Preventive Healthcare Utilization among Asian Americans in the U.S.: Testing the Institute of Medicine’s Model of Access to Healthcare

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Introduction

Line 29 – Please specify „substantial proportion”. How many?

The introductions is lacking of social theories, so it do not fit journal scope. Authors should develop theory if they want to publish here.

Method

 Using „sample's representativeness” is not proper here, I have an impression that your sample was purposive, as it was not random sample. Am I right? This should be properly explained.

Measures – I would delate it, you will have more space for development of social theory in introduction.

Results

You do not need to describe in detail what can be read from the table 1. Just simple statement about the data in table 1 is enough.

Discussion

Discussion will benefit with some social theory

Author Response

Introduction

1. Line 29 – Please specify „substantial proportion”. How many?

Response: The sentences were revised with specific numbers.

However, only 4% of total national health expenditures was spent for preventive care in the U.S., and approximately 28% of the U.S. population lacks preventive care utilization (Lambrew & Washington, 2007; Lines et al., 2014; O’Connor et al., 2023; Yagi et al., 2022).

2. The introductions is lacking of social theories, so it do not fit journal scope. Authors should develop theory if they want to publish here.

Response: We appreciate the reviewer’s suggestions. The following statements about ‘Intersectionality Theory’ have been added in both the introduction and discussion sections.

-Introduction Section

Intersectionality theory, developed by Crenshaw (1989), provides a valuable frame-work for the current study. Intersectionality emphasizes that individuals experience multiple, overlapping forms of disadvantages based on their intersecting social identities, such as race, ethnicity, immigration status, and language proficiency (Cho et al., 2013). In particular, intersectionality theory helps to highlight barriers to healthcare access, identify at risk groups, and design targeted interventions to address specific health and healthcare challenges faced by these marginalized groups. Given that Asian Americans face various linguistic, cultural, economic, immigration related-barriers to healthcare access (Derose et al., 2007; Hacker et al., 2015; Ngo-Metzger et al., 2004), consideration of intersected barriers to preventive healthcare among Asian Americans is imperative to identify and respond to their unique needs and challenges.

Cho, S., Crenshaw, K. W., & McCall, L. (2013). Toward a field of intersectionality studies: Theory, applications, and praxis. Signs: Journal of Women in Culture and Society, 38(4), 785-810.

Crenshaw, K. (1989). Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics. University of Chicago Legal Forum, 1989(1), 139-167.

Derose, K. P., Escarce, J. J., & Lurie, N. (2007). Immigrants and health care: sources of vulnerability. Health Affairs, 26(5), 1258-1268.

Hacker, K., Anies, M., Folb, B. L., & Zallman, L. (2015). Barriers to health care for undocumented immigrants: A literature review. Risk Management and Healthcare Policy, 8, 175-183.

Ngo-Metzger, Q., Legedza, A. T., & Phillips, R. S. (2004). Asian Americans' reports of their health care experiences: Results of a national survey. Journal of General Internal Medicine, 19(2), 111-119

-Discussion Section

Intersectionality theory also provides rationales for discussing the findings and implications of this study. For instance, according to our results, for newly arrived Asian immigrants, intersecting identities such as ethnic minority status and immigration can compound their vulnerabilities and barriers to accessing preventive healthcare. Legal and policy obstacles frequently prevent new immigrants, particularly those from ethnic minority backgrounds, from accessing public health benefits and programs. For instance, policies that deny public health insurance options significantly limit their ability to receive preventive care. Additionally, the five-year waiting period for lawful permanent residents (i.e., green card holders) before they can access federal healthcare benefits, including Medicaid, further restricts healthcare access for new immigrants (Kaiser Family Foundation, 2022). These policies create significant obstacles for newly arrived immigrants seeking necessary health services.

On the other hand, new immigrants from ethnic minority backgrounds often hold distinct cultural beliefs about health and healthcare that can influence their acceptance and utilization of preventive healthcare services. For instance, certain cultures may prioritize acute care over preventive measures or follow alternative health practices that do not align with conventional preventive healthcare approaches (Spector, 2017). Moreover, in the context of access to health insurance, intersecting identities of being from an ethnic minority group, having limited English proficiency, and possibly belonging to a lower-income community may create compounded barriers to accessing preventive healthcare. Further detailed research on these topics is warranted in future studies. In conclusion, intersectionality theory underscores the importance of enhancing the capability of healthcare providers and organizations to effectively understand and respond to the multiple, intersecting identities of their patients.

