O R I G I N A L P A P E R

Acculturation and Disability Rates Among Filipino-Americans

Leanne R. De Souza • Esme Fuller-Thomson

Published online: 11 October 2012

� Springer Science+Business Media, LLC 2012

Abstract Filipinos are the fastest growing Asian

subgroup in America. Among immigrants, higher accul-

turation (adaptation to host society) predicts disability

outcomes and may relate to disability prevalence among

older Filipinos. We conducted a secondary analysis of the

2006 American Community Survey using a representative

sample of older Filipinos (2,113 males; 3,078 females) to

measure functional limitations, limitations in activities of

daily living, blindness/deafness and memory/learning

problems. Filipino males who were Americans by birth/

naturalization had higher odds of blindness/deafness (OR

2.94; 95 % CI = 1.69, 5.12) than non-citizens. Males who

spoke English at home had higher odds of blindness/

deafness (OR 1.82; 95 % CI = 1.05, 3.17) and memory/

learning problems (OR 2.28; 95 % CI = 1.25, 4.15), while

females had higher odds of memory/learning problems (OR

1.75; 95 % CI = 1.13, 2.73). Acculturation is associated

with greater odds of disabilities for Filipino men. Males

may be more sensitive to acculturation-effects than females

due to culturally prescribed roles and gender-specific

experiences at the time of immigration.

Keywords Filipino � Disability � Activities of dailyliving � Immigration � Assimilation � Functional limitations

Introduction

The Asian American and Pacific Islander (AAPI) popula-

tion is the fastest growing minority group in the United

States, accounting for approximately 4 % of the total

population, with estimates projecting increases to 11 % or

41 million U.S. residents by the year 2050 [1]. To date,

studies about the health of Asian Americans have typically

aggregated ethnic groups into one category despite the fact

that there are considerable ethnic diversities in culture,

language, and immigration history among the different

Asian groups. However, recent research has highlighted the

importance of separating the study of each AAPI group

separately to focus on disparities among subpopulations

[2–5].

Among AAPIs in the United States, Filipinos form the

second largest subgroup after the Chinese, with one in five

Asians reporting Filipino ancestry [6]. The number of

Filipinos and other Asians immigrating to America

increased dramatically following amendments to immi-

gration laws in 1965 that removed Asian immigration

quotas. As such, by 2007 over 90 % of Filipinos in the U.S.

were foreign-born [7].

Older Filipino-Americans are comprised of three dis-

tinct groups based on their age at immigration: 35 %

immigrated before age 40, 30 % immigrated between 40

and 59 years of age and 35 % immigrated at 60 years or

older [7]. Growing evidence underscores the disparities in

health outcomes among individuals of Filipino ancestry

compared to their AAPI and Caucasian counterparts.

Studies range from child and adolescent health showing

higher prevalence of neonatal mortality, malnutrition, and

obesity [8], to studies demonstrating higher rates of cancer,

cardiovascular disease, diabetes, and mental illness among

adults [9–15]. Many of these chronic diseases show

L. R. De Souza (&)Institute of Medical Sciences, University of Toronto, Toronto,

ON, Canada

e-mail: [email protected]

E. Fuller-Thomson

Sandra Rotman Chair in Social Work, Factor Inwentash Faculty

of Social Work, University of Toronto, 246 Bloor Street West,

Toronto, ON M5S 1V4, Canada

e-mail: [email protected]

123

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DOI 10.1007/s10903-012-9708-1

increasing prevalence with increasing age and accultura-

tion [14]. Though only a few studies have compared older

Filipinos to other AAPI subgroups, these consistently

report substantial vulnerabilities with respect to self-

reported mortality, depression, chronic diseases, physical

inactivity and disabilities [5, 16–18]. Moreover, higher

incidence and prevalence of blindness/deafness occurs

among immigrants, which may be related to socioeconomic

inequalities [19], type of employment and limited access to

job-related resources [20]. In the same way, blindness may

also be affected by similar socioeconomic variables and is

associated with many chronic diseases as a common

comorbidity [21].

In keeping with much of the recent gerontological

research [22, 23], we define ‘‘older’’ as age 55 and over.

Research indicates that functional health inequalities peak

in the 55–64 year old group, whether socioeconomic status

or differenes among visible minorities [24] are examined.

Indeed, studies have also demonstrated gender disparities

in disability outcomes that increase with age, where men

have worse outcomes of a serious medical nature than

women, while women have greater functional limitations

as they age [25]. The association between gender differ-

ences and health outcomes is complex and is affected by

variables such as reporting bias, acquired risk and biolog-

ical risk [26], and these in turn translate into different

mortality and morbidity outcomes [27].

