This study examines racial/ethnic differences in informal and formal health-related home care utilization among a nationally representative sample of U.S. elders. Consistent with previous studies, we find that even after controlling for various individual and community characteristics, NH-Asian elders are significantly more likely to use informal home care and less likely to use formal care compared with NH-white elders (Olson 2001
). We extend prior research by exploring how the interaction between individual race/ethnicity and community racial/ethnic composition is associated with home care use. We find that NH-Asian and Hispanic elders who live in block groups with 25 percent or more of residents being NH-Asian or Hispanic, respectively, are more likely to report informal home care utilization than their counterparts in other block groups. No such effect is apparent for formal home care. Furthermore, these findings remain consistent in sensitivity analysis using cutoff points between 15 and 35 percent for block group-level racial/ethnic composition.
Unlike Hispanics and NH-Asians, NH-black elders do not seem to have a higher likelihood of using home care if they live in communities with higher proportions (25 percent or greater) of NH-blacks. One possible explanation for this is that NH-Asian and Hispanic elders may face barriers to obtaining home care that differ from those encountered by other older adults, such as those related to English proficiency, immigration status, or citizenship status. Moreover, these barriers may be ameliorated by concordance between individual race/ethnicity and community racial/ethnic composition. Another possible explanation is that communities with higher proportions of NH-blacks may not offer the same level of social capital that other racial/ethnic communities may provide. Prior studies have found that NH-black elders have limited ties to their residential communities, particularly in areas with high poverty or crime rates (Klinenberg 2002
Previous studies often exclude household living arrangement as a control variable from their analysis in identifying risk factors of home care utilization because of potential endogeneity (Kemper 1992
). However, regardless of household living arrangement, this study finds that community racial/ethnic composition remains significantly associated with informal home health use in Hispanic and NH-Asian elders. This suggests that communities may offer additional resources helpful in obtaining home care above and beyond the availability of live-in family caregivers for Hispanic and NH-Asians elders.
Our findings also indicate that while Hispanic and NH-Asian elders living in communities with higher proportions of their own race/ethnicity are more likely to use informal care, they are not more likely to use formal care. These differences may be a result of racial/ethnic preferences for informal home care over formal home care services, regardless of community racial/ethnic composition (Cagney and Agree 1999
). Furthermore, this study examines the use of “any” formal home health services, a global measure captured in the MEPS data. Our findings might have been different if we were able to examine racial/ethnic differences in the use of various formal home-based services ranging from highly skilled nursing assistance to personal care. Prior studies have found racial/ethnic variations in different types of formal home care utilization (Dietz, John, and Roy 1998
; Laditka, Laditka, and Drake 2006
;). Because formal assistance is important for supplementing care provided by informal caregivers, further research is warranted to examine the supply, competency, and stress management of informal caregivers who provide elder care, particularly in communities with higher proportions of Hispanics or NH-Asians. Ensuring adequate formal resources and respite care is of policy relevance to help educate, support, and relieve informal caregivers.
This study has several limitations that should be considered. First, while we offer plausible explanations for our findings, the underlying causal mechanisms were not directly tested. There may be unobserved characteristics related to both community racial/ethnic composition and the use of home care that may partly explain our findings. For example, prior studies have found that psychosocial factors, economic factors, and presence of informal caregivers may contribute to racial/ethnic differences in the use of home care (Burton et al. 1995
; Yeo 2001
; Bradley et al. 2004
;). They may also contribute to the observed differences within
racial/ethnic groups living in communities with different racial/ethnic compositions. In our descriptive analysis, we find that more NH-Asian elders are married, have more education, and have higher income than elders of other race/ethnicity. Other unmeasured characteristics, such as acculturation or knowledge of and attitudes toward home care, that differ across community racial/ethnic composition and individual race/ethnicity may in part explain our findings. Further research is necessary to investigate the extent to which our findings are a result of causation or selection.
Another limitation is that we examine only the likelihood of using any home care, not the amount or intensity of the care used. The underlying need for home care and the satisfaction of such care also are not observed and therefore cannot be examined in this study. Finally, the sample limits our ability to assess the heterogeneity of Hispanic and NH-Asian subgroups. These subgroups encompass different cultural values, history, languages, and acculturation.
Despite these limitations, this study provides evidence that the interaction between individual-level race/ethnicity and community-level racial/ethnic composition is associated with the likelihood of home care use among older adults in the United States. Specifically, NH-Asian and Hispanic elders are more likely to use informal home health care if they live in communities with a higher proportion of residents who share their race/ethnicity. As previous research suggests that reliance on informal health care is associated with a reduced risk of nursing home placement, it is important that future research clarify the causal mechanisms underlying our findings. Such research may help programs draw on resources inherent in communities and social networks to foster the accessibility and desirability of informal home care. A better understanding of how informal care is provided within NH-Asian and Hispanic communities also may be important to policy makers concerned with providing formal home care either as a substitute or supplement to informal home care. These efforts, in turn, could improve the likelihood of “aging in place” for more elderly Americans.