Kaiser Family Foundation. (2022). Health coverage and care for immigrants. Retrieved from https://www.kff.org/medicaid/issue-brief/health-coverage-and-care-for-immigrants/

Spector, R. E. (2017). Cultural diversity in health and illness (9th ed.). Pearson.

Method

3. Using „sample's representativeness” is not proper here, I have an impression that your sample was purposive, as it was not random sample. Am I right? This should be properly explained.

Response: In response to this comment, we eliminated “sample’s representativeness” and added “a non-probability sampling technique. ” And limitation of using purposive sampling was addressed in the limitation section.

To ensure inclusivity, we employed culturally and linguistically sensitive methodologies.

The survey used a non-probability sampling technique and targeted self-identified Asian Americans aged 18 years or older residing in the Austin area.

The utilization of a cross-sectional design and purposive sampling implies the need for caution when generalizing the findings and drawing causal inferences. The nature of the samples limits the conclusiveness of the findings, and further investigation is warranted. Future studies should strive to include more representative samples and employ a longitudinal design to comprehensively assess factors influencing preventive healthcare utilization within a multicultural context.

4. Measures – I would delate it, you will have more space for development of social theory in introduction.

Response: We have included elaborations on social theory in the introduction and discussion sections.

Results

5. You do not need to describe in detail what can be read from the table 1. Just simple statement about the data in table 1 is enough.

Response: We added simple statements summarizing the data in Table 1

Table 1 summarizes descriptive characteristics of the overall sample. The mean age was 42.6 years (SD = 16.9), with a range from 18 to 98. About half of the participants were age 18–39, and about 20% were age 60 or older. More than half (54.9%) were female. The sample included Chinese (24.2%), Asian Indians (22.2%), Koreans (18.2%), Vietnamese (19.6%), Filipinos (10.2%), and individuals from other Asian ethnic groups (5.6%). More than 67% of the sample reported that they had visited medical clinics for a routine check-up in the past 12 months.

Discussion

6. Discussion will benefit with some social theory

Response: Please see the response to the comment #2.

 

Reviewer 2 Report

Comments and Suggestions for Authors

I think this is a well-written manuscript and interesting for the readers. However, I suggest some minor changes that might make more clarity in the structure and presentation of the results:

It would be good to include a short explanation of what is included in the preventive services. It is not defined as I can see it.

The aim is now presented in two places and a bit differently, on page 2, lines 46-47 and again lines 72-74. Perhaps express that aim only once. The lines 72-74 are more detailed, so perhaps choose that.

Table 1, page 5: I can only see two columns in it; the demographic variables and the the column %. I wonder if some information is not visible or if it was only these two columns that were meant to be there. Anyway, the table should be fitting into the site.

The same concerns Table 2. It takes now two pages. Please, edit it so that it fits to the page. And also in the table 2, only two columns are visible. Should that be like this?

In the Discussion section, there are some statements in the middle of the text, that to my mind belong to a kind of future recommendations e.g. page 8, lines 244-246. How is that statement connected to the findings of your study? The same with lines 255-261 and 277-281 and again for lines 332-339.

On lines 340-346, you declare some limitations of the study. I think you can leave this to the end of the discussion and give it a subheading. In the same paragraph, you can add the strengths of the study, which you declare on lines 385-393.

Suggestions for future studies also can be placed under a subheading. Your suggestions for future studies are declared on pages 10-11 lines 347-384.

Please, add a chapter of Conclusions in which you should shortly summarize what did this study found in relation to your research aims.

Using the subheadings makes it easier to read and understand.

Author Response

I think this is a well-written manuscript and interesting for the readers. However, I suggest some minor changes that might make more clarity in the structure and presentation of the results:

1. It would be good to include a short explanation of what is included in the preventive services. It is not defined as I can see it.

Response: Thank you for your comment. The following statement has been added in introduction. As you recognized, preventive healthcare service utilization was assessed by asking whether participants had visited medical clinics for a routine checkup within the previous 12 months. It was also addressed in the discussion section.

According to the Centers for Disease Control and Prevention (CDC, 2020), preventive care refers to medical services that aim to prevent illnesses, detect health issues at an early stage, and promote overall health and well-being. They include a variety of screenings, vaccinations, counseling, and routine check-ups designed to prevent or catch diseases early when they are easier to treat.