A national survey study revealed that compared to their

U.S.-born counterparts, Chinese, Japanese and Filipino

immigrants had lower life expectancy and the risk of disability

and chronic disease increased according to length of residence

[28]. We recently showed that compared to Chinese respon-

dents, Filipinos had lower odds of cognitive problems, higher

odds of functional limitations and comparable odds of ADL

limitations [18]. Similarly, Kim and colleagues [17] found that

Filipinos exhibited marked differences in chronic diseases and

disability rates, and tended to have poor overall physical

health compared to Chinese, Japanese, and Koreans [17]. A

growing body of research underscores the apparent need to

disaggregate research of AAPIs to accurately portray the

varying disease burden of especially vulnerable subgroups

and to examine their respective life histories that lead to dis-

parities in disability rates.

Socioeconomic status (SES) and indicators of accultur-

ation are thought to influence health status [29]. A

comparison of older Asian-Americans with U.S.-born non-

Hispanic Whites showed that in later life, immigrant status

confers few disability advantages [30]. Moreover, disabil-

ity rates are influenced by the combined effects of age at

immigration and duration of residence in the U.S. [30].

Indeed, Cho and Hummer [16] found marked differences in

disability status across AAPI subgroups with variations

attributable to nativity, age and SES status.

Chronic health conditions often culminate in some form

of disability with older age and in turn, disability can

reflect the severity of chronic diseases and their co-

morbidities [29, 30]. Accordingly, disability is considered a

reliable quality-of-life indicator capturing the diseased and

healthy conditions and has been proposed as a more

accurate assessment of well-being than traditional mor-

bidity and mortality data [31]. Careful monitoring of dis-

ability rates in vulnerable populations can facilitate

intervention strategies [32, 33] and health promotion.

Considering the disparities of chronic diseases among adult

Filipinos compared to other AAPIs, it is evident that dis-

ability prevalence is an important issue to examine in this

group.

Previously we described the variability in disability rates

across seven AAPI subgroups [18]. In the present study, we

conducted a secondary analysis of the Filipino subgroup to

develop a profile of older Filipino-Americans living with

disabilities. This may provide insight to help policy makers

drive decision-making, resource allocation and develop-

ment of social support programs targeting the needs of

older Filipino-Americans. In addition, such an analysis

may also improve health care professionals’ ability to tailor

services to the most vulnerable Filipino-Americans.

Methods

The American Community Health Survey (ACS) is a

nationally representative survey of community-dwelling

and institutionalized Americans, conducted annually by the

U.S. Census Bureau [34]. The ACS replaces the long-form

of the U.S. Census. Sampling is based on the US Census

Bureau’s Master Address File [35]. Data collection started

with multiple mailed surveys; non-respondents were then

contacted through computer-assisted telephone surveys. A

random sample of those who were non-responders to both

the mail and telephone survey were visited in person and

interviewed face to face. This strategy resulted in a

response rate of 97.5 %. Institutionalized community

members included those living in nursing homes, in-patient

hospice facilities, psychiatric hospitals, and adult correc-

tional facilities were included [34].

In the present study, we use the 2006 ACS (98 %

response rate) to examine disability outcomes of older

Filipino adults aged 55 and older (n = 5,192) to charac-

terize a disability profile in this cross-section of the pop-

ulation. Four self-reported disability outcomes were

examined: Respondents were asked if they had any of the

following long-lasting conditions: (a) ‘‘Blindness, deafness

or a severe vision or hearing impairment’’ (vision/hearing

limitations) (b) ‘‘A condition that substantially limits one

or more basic physical activities such as walking, climbing

J Immigrant Minority Health (2013) 15:462–471 463

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stairs, reaching, lifting, or carrying’’ (functional limita-

tions); and whether ‘‘Because of a physical, mental, or

emotional condition lasting 6 months or more’’ they had

difficulty: (a) ‘‘Learning, remembering, or concentrating’’

(memory loss and learning difficulties) and/or (b) ‘‘Dress-

ing, bathing, or getting around inside the home’’ (ADL

limitations). Each item included a dichotomous yes/no

response option.

Demographic variables collected included age groups

(55–64, 65–74, 75–84, and 85 years or older) and marital

status (never married, separated, divorced or widowed

versus ‘‘now married’’). The socioeconomic variable

measured was level of education (only primary school or

less, some high school, high school graduate, bachelor

degree and graduate degree). Factors of acculturation

included age at immigration (U.S. born, immigrated prior

to age 20, aged 20–39, 40–59, 60 or older), citizenship

(American by birth or naturalization, non-citizen), and

speaking English at home (yes, no).

