Using three years of recently available state-based BRFSS data, our findings suggest that Hispanic persons, 65 years of age and older, in the United States who prefer to communicate in Spanish are significantly less likely to have received their recommended influenza vaccinations as compared to their elderly Hispanic counterparts who prefer to communicate in English. Furthermore, there was no evidence that this gap narrowed during the three-year period. It appears that language preference among a Hispanic population, 65 years of age and older, in the U.S. are associated with lower rates of influenza vaccinations, indicating a possible health disparity that could have significant public health implications for the nation.
Our data on differences in the receipt of vaccinations among Hispanic persons based on language preference is similar to previous reports that examined this association. For example, using data from the 1996–1997 Community Tracking Survey, Fiscella and colleagues demonstrated that Spanish speaking Hispanic respondents were less likely to receive influenza vaccinations than non-Hispanic white respondents. These researchers concluded that ethnic disparities in the receipt of care were largely explained by differences in English fluency [23
]. Fiscella and colleagues further reported that increasing the number of persons receiving influenza vaccination among Hispanics and other minority groups would significantly reduce the level of mortality among these groups [20
]. Thus, our study provides additional evidence that Spanish language preference among older Hispanic persons may be an important barrier to receiving the influenza vaccine, which may adversely impact morbidity and mortality rates among the Hispanic population. And most recently, Dubard and Gizlice used data from earlier years of the same dataset, the BRFSS, to show decreased percentages of influenza vaccinations among Spanish-speaking Hispanic persons compared to English-speaking Hispanic persons [24
]. Our study promotes this point even further by using more up to date data and using logistic regression models to take into account other variables which might affect influenza vaccination.
In addition to country-of-origin, length of time spent in the host country, and feelings of interaction with the new culture, language preference has been cited as one of the measures of “acculturation” [25
] which is defined as the cultural modification of an individual, group, or people by adapting to or borrowing traits from another culture. All of these measures can be associated with barriers to receiving care however, research has indicated that limited English proficiency remains a significant barrier to access and use of health care services among Hispanic persons, even when taking into consideration other measures of acculturation. Previous work has demonstrated that after adjusting for demographics, health status, and access to care variables, Hispanic persons with “fair” and “poor” English proficiency reported significantly less visits to their health care provider than did English speaking non-Hispanic persons [27
]. In terms of acculturation, language preference is an important and measurable correlate to receiving adequate preventive health care services.
Several limitations should be considered when interpreting these analyses. First, the BRFSS is a land-line telephone survey, which excludes persons who have no telephone, and those with a cell phone only. Because of this, there is a possibility that some Hispanic households would not have had the opportunity to participate in this survey. However, because of the large sample size of the BRFSS, a relatively large sample of Hispanic persons was obtained, making this more likely to be representative of the Hispanic persons 65 years of age and older in the U.S.
A second limitation of this study is that determination of language preference was measured through the participants' choice of taking the survey in Spanish or English, so questions addressing cultural attitudes and beliefs about vaccines, as well as other measures of acculturation were not included. However, language preference only, as measured by preferred language for the survey or primary language spoken in the household, has been used in other studies to examine barriers to receiving adequate health care among Hispanic populations [11
] as well as engagement in risky health behaviors [30
]. These studies have shown that language preference by itself is associated with negative health outcomes.
A third limitation of this study is that the cross-sectional nature of the data does not permit causal inferences in the observed associations to be made. However, the findings of the association between Spanish language preference and decreased receipt of influenza vaccinations were present and significant for three consecutive years.
A fourth limitation of this study was the self-report of influenza vaccination which is susceptible to recall bias. Although, findings from a study comparing several national surveys collecting health information, including receipt of influenza vaccinations, via different modes (i.e., in person and telephone) showed that responses to self-reported influenza vaccination had relatively small variation in reported rates across the different surveys [32
]. By demonstrating similar response rates across surveys utilizing different modes of data collection, the validity of the information collected in this study is strengthened.
In conclusion, we found that among a large population-based sample of Hispanic persons aged 65 years and older, residing in the U.S., Spanish language preference was associated with lower rates of influenza vaccinations. The importance of this research is two-fold. Firstly, influenza infections can be more often fatal in elderly persons, and secondly, influenza may disparately affect minority populations such as Hispanic persons. Therefore, understanding barriers to receipt of an effective preventive health measure (e.g., vaccinations) is needed. Also, further research is needed to understand cultural sensitivities among Hispanic persons with regards to beliefs about vaccines in general.Such studies may provide further information about other barriers encountered by Hispanic persons with respect to receipt of influenza vaccinations. Information such as this may help increase vaccination rates and improve the overall well-being of older Hispanic persons in the United States.