to poor health literacy may be beneficial in determining an approach to minimizing health disparities. Primary data analysis may serve to provide broader flexibility to tailor analyses and critically examine socioeconomic factors, generating more conclusive findings.

Acknowledgments

We would like to thank Brian J. Piper, PhD, Elizabeth Kuchinski, and Catherine Freeland for their assistance throughout our research. We would also like to thank Christine Nguyen for their participation in this project.

Disclosures

There are no known conflicts of interest regarding this project.

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