Because the only socioeconomic variable available for

the institutionalized respondents was level of education we

used it as a surrogate for SES in our analysis.

Marital status, education level, speaking English at

home, age at immigration and citizenship were included in

each analysis in a nationally representative sample of Fil-

ipino-Americans. Each of these variables was included in a

series of gender-specific multivariate logistic regression

analyses to characterize factors associated with each of the

four types of disability. The weighted prevalence, odds

ratios (OR), and 95 % confidence intervals (CIs) for each

disability type were calculated. All statistical analyses were

conducted using SPSS 17.0. Due to the dichotomous out-

come measure in logistic regression, a regular R-Square

could not be used. The Nagelkerke R-square is a pseudo-

R-Square measure for logistic regression analyses that

provides a measure of the explained variability in the

model.

Results

Results for demographic information and all four disability

types: ADLs, functional limitations, blindness/deafness,

and memory/learning disabilities are shown in Tables 1

through 5 respectively. We report the Odds Ratios (OR)

and 95 % Confidence Intervals (CI) in the tables.

Acculturation Factors

The odds of memory or learning disabilities (Table 5) were

significantly higher among women who spoke English at

home compared to those who did not (OR 1.75; 95 %

CI = 1.13, 2.73) and among women who immigrated at

age 60 years or older in comparison to those born in the

U.S. (OR 1.93; 95 % CI = 1.03, 3.62). Alternatively,

among Filipino males, those who immigrated at age

20 years or younger had significantly higher odds for all

four disability types, in comparison to those born in the

U.S. as follows: ADLs (Table 2: OR 4.19; 95 % CI =

1.73, 10.15), functional limitations (Table 3: OR 1.95;

95 % CI = 1.13, 3.36), blindness or deafness (Table 4: OR

1.91; 95 % CI = 1.00, 3.67), and memory or learning

problems (Table 5: OR 3.30; 95 % CI = 1.40, 7.78).

Compared to non-citizens, Filipino males with Ameri-

can citizenship had significantly higher odds of blindness

or deafness (Table 4: OR 2.94; CI 1.69, 5.12). Compared to

those who did not speak English at home, males who spoke

English at home had significantly higher odds of blindness

or deafness (Table 4: OR 2.09; 95 % CI = 1.29, 3.39) and

memory or learning problems (Table 5: OR 2.28; 95 %

CI = 1.25, 4.15). Women who spoke English at home in

comparison to those who did not had increased odds of

memory or learning problems (Table 5: OR 1.75;

CI = 1.13, 2.73).

Demographic Factors

In comparison to females in the 55–64 year old age

bracket, each older age cohort had higher odds of disabil-

ity. For example as shown in Table 2, the odds of limita-

tions in ADLs were 2.05 (95 % CI 1.28, 3.28) times higher

for 65-74 year old women, 6.20 times higher (95 % CI

3.79, 10.16) for 75–84 year olds and 20.26 (95 %

CI = 11.18, 36.69) times higher for women aged 85 or

older. Similarly, for females, odds of functional limitations

were 2.6, 4.9 and 10.9 times higher, in the 65–74, 75–84

and 85? cohorts, respectively (Table 3). The patterns were

also similar for the other disability types: for those aged 85

and older in comparison to those aged 55–64, females odds

of blindness/deafness reached 13.20 (Table 4: 95 %

CI = 7.41, 23.53) and the odds of memory/learning prob-

lems was 11.05 (Table 5: 95 % CI = 6.47, 18.86). Similar

outcomes were found for males (Tables 2, 3, 4, 5).

Unmarried females had significantly higher odds of

functional limitations (Table 1: OR 1.28; 95 % CI = 1.05,

1.56), memory or learning problems (Table 5: OR 1.50;

95 % CI = 1.13, 2.00) and blindness or deafness (Table 4:

OR 1.63; 95 % CI = 1.19, 2.22), in comparison to married

females. Among males, unmarried status was associated

with higher odds of functional limitations in comparison to

married males (Table 3: OR 1.48; 95 % CI = 1.10, 2.01).