Centers for Disease Control and Prevention. (2020). Preventive care. Retrieved from https://www.cdc.gov/preventive-care

While we defined a routine checkup as the utilization of preventive healthcare services, future studies should consider incorporating other preventive services recommended by the U.S. Preventive Services Task Force (e.g., flu vaccination, cholesterol screening, blood pressure checkup, pap test, mammogram, colorectal cancer screening). This could better assess the overall preventive healthcare behaviors and needs of Asian Americans, identify specific gaps in service utilization, and develop targeted interventions to improve preventive care uptake across diverse groups.

2. The aim is now presented in two places and a bit differently, on page 2, lines 46-47 and again lines 72-74. Perhaps express that aim only once. The lines 72-74 are more detailed, so perhaps choose that.

Response: As you suggested, we deleted the first sentence.

3. Table 1, page 5: I can only see two columns in it; the demographic variables and the the column %. I wonder if some information is not visible or if it was only these two columns that were meant to be there. Anyway, the table should be fitting into the site.

Response: The table has only two columns, variables and % to help readers understand the demographics and other relevant attributes of the participants involved in the current study. We edited to fit them to the page.

4. The same concerns Table 2. It takes now two pages. Please, edit it so that it fits to the page. And also in the table 2, only two columns are visible. Should that be like this?

Response: We also edited to fit them to the page

5. In the Discussion section, there are some statements in the middle of the text, that to my mind belong to a kind of future recommendations e.g. page 8, lines 244-246. How is that statement connected to the findings of your study? The same with lines 255-261 and 277-281 and again for lines 332-339.

Response: Thank you so much for your insightful comments. We have elaborated to connect those statements to the study findings.

In the multivariate analyses, disparities in the utilization of preventive care were evident across Asian American subgroups. Vietnamese Americans, compared to Chinese Americans, exhibited lower rates of preventive care utilization. This finding aligns with previous literature indicating variations in preventive healthcare services utilization among Asian American subgroups (Park et al., 2019). These disparities suggest that a one-size-fits-all approach to healthcare is insufficient to meet the unique needs of all Asian American subgroups. Consequently, our results highlight the necessity for developing tailored public health intervention programs designed specifically for Asian American subgroups to enhance their utilization of preventive services.

As variables specific to the experiences of immigrants, the length of stay in the United States, English proficiency, and acculturation were considered. The use of preventive healthcare was only found to be promoted among those who had lived in the U.S. for a longer time (≥ 10 years). This finding is in line with literature showing that years of residence in the U.S. are more prominent predictor of service use than the level of English language proficiency and of acculturation (Luo & Wu, 2016). The time spent in the U.S. seemed to improve knowledge of healthcare systems in the mainstream society and local resources (e.g., interpretation and transportation services) and then facilitate the use of preventive health services. Given these findings, it becomes evident that newly arrived immigrants are particularly vulnerable due to their limited knowledge of the healthcare system and available resources. Thus, such vulnerabilities seen in newly arrived immigrants should be taken into consideration in developing and implementing targeted interventions and health planning to improve the use of preventive healthcare. The practical implications of these findings are also significant for social workers. Considering that social workers are in a unique position to play a crucial role in the process of adapting to immigrant life among newly arrived immigrants, they can offer integrated support that addresses not only social services such as housing, employment, and language training but also healthcare needs of newly arrived immigrants.

Not surprisingly, health insurance emerged as a significant factor influencing preventive healthcare utilization among Asian Americans. Those with health insurance coverage had 2.69 times higher odds of utilizing preventive healthcare compared to those without coverage. The Patient Protection and Affordable Care Act (ACA) has been instrumental in extending health insurance coverage through federal and state marketplaces, as well as Medicaid expansion. While the ACA has provided millions of Americans with health insurance coverage, including many preventive services at no cost, Asian Ameri-cans still encounter numerous challenges and barriers in accessing and utilizing the ser-vices and benefits offered by the ACA. For instance, there remains a shortage of linguistically appropriate resources (such as factsheets, webinars, videos, and a workforce proficient in multiple languages) available to many limited English proficient, uninsured, im-migrant, and low-income Asian American communities (National Council of Asian Pacific Islander Physicians, 2015). The findings of this study emphasize the urgent need for comprehensive efforts to educate Asian Americans about their healthcare reform benefits and coverage. This may include training community health workers (CHWs) who are proficient in Asian languages and familiar with the cultural contexts of Asian American communities to assist community members with health insurance enrollment and preventive care utilization.

