This study examined ethnic differences between Mexican-American and non-Latino White elders on caregiver preference in the likely event of hip fracture based on an enhanced Andersen’s behavioral model of health service utilization. We examined whether ethnicity
and a measure of cultural values
independently affected caregiver preference. The findings indicated that there was a significant difference between Mexican-American and non-Latino White elders in their caregiver preferences. Fewer Mexican-American elders than non-Latino White elders preferred to rely on formal/professional caregivers, and a greater proportion of Mexican-American than non-Latino White elders preferred to rely on informal caregivers. In addition, based on the multivariate analysis, the cultural factor significantly mediated the ethnic effect on the caregiver preference. The cultural factor assessed familism and attitude toward nursing home care. Familism has been considered a major influence in caregiving practices in Mexican culture (John et al. 1997
) but has not been explicitly assessed in caregiver preferences among Mexican-American elders. The significant effect of a cultural factor on the caregiver preference by Mexican-American elders in the present study is consistent with previous research among Korean Americans elders, an ethnic group also known for their collectivistic cultural orientation (Min 2005a
). Min (2005a)
found a significant cultural effect on the preference for a caregiver. Similarly, the study by Bradley and colleagues (2004)
found that race/ethnicity alone did not explain the intended use of long-term care, while psychological factors mediated the racial effect on the intended use of long-term care. Taken together, the findings above demonstrate that race/ethnicity alone does not account for preference for long-term care among Mexican-American elders. In addition, Medicaid coverage significantly decreased the odds of relying on informal caregivers, which was also consistent with previous research (Min 2005a
; Wallace et al. 1998
). A significant effect of living alone on the preference for caregiving arrangement was consistent with a previous study that reported a greater preference for informal assistance among older adults living with spouses than those who were living alone (Sudha and Mutran 1999
). However, in the present study, variables that have been associated with preference for long-term care in previous research (i.e., age, gender, education, self-rated health status, and functional limitation) did not have a significant effect on preference for a caregiving arrangement.
The findings from this study have several implications for informing and thereby improving the cultural relevance of services to the growing numbers of Mexican-American elders. National reports have identified such factors as low socioeconomic status and the health care delivery system that do not consistently consider the cultural relevance of services as comprising some of the underlying causes for the persistent ethnic disparities in health care access and outcomes (Institute of Medicine 2002
; U.S. Surgeon General 2001
; U.S. Department of Health and Human Service 2003
). Given the demonstrated pattern of underutilization of formal services among Mexican-American elders compared with other older groups in the population (Dietz 2001
; Hinton 2002
; Ho et al. 2000
; Lampley-Dallas 2002
), patient preferences may explain in part the racial and ethnic disparities in use of health care resources (Katz 2001
). Identification and incorporation of caregiving preferences in assessment and service provision (Kane & Kane 2000
) is an essential first step for enhancing the cultural relevance of care for ethnic minority elders and non-minorities as well (Min 2005b
). Findings on caregiving preferences also have policy implications due to the long lasting consequences of racial discrimination and social and economic inequities that historically have limited the availability and accessibility of services (Katz 2001
The present findings revealed the salience of cultural values in caregiving preferences, which were consistent with previous studies indicating that Latino elderly have a greater tendency to rely on informal support for their care needs based on their deep rooted familism (Wallace et al. 1994
). The preference for informal caregiving among Mexican-American elders may contribute to their reluctance to use paid professional services even when they are medically necessary or when familial or informal caregivers are not available to provide appropriate care. Such reluctance may result in “bumping-down” (Wallace et al. 1998
) of their long-term care needs. This suggests that ethnic minority families shoulder a disproportionate share of the caregiving burden. It may also mean that if family members are not available, the needs of elders may go unattended or a crisis may result before appropriate care is obtained (Min 2005a
). Although familism engenders a sense of obligation in adult children toward their aging parents, multiple issues, such as intergenerational conflict, family stress, and geographical distance, may prevent family members from being able to fulfill traditional role expectations for caring of the elderly. For example, one study found that although many Mexican-American families maintained contact with aging relatives, they were not be able to provide instrumental support for critical problems that impact ADL (Dietz 2001
). Conversely, it is also important to highlight the cultural strengths and resources that are reflected in the beliefs and values that underlie the cultural preference toward informal caregiving. Studies suggest that protective factors such as high family and social support are associated with better health and mental health outcomes among Mexican immigrant families (Finch and Vega 2003
). As such, an assessment of the beliefs, perceptions, and preferences of the elder and the family system that indicates a familistic cultural orientation can be useful; such qualities can be cultivated and fostered in group or family centered modalities to increase the cultural fit of services with the culture of the population being served. Providers should also provide guidance on how to balance formal and informal care options so that culture-laden preferences and expectations for informal care can be managed better by available family caregivers. It is also important for service programs to provide culturally appropriate education and advocacy services to Mexican-American elders and their families. Such services need to take into account preferred language and literacy level; they should provide useful information about available service options and ways of accessing them (Brach & Fraserirector 2000
In particular, by enhancing the Andersen model (1995) with the addition of culture as the fourth factor, this study makes a theoretical contribution to the field by bringing to light the significant influence of a cultural dimension in the empirical investigation of long-term care among Mexican-American elders. While the race or ethnicity variable has been used as a proxy for such cultural characteristics (LaVeist 1994
) in previous studies, the enhancement via the cultural factor in this study allowed for the empirical testing of cultural components that have not been explicitly specified before. This study underscores the importance of considering cultural factors and explicitly measuring them. Such explicit conceptualization and operationalization of culture is an essential empirical step in helping us to advance our understanding of its role in health disparities. The findings from this research support the development of long-term care services and programs that are more responsive to the needs and preferences of an increasingly diverse older population (Bradley et al. 2004
). In addition, this study shows that when modified with strong theoretical rationale, the Andersen model remains a powerful and useful conceptual framework that can be adapted specifically for cross-ethnic studies on service utilization in older populations.
Findings from this study should be interpreted with the following limitations in mind. First, this study was based on a relatively small sample size and a nonprobability sampling method that limits generalizability of the findings. Second, in the current study, because the focus was on a cross-cultural comparison of preference for long-term care arrangement between two ethnic groups, there were important variables specific to Mexican-American elders (i.e., nativity, the length of residence in the U.S., linguistic acculturation) that were not included in the analysis. Finally, this study was based on a cross-sectional research design, which limited our understanding of the long-term effects of cultural values on caregiver preferences between two the ethnic groups.
In sum, the findings from this study indicate that any long-term care, home- and community-based or institutional, should consider the service needs of ethnic minority elders by explicitly taking into account their care preference and thereby provide service options that are respectful and relevant to their cultural values.