Socioeconomic Factors

Lower levels of education were associated with higher

odds of disability. In comparison to those with a graduate

464 J Immigrant Minority Health (2013) 15:462–471

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degree, higher odds of functional limitations were apparent

for both males (OR 2.12; 95 % CI = 1.19, 3.77) and

females (OR 2.01; 95 % CI = 1.28, 3.16) who had only

completed primary school (Table 3). Similarly, the odds of

blindness or deafness were higher among males (OR 2.32;

95 % CI = 1.09, 4.91) and females (Table 4: OR 3.26;

95 % CI = 1.19, 7.82) with only primary school education

and the same was true for memory or learning problems

among males (OR 6.98; 95 % CI = 2.07, 23.54) and

females (OR 4.94; 95 % CI = 2.24, 10.90). The odds of

Table 1 Demographicdescription of Filipino male and

female respondents to the 2006

ACS survey

Variables Males

(n = 2,113)Females

(n = 3,079)Total

(n = 5,192)p value

ADL

No 2,000 (94.7 %) 2,883 (93.0 %) 4,883 (93.7 %) 0.014

Yes 113 (5.3 %) 196 (7.0 %) 309 (6.3 %)

Functional limitations

No 1,742 (83.2 %) 2,452 (79.4 %) 4,194 (80.9 %) 0.001

Yes 371 (16.8 %) 627 (20.6 %) 998 (19.1 %)

Blindness/deafness

No 1,899 (89.5 %) 2,844 (92.1 %) 4,743 (91.1 %) 0.001

Yes 214 (10.5 %) 235 (7.9 %) 449 (8.9 %)

Memory/learning

No 1,970 (93.4 %) 2,808 (90.5 %) 4,778 (91.6 %) 0.000

Yes 143 (6.6 %) 271 (9.5 %) 414 (8.4 %)

Demographics

Age

55–64 1,134 (53.7 %) 1,636 (50.9 %) 2,770 (52.0 %) 0.013

65–74 604 (27.9 %) 864 (28.5 %) 1,468 (28.3 %)

75–84 296 (14.9 %) 457 (16.0 %) 753 (15.6 %)

85? 79 (3.4 %) 122 (4.6 %) 201 (4.1 %)

Marital status

Never married/divorced/

separated/widowed

322 (16.1 %) 1,237 (44.2 %) 1,559 (33.1 %) 0.000

Yes 1,791 (83.9 %) 1,842 (55.8 %) 3,633 (66.9 %)

Education in levels

Primary 166 (7.8 %) 429 (14.8 %) 595 (12.0 %) 0.000

High school (no diploma) 110 (4.9 %) 210 (6.3 %) 320 (5.8 %)

High school (diploma ? other

education/not bachelors)

913 (42.5 %) 1,047 (35.6 %) 1,960 (38.3 %)

Bachelors degree 717 (34.5 %) 1,149 (35.5 %) 1,866 (35.1 %)

Graduate degree 207 (10.4 %) 244 (7.7 %) 451 (8.8 %)

Age at immigration

Born in the US 245 (11.4 %) 240 (7.4 %) 485 (9.0 %) 0.000

20 146 (6.4 %) 84 (2.3 %) 230 (3.9 %)20–39 954 (43.1 %) 1,429 (43.0 %) 2,383 (43.0 %)

40–59 553 (27.4 %) 984 (33.8 %) 1,537 (31.2 %)

60–100 215 (11.8 %) 342 (13.6 %) 557 (12.9 %)

Citizenship

Not a citizen 370 (19.6 %) 637 (23.3 %) 1,007 (21.8 %) 0.002

Citizen by birth or

naturalization

1,743 (80.4 %) 2,442 (76.7 %) 4,185 (78.2 %)

English-speaking

Does not speak English at home 1,829 (87.2 %) 2,697 (87.8 %) 4,526 (87.5 %) 0.52

Speaks english at home 284 (12.8 %) 382 (12.2 %) 666 (12.5 %)

J Immigrant Minority Health (2013) 15:462–471 465

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ADL disabilities were increased among females with only

primary school education (OR 2.48; 95 % CI = 1.06, 5.83)

compared to those with a graduate degree (Table 2). Fur-

thermore, women with only some high school had higher

odds of blindness or deafness (Table 4: OR 4.08; 95 %

CI = 1.60, 10.40) and memory or learning problems

(Table 5: OR 3.10; 95 % CI = 1.30, 7.41) than women

with a graduate degree. Women with a high school diploma

reported greater odds of memory or learning problems than

their peers with a graduate degree (Table 5: OR 2.54; 95 %

CI = 1.16, 5.55).