This study also underscores the importance of recognizing the role of social workers in healthcare settings for Asian American communities. Prior research has highlighted the necessity for healthcare service delivery to transition from hospitals to community-based settings (Ross & de Saxe Zerden, 2020). Moreover, collaborative interprofessional teams, typically comprising a physician, registered nurse, and social worker, have demonstrated superior outcomes in preventive healthcare services compared to independent physician practices (Fowler et al., 2020; Fraher et al., 2018). In addition, the study highlights the social workers’ role of advocacy in improving healthcare access for Asian American communities, emphasizing the need for culturally competent health education and services (Wong et al., 2005). Thus, healthcare policies should incorporate initiatives aimed at enhancing cultural competency training among social workers in healthcare set-tings. This training would enable them to gain a deeper understanding of the unique health needs of Asian Americans. Consequently, it would empower them to effectively de-liver health interventions, facilitate communication among interdisciplinary teams, Asian American patients, and their families, and link patients and their families to community resources.

Wong, S. T., Yoo, G. J., & Stewart, A. L. (2005). The changing meaning of family support among older Chinese and Korean immigrants. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 60(1), S3-S10.

6. On lines 340-346, you declare some limitations of the study. I think you can leave this to the end of the discussion and give it a subheading. In the same paragraph, you can add the strengths of the study, which you declare on lines 385-393.

Response: Thank you so much for your suggestion. We added a subheading for the limitation of the study and suggestions for future studies as you suggested. We believe that rather than separating the limitations and future research directions into distinct subheadings, it is more logical to present the limitations and then propose future research directions related to each of these limitations. So we outlined the limitations of the study and then proposed how future research should proceed based on each of these limitations.

1. Limitations of the Study and Suggestions for Future Studies
2. Suggestions for future studies also can be placed under a subheading. Your suggestions for future studies are declared on pages 10-11 lines 347-384.

Response: Please see the response of the previous comment.

8. Please, add a chapter of Conclusions in which you should shortly summarize what did this study found in relation to your research aims.

Response: We added a section of conclusion as you suggested.

 

5. Conclusions

              The findings of the study indicated that extended durations of stay in the U.S., having health insurance coverage, a regular source of healthcare, and higher satisfaction with previous healthcare services were linked to greater likelihood of using preventive healthcare services. Despite these limitations, the study's findings contribute significantly to our comprehension of the factors influencing the utilization of preventive care, offering valuable insights for the development of effective social work and public health interventions. Although the study focuses specifically on Asian Americans, its approach and findings have broader implications for reducing health disparities and ensuring access to appropriate preventive health services for other racial and ethnic minority populations as well. Our approach effectively identified subgroups at greatest risk, and the identified in-dividual- and patient-provider related factors can be used for targeted interventions and strategic health planning in racial/ethnic minority in the U.S.

 

9. Using the subheadings makes it easier to read and understand.

Response: Yes we added them.

Reviewer 3 Report

Comments and Suggestions for Authors

The paper is well written, addresses an important issue. It uses a well- established conceptual design and uses multivariate analysis to assess the association of factors with preventive care visits among Asian Americans in Austin, Texas. 

 

The paper uses detailed survey data on Asian American population with a sample size of  2535.  While the sample size is good, the power issues have still to be addressed. The one disadvantage of this sample population is that there is no control group to compare Asian Americans with. The study will be improved if the discussion section contains some comparisons with other minority groups such as African Americans or Hispanics. Alternatively, a comparison  of the same population group in another state will also be helpful. 

 

Another way the discussion can be enriched is by testing some interaction effects. For example, are those more recent immigrants have also no health insurance coverage causing them not to seek preventive care? Why are younger people more likely to get preventive care than the elderly? Intuitively, it appears that the elderly should see the doctor more frequently than younger people. Could that be that the elderly were people who came more recently as parents of immigrants?

 

These kind of exploratory analysis will enrich the content of the manuscript. Absent of that and a control group or longitudinal analysis, the policies recommended in the paper will not be strong. Also we need to realize that generalizability is an issue in this paper  since it focuses on only one state. Overall, the paper is well written but lacks an in - depth analysis. 

Author Response

The paper is well written, addresses an important issue. It uses a well- established conceptual design and uses multivariate analysis to assess the association of factors with preventive care visits among Asian Americans in Austin, Texas. 

 

Response: We appreciate the Referee 3 for the favorable comments on our work.