Males with only a high school diploma had higher odds

of blindness or deafness (Table 4: OR 2.53; 95 %

CI = 1.33, 4.80) compared to those with a graduate

degree. There was also a graded increase in the odds of

functional limitations among males who graduated from

high school (OR 1.64; CI 1.02, 2.63), to completion of only

some high school (OR 2.06; CI 1.09, 3.89), to only primary

school education (reported above) compared to those with

a graduate degree (Table 3). This increasing risk compared

to those with a graduate degree, was also observed for

memory or learning problems among Filipino males

(Table 5), from high school graduate (OR 5.42; CI 1.71,

17.18), to only some high school completed (OR 6.62; CI

1.83, 23.97), to only primary school (reported above).

Discussion

Few studies have investigated health outcomes of older

adults from distinct AAPI subpopulations [5, 16–18].

Disaggregating the study of AAPIs to evaluate the impact

Table 2 Logistic regression oflimitations in activities of daily

living (ADL) according to

demographic, socioeconomic

and immigration-related

variables in older Filipino males

(n = 2,113) and Females

(n = 3,079)

Per cent change in Nagelkerke

R Square associated with the

addition of education

level = 0.8 % male, 0.6 %

female

Per cent change in Nagelkerke

R Square associated with

addition of age at

immigration = 2.6 % male,

0.2 % female

Per cent change in Nagelkerke

R Square associated with

addition of citizenship status

and language spoken at

home = 0.01 % male, 0.1 %

female

Total Nagelkerke R-Square

value for full model = 0.179

male, 0.207 female

Nagelkerke R Square associated

with age and marital

status = 0.144 male, 0.198

female

Male Female

OR 95 % CI OR 95 % CI

Demographic variables

Age

55–64 1.00 Referent 1.00 Referent

65–74 1.05 (0.56, 1.93) 2.05 (1.28, 3.28)

75–84 4.23 (2.36, 7.58) 6.20 (3.79, 10.16)

85? 12.04 (5.85, 24.77) 20.26 (11.18, 36.69)

Marital status

Marital status

Not married 1.19 (0.72, 1.96) 1.21 (0.87, 1.69)

Married 1.00 Referent 1.00 Referent

Adult socioeconomic status

Education

Primary 1.59 (0.60, 4.25) 2.48 (1.06, 5.83)

Some high school 2.66 (0.96, 7.36) 2.00 (0.77, 5.20)

High school graduate 1.51 (0.64, 3.55) 2.15 (0.93, 4.94)

Bachelor degree 1.36 (0.55, 3.34) 1.46 (0.62, 3.42)

Graduate degree 1.00 Referent 1.00 Referent

Immigration and citizenship

Age at immigration

U.S. born 1.00 Referent 1.00 Referent

20 4.19 (1.73, 10.15) 0.97 (0.27, 3.44)20–39 0.90 (0.37, 2.23) 1.42 (0.69, 2.90)

40–59 1.33 (0.53, 3.31) 1.48 (0.74, 2.97)

60–100 1.58 (0.61, 4.09) 1.74 (0.84, 3.61)

Citizenship

American by birth or naturalization 1.44 (0.76, 2.72) 1.05 (0.71, 1.56)

Not a citizen 1.00 Referent 1.00 Referent

Speaks english at home

Yes 0.98 (0.48, 1.99) 1.25 (0.73, 2.15)

No 1.00 Referent 1.00 Referent

466 J Immigrant Minority Health (2013) 15:462–471

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of migration histories, indicators of acculturation and

socio-demographic variables on health outcomes reveals

important insights into the health of vulnerable subgroups

[5] such as older Filipino-Americans.

Among the adult Filipino population we found that older

age, marriage, education and common indicators of

acculturation: speaking English at home, age at immigra-

tion and citizenship, were associated with higher odds of

functional disability, limitations in ADLs, memory or

learning problems and blindness or deafness. These asso-

ciations were different between men and women, indicat-

ing unique sex-specific factors associated with disability

outcomes.

Older age often involves some deterioration in physical

(functional limitations, ADLs, blindness or deafness) and

cognitive function (memory or learning problems) that

varies between genders regardless of ethnicity [36–38].

Research indicates that older women have a higher prev-

alence of disability and functional limitations than their

male peers [39]. The incidence of new disability among

older adults is generally higher in women, than in men

[40]. However, a systematic review of the literature indi-

cates that when studies control for socioeconomic factors

and health conditions, the gender differences in incidence

of functional disability are often reduced to non-signifi-

cance [40].