 

1. The paper uses detailed survey data on Asian American population with a sample size of   While the sample size is good, the power issues have still to be addressed. The one disadvantage of this sample population is that there is no control group to compare Asian Americans with. The study will be improved if the discussion section contains some comparisons with other minority groups such as African Americans or Hispanics. Alternatively, a comparison  of the same population group in another state will also be helpful. 

 

Response: Thank you for the comment. We believe that comparing the Asian American population with other minority groups such as African Americans or Hispanics or a comparison of the same population group in another state would indeed strengthen the study. This comparison could help in understanding whether the observed trends are unique to Asian Americans or are prevalent across different minority groups. As you suggested, this was added in the discussion.

 

Approximately 67% of survey participants utilized preventive healthcare services (represented by routine checkups here). These findings align with data indicating that approximately 68% of Asian American adults in California have reported having a routine checkup within the past year (California Health Interview Survey, 2023). However, rates of those using preventive healthcare services in the current study are lower than the reported 72% for all Americans based on data from the Medical Expenditure Panel Survey (Lines et al., 2014). This finding is consistent with existing research indicating that Asian Ameri-cans experienced the largest proportional reductions in their rates of various preventive healthcare services compared to other racial and ethnic minority groups including African Americans and Hispanics (Alba et al., 2024). Moreover, about 15% of Asian Ameri-cans in the current study lacked health insurance coverage, a proportion higher than the reported 10% for the U.S. population according to data from the 2019 National Health Interview Survey (Cohen et al., 2016). This study result also aligns with the finding that the Asian American group had higher uninsured rates than other minority groups such as African Americans and Hispanics (U.S. Census Bureau, 2023). Additionally, a significant portion (38.1%) of the current sample lacked a usual source of care, markedly higher than the 7% reported for a national sample of non-Hispanic White adults (McMenamin et al., 2020). While caution should be exercised in directly comparing rates across different studies due to methodological heterogeneity, these findings align with previous literature indicating that Asian Americans face disparities in health insurance coverage and access to healthcare services, positioning them as a disadvantaged minority group in the U.S. (Brown et al., 2000; Escarce, 2007; McMenamin et al., 2020).

 

Alba, C., Zheng, Z., & Wadhera, R. K. (2024). Changes in health care access and preventive health screenings by race and ethnicity. JAMA Health Forum, 5(2), e235058.

California Health Interview Survey (CHIS). (2023). AskCHIS. UCLA Center for Health Policy Research. Retrieved from https://healthpolicy.ucla.edu.

U.S. Census Bureau. (2023). Health Insurance Coverage in the United States: 2022. Retrieved from Census.gov

 

 

2. Another way the discussion can be enriched is by testing some interaction effects. For example, are those more recent immigrants have also no health insurance coverage causing them not to seek preventive care? Why are younger people more likely to get preventive care than the elderly? Intuitively, it appears that the elderly should see the doctor more frequently than younger people. Could that be that the elderly were people who came more recently as parents of immigrants? These kind of exploratory analysis will enrich the content of the manuscript. Absent of that and a control group or longitudinal analysis, the policies recommended in the paper will not be strong. Also we need to realize that generalizability is an issue in this paper since it focuses on only one state. Overall, the paper is well written but lacks an in - depth analysis. 

 

 

Response: Thank you for your comment. We agree that using interaction terms in analysis can provide deeper insights, but there are several reasons why we chose not to include them in the current study. The current study employed the exploratory research approach since this topic was not well understood and existing knowledge about Asian Americans is limited. So we believe that focusing on the main effects of variables can provide sufficient insights for practical decision-making. We also believe that the findings of the current study provide a foundation for more detailed and structured research, helping researchers to clarify concepts, develop hypotheses, and identify key variables for further study. That is, once the foundational relationships are well understood, future research can explore interaction terms to uncover more nuanced findings. However, as you mentioned, we addressed the needs of testing interaction effects in the section of study limitation.

 

Additionally, exploring variables such as cultural beliefs about preventive healthcare, interpersonal networks and support, and health behaviors could provide valuable in-sights. System-level variables, such as the availability of healthcare providers offering culturally and linguistically appropriate services in the local area, should also be taken into account when assessing individuals' utilization of preventive health services. In particular, since exploring interaction effects based upon the intersectionality theory can pro-vide insights into the complex relationships in preventive care utilization among different factors, future study should consider interaction effects to uncover more nuanced findings.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

No further comments.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for addressing my comments. I would like to see more nuanced analysis even though it is not part of the main analysis. Some additional tests would be helpful for a future paper.