We found that unmarried females demonstrated signif-

icantly higher odds of functional limitations, blindness or

deafness and memory or learning problems in comparison

to married women. Conversely, marital status of males

showed no significant association with any of the four

types of disability and only approached significance with

functional limitations. Approximately half of Filipinos in

America are married, according to the 2000 U.S. census

Table 3 Logistic regression offunctional limitations according

to demographic, socioeconomic

and immigration-related

variables in older Filipino males

(n = 2,113) and females

(n = 3,079)

Per cent change in Nagelkerke

R Square associated with the

addition of education

level = 1.3 % male, 0.7 %

female

Per cent change in Nagelkerke

R Square associated with

addition of age at

immigration = 1.1 % male,

0.0 % female

Per cent change in Nagelkerke

R Square associated with

addition of citizenship status

and language spoken at

home = 0.3 % male, 0.1 %

female

Total Nagelkerke R-Square

value for full model = 0.168

male, 0.182 female

Nagelkerke R Square associated

with age and marital

status = 0.141 male, 0.174

female

Male Female

OR 95 % CI OR 95 % CI

Demographic variables

Age

55–64 1.00 Referent 1.00 Referent

65–74 1.37 (1.00, 1.88) 2.62 (2.05, 3.34)

75–84 4.49 (3.15, 6.41) 4.90 (3.64, 6.60)

85? 7.82 (4.45, 13.72) 10.88 (6.98, 16.94)

Marital status

Marital status

Not married 1.48 (1.10, 2.01) 1.28 (1.05, 1.56)

Married 1.00 Referent 1.00 Referent

Adult socioeconomic status

Education

Primary 2.12 (1.19, 3.77) 2.01 (1.28, 3.16)

Some high school 2.06 (1.09, 3.89) 1.58 (0.93, 2.67)

High school graduate 1.64 (1.02, 2.63) 1.45 (0.95, 2.22)

Bachelor degree 1.16 (0.70, 1.89) 1.21 (0.79, 1.85)

Graduate degree 1.00 Referent 1.00 Referent

Immigration and citizenship

Age at immigration

U.S. born 1.00 Referent 1.00 Referent

20 1.95 (1.13, 3.36) 0.90 (0.43, 1.90)20–39 0.94 (0.58, 1.52) 0.91 (0.60, 1.40)

40–59 0.88 (0.53, 1.48) 0.90 (0.59, 1.39)

60–100 1.16 (0.65, 2.05) 0.96 (0.60, 1.55)

Citizenship

American by birth or naturalization 1.42 (0.98, 2.08) 1.03 (0.80, 1.33)

Not a citizen 1.00 Referent 1.00 Referent

Speaks english at home

Yes 1.25 (0.83, 1.90) 0.84 (0.59, 1.19)

No 1.00 Referent 1.00 Referent

J Immigrant Minority Health (2013) 15:462–471 467

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[6]. Research studies have described marriage as a pro-

tective factor for disability outcomes [7]. Moreover, evi-

dence shows that cognitive decline is more apparent in

women without a stable partnership [7].

Higher levels of education are considered protective

against cognitive problems and other disabilities [16]. In

the present study, for both genders, lower education levels

were associated with higher odds of functional limitations,

blindness or deafness and memory or learning problems.

A particularly strong association was apparent between

lower education level and memory or learning disabilities.

Education is a surrogate indicator of SES as it usually

indicates the propensity for job acquisition and career

development [7, 38, 41, 42]. Those individuals with higher

education are more likely to be employed and may receive

benefits that support resources for medical care and

improved quality of life, important factors to delaying

disability. Even with lower education, men in this cohort

may have been able to access job opportunities for financial

security. Moreover, men in our cohort may have belonged

to a population of early immigrant Filipino men who were

active members of the U.S. military and as such, acquired

citizenship through the U.S. Immigration and Naturaliza-

tion Act, which in 1990 permitted special provision of U.S.

citizenship to Filipino male veterans. Many of the older

Filipino males in our sample may have belonged to this

unique group, which could in turn contribute to some

specific cohort effects in our study [43].

Our findings are consistent with other research demon-

strating that higher SES as indicated by education corre-

sponds to lower mortality and morbidity rates [5, 44]. The

major exception in this study was the lack of a significant

Table 4 Logistic regression ofblindness/deafness/severe

sensory impairment according

to demographic, socioeconomic

and immigration-related

variables in older Filipino males

(n = 2,113) and females

(n = 3,079)

Per cent change in Nagelkerke

R Square associated with the

addition of education

level = 1.9 % male, 1.4 %

female

Per cent change in Nagelkerke

R Square associated with

addition of age at

immigration = 1.0 % male,

0.8 % female

Per cent change in Nagelkerke

R Square associated with

addition of citizenship status

and language spoken at

home = 2.1 % male, 0.0 %

female

Total Nagelkerke R-Square

value for full model = 0.220

male, 0.211 female

Nagelkerke R Square associated

with age and marital

status = 0.170 male, 0.189

female

Male Female

OR 95 % CI OR 95 % CI

Demographic variables

Age

55–64 1.00 Referent 1.00 Referent

65–74 2.76 (1.83, 4.17) 2.49 (1.61, 3.87)

75–84 6.66 (4.23, 10.50) 6.17 (3.87, 9.84)

85? 15.66 (8.39, 29.22) 13.20 (7.41, 23.53)

Marital status

Marital status

Not married 0.92 (0.62, 1.36) 1.63 (1.19, 2.22)

Married 1.00 Referent 1.00 Referent

Adult socioeconomic status

Education

Primary 2.32 (1.09, 4.91) 3.26 (1.36, 7.82)

Some high school 2.02 (0.88, 4.63) 4.08 (1.60, 10.40)

High school graduate 2.53 (1.33, 4.80) 2.31 (0.98, 5.47)

Bachelor degree 1.32 (0.66, 2.63) 1.90 (0.79, 4.57)

Graduate degree 1.00 Referent 1.00 Referent

Immigration and citizenship

Age at immigration

U.S. born 1.00 Referent 1.00 Referent

20 1.91 (1.00, 3.67) 0.37 (0.08, 1.62)20–39 1.06 (0.59, 1.91) 0.78 (0.41, 1.50)

40–59 1.30 (0.70, 2.41) 1.35 (0.73, 2.48)

60–100 1.75 (0.90, 3.40) 0.97 (0.50, 1.88)

Citizenship

American by birth or naturalization 2.94 (1.69, 5.12) 1.19 (0.82, 1.72)

Not a citizen 1.00 Referent 1.00 Referent

Speaks English at home

Yes 2.09 (1.29, 3.39) 0.97 (0.56, 1.67)

No 1.00 Referent 1.00 Referent

468 J Immigrant Minority Health (2013) 15:462–471

123

link between education and ADL limitations for males.

Speaking English at home and citizenship status were each

measured as common indicators of acculturation. The 2000

U.S. census reports that 29 % of Filipinos have less than a

9th

grade education and that 17 % are linguistically iso-

lated, with 56 % reporting that they do not speak English

very well [6]. Males who speak English at home had higher

odds of blindness or deafness. Speaking English at home

was also associated with higher odds of memory or

learning problems for both males and females. These sur-

prising findings should be replicated in other, large,

nationally representative surveys. Future research is also

needed to examine possible pathways and/or confounding

factors that may shed light on this association.

We also found that Filipino males who were U.S. citi-

zens had increased odds of blindness or deafness compared

to non-citizens. Foreign-born persons are thought to be

healthier than their U.S.-born counterparts because of the

self-selectivity of immigration and prerequisite health

requirements to migrate to the U.S. [45], their strong

family support systems [46] and resilience [7]. These

characteristics that describe the ‘healthy migrant effect’ are

thought to diminish over time with longer residence in the

U.S. due to deterioration of healthy behaviours [7, 28] and

adoption of American lifestyle and practices. In addition,

reasons for migration such as family reunification and

pursuit of job opportunities, alongside acculturation factors

can also have a positive influence toward improved

opportunities, access to healthy behaviours in the host

nation, knowledge and attitudes about health, stress man-

agement and accumulation of health resources [5].

In comparison to the US-born, only Filipino males who

immigrated before 20 years old had significantly higher

odds of all four disability types. This may be due to the

Table 5 Logistic regression ofmemory/learning problems

according to demographic,

socioeconomic and

immigration-related variables

for older Filipino males

(n = 2,113) and females

(n = 3,079)

Per cent change in Nagelkerke

R Square associated with the

addition of education

level = 2.6 % male, 2.6 %

female

Per cent change in Nagelkerke

R Square associated with

addition of age at

immigration = 1.7 % male,

0.4 % female

Per cent change in Nagelkerke

R Square associated with

addition of citizenship status

and language spoken at

home = 0.8 % male, 0.3 %

female

Total Nagelkerke R-Square

value for full model = 0.189

male, 0.212 female

Nagelkerke R Square associated

with age and marital

status = 0.138 male, 0.179

female

Male Female

OR 95 % CI OR 95 % CI

Demographic variables

Age

55–64 1.00 Referent 1.00 Referent

65–74 1.19 (0.70, 2.02) 2.36 (1.61, 3.47)

75–84 3.63 (2.13, 6.19) 4.82 (3.16, 7.37)

85? 8.89 (4.48, 17.62) 11.05 (6.47, 18.86)

Marital status

Marital status

Not married 0.94 (0.59, 1.50) 1.50 (1.13, 2.00)

Married 1.00 Referent 1.00 Referent

Adult socioeconomic status

Education

Primary 6.98 (2.07, 23.54) 4.94 (2.24, 10.90)

Some high school 6.62 (1.83, 23.97) 3.10 (1.30, 7.41)

High school graduate 5.42 (1.71, 17.18) 2.54 (1.16, 5.55)

Bachelor degree 3.17 (0.97, 10.42) 1.70 (0.77, 3.78)

Graduate degree 1.00 Referent 1.00 Referent

Immigration and citizenship

Age at immigration

U.S. born 1.00 Referent 1.00 Referent

20 3.30 (1.40, 7.78) 0.56 (0.15, 2.19)20–39 1.84 (0.80, 4.21) 1.48 (0.81, 2.71)

40–59 2.26 (0.96, 5.30) 1.69 (0.93, 3.04)

60–100 4.71 (1.95, 11.41) 1.93 (1.03, 3.62)

Citizenship

American by birth or naturalization 1.24 (0.74, 2.09) 1.04 (0.74, 1.45)

Not a citizen 1.00 Referent 1.00 Referent

Speaks english at home

Yes 2.28 (1.25, 4.15) 1.75 (1.13, 2.73)

No 1.00 Referent 1.00 Referent

J Immigrant Minority Health (2013) 15:462–471 469

123

early age at immigration, or potential cohort effects of this

particular age group. On the other hand, both men and

women who immigrated over the age of 60 years had

higher odds of memory or learning disabilities than US

born Filipino-Americans, which may reflect the reason for

immigration. The reasons for immigrating and timing of

migration among Filipinos are diverse and their experience

in the U.S. varies accordingly [7, 32]. Perhaps adult chil-

dren established in the U.S. sponsor their parents to

immigrate through family reunification policies when their

parents are in need of care, as would be the case for those

with Alzheimers disease or other chronic disease. [47].

There are a several limitations of this study that should be

considered when interpreting the results. Income and wealth

vary greatly among AAPI subpopulations [4, 42, 43,48] and

are highly correlated with level of disability in older adults.

However, information about wealth was not available in the

dataset, which precluded our analysis of this relationship.

Additionally, this data is based on a cross-sectional sample

that did not provide information about the onset and pro-

gression of disability; therefore we cannot determine causal

relationships in our findings [7]. Also, as described earlier,

another limitation inherent to the cross-sectional design of

this study is the potential cohort effects of particular waves of

immigrants that may render some of our findings specific to

this population.

Future cohorts of AAPI elders will differ with respect to

their early life experiences, education and economic status

that may correspond to improvements to functional status

[49].

Finally, the behavioural risk factors of Asian subpopu-

lations may change with time and could affect future

cohorts of aging Filipinos. For example, current neonatal

and childhood diabetes and obesity trends [8], and a shift

in employment opportunities away from agricultural jobs

[3–5], may change future disability trends. The rapid

growth of the AAPI population necessitates accurate and

representative data to make informed health policy and

planning decisions. Each AAPI ethnic group deserves

distinct attention in order to offer culturally-sensitive rec-

ommendations for vulnerable populations. The data

reported here were obtained from a nationally-representa-

tive sample including community-based and institutional-

ized elders. This study identified factors associated with

each of the four types of disabilities among older male and

female Filipino-Americans. Older adults, those who speak

English at home, the unmarried and those with only a

primary school education had higher odds of disability and

therefore Filipino-Americans with these characteristics

should be targeted for improved prevention and treatment

interventions.

Continued surveillance of national surveys and pro-

spective studies will permit further understanding of the

trends in disability outcomes among older Filipinos and

other under investigated AAPI subgroups. There is likely a

complex interplay between migrant selection effects,

positive versus negative acculturation effects, and SES

factors that relate to both timing of immigration and

country of origin [50]. This area of public health research is

especially important given the high prevalence and inci-

dence rates of chronic diseases and disability. Both chronic

diseases and disabilities result in a substantial economic

burden for the country as well as decreased quality of life

for the individual.

Acknowledgments The authors would like to thank Rachel Zhoufor her assistance with preparation of the tables.

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