Perceived Quality of Care, Receipt of Preventive Care, and Usual
Source of Health Care Among Undocumented and Other Latinos
Michael A. Rodríguez, MD1, Arturo Vargas Bustamante, PhD2, and Alfonso Ang, PhD1
1UCLA Department of Family Medicine, Los Angeles, CA, USA;2Department of Health Services, UCLA School of Public Health, Los Angeles, CA,
BACKGROUND: Latinos are the largest minority group in
the United States and experience persistent disparities in
access to and quality of health care.
OBJECTIVES: (1) To determine the relationship be-
tween nativity/immigration status and self-reported
quality of care and preventive care. (2) To assess the
impact of a usual source of health care on receipt of
preventive care among Latinos.
DESIGN: Using cross-sectional data from the 2007 Pew
Hispanic Center/Robert Wood Johnson Foundation
Hispanic Healthcare Survey, a nationally representative
telephone survey of 4,013 Latino adults, we compared
US-born Latinos with foreign-born Latino citizens,
foreign-born Latino permanent residents and undocu-
mented Latinos. We estimated odds ratios using sepa-
rate multivariate ordered logistic models for five
outcomes: blood pressure checked in the past 2 years,
cholesterol checked in the past 5 years, perceived
quality of medical care in the past year, perceived
receipt of no health/health-care information from a
doctor in the past year, and language concordance.
RESULTS: Undocumented Latinos had the lowest
percentages of insurance coverage (37% vs 77% US-
born, P<0.001), usual source of care (58% vs 79% US-
born, P<0.001), blood pressure checked (67% vs 87%
US-born, P<0.001), cholesterol checked (56% vs 83%
US-born, P<0.001), and reported excellent/good care in
the past year (76% vs 80% US-born, P<0.05). Undocu-
mented Latinos also reported the highest percentage
receiving no health/health-care information from their
doctor (40% vs 20% US-born, P<0.001) in the past year.
Adjusted results showed that undocumented status
was associated with lower likelihood of blood pressure
checked in the previous 2 years (OR=0.60; 95% CI, 0.43–
0.84), cholesterol checked in the past 5 years (OR=0.62;
95% CI, 0.39–0.99), and perceived receipt of excellent/
good care in the past year (OR=0.56; 95% CI, 0.39–0.77).
Havinga usual source ofcare increasedthelikelihoodof a
bloodpressurecheck in thepast 2 years and a cholesterol
check in the past 5 years.
CONCLUSION: In this national sample, undocumented
Latinos were less likely to report receiving blood pressure
and cholesterol level checks, less likely to report having
received excellent/good quality of care, and more likely to
receive no health/health-care information from doctors,
even after adjusting for potential confounders. Our study
shows that differences in nativity/immigration status
should be taken into consideration when we discuss
perceived quality of care among Latinos.
KEY WORDS: Latinos; quality of care; immigrants; preventive care.
J Gen Intern Med 24(Suppl 3):508–13
© Society of General Internal Medicine 2009
Latinos are one of the fastest growing populations in the US.
Approximately 45 million Latinos lived in the US in 20061, and
18% (8.5 million) are estimated to be undocumented immi-
grants.2Latinos report having less access to health care3and
lower use of health care compared to non-Latino whites.4–6
Latinos are also less likely to have health insurance coverage,7
which adversely affects health-care access and utilization.8
Legal status is an additional factor that affects undocumented
Latinos’ access and utilization of health care.9–10Most litera-
ture on quality of care has focused on the general Latino
population5with very few studies looking at variability among
Latinos by nativity and immigration status. This is the first
study that we are aware of using a national data set reporting
on perceived quality of care and receipt of selected preventive
care among Latinos by nativity/immigration status.
Several studies report that Latinos have fewer physician
visits, lower utilization of emergency services, and a lower
likelihood of having a regular source of care than non-Latino
groups despite research that suggests that Latinos have a
greater likelihood of chronic disease.11–12These differences
are particularly pronounced among undocumented Lati-
nos.9,13While 75% of the average population in the US
reported a physician visit in a recent national survey, only
56% of Mexican Americans and 59% of Central/South
Americans reported at least one physician visit in the same
survey.5,14Slightly more than one third of undocumented
Latinos (36.5%) reported having access to a regular health-
Published literature on quality of care suggests that the
patient’s perspective is an important element of quality of
care.5,15,16Positive perceptions of interpersonal processes of
care may influence patient outcomes through better adherence
to treatment regimens and greater motivation to manage their
health problems. As such, clinicians are encouraged to
acknowledge patients’ cultural beliefs and preferences, and
recognize that communication is fundamental to patient
satisfaction and the quality of care received.5,15Previous
research from national and regional studies found that
undocumented immigrants experienced lower quality health
care due to lower social integration and English language
dominance, which negatively influence their utilization of the
US health-care system.14,17,18
Consistent with the literature, we hypothesized that nativ-
ity/immigration status,14as well as having usual sources of
health care19are important factors associated with percep-
tions of quality of care received.
The results of this study come from the Pew Hispanic Center/
Robert Wood Johnson Foundation Hispanic Healthcare survey
(Wave 1),20a nationally representative telephone interview
survey of 4,013 randomly selected Latino adult participants,
aged≥18 years, living in the US.
Potential eligible respondents were randomly selected from
stratified listings of telephone area codes and exchanges in the
US. Telephone interviews were conducted in summer 2007 and
yielded a total sample of N=4,013 with a response rate of
39.5%. Of these, 3,005 (75%) interviews were conducted in
Spanish, 837 (21%) were conducted in English, and 171 (4%)
were conducted in a mix of Spanish and English.
After excluding the 166 participants who refused to answer
critical questions for this analysis (age, sex and citizenship
status), a total of 3,847 survey responses remained for
analysis. All interviews were conducted using trained inter-
viewers on the Computer Assisted Telephone Interviewing
(CATI) system. Sampling weights were used to yield a statisti-
cally representative sample of Latinos in the contiguous US.
Poststratification adjustment of weights by nativity, sex, age
and education was performed to make the sample representa-
tive of the distribution of Latinos in the Current Population
Survey annual demographic file.21All data presented in the
tables were weighted according to these procedures.
Nativity/immigration status was assessed through a series of
questions on place of birth. Participants were first asked
whether they were born in the US. If they were not born in
the US, they were asked whether they were US citizens. If they
were not citizens, participants were asked if they were legal
permanent residents of the US. From these series of questions,
we classified Latinos into four categories: US-born citizens,
foreign-born citizens, legal foreign-born permanent residents,
and undocumented residents. This classification scheme is
similar to other studies on undocumented Latinos.6
Aside from nativity/immigration status, we controlled for
other independent variables in our multivariate models. These
included sociodemographic variables such as sex, marital
status (single, married, or divorced/separated), age (18–24,
25–34, 35–44, 45–54, 55–64, ≥65 years), education (<high
school graduate, high school/GED graduate, some college or
more), and income categories (≤$14,999, $15,000 to $24,999,
$25,000 to $34,999, $35,000 to $59,999, >$60,000).
Several measures of self-reported health-care access and
quality of care received were used as dependent variables in
the analyses. (1) Usual source of health care was defined by the
following two questions: (a) do you have a usual place to go
when sick or need advice about health? and (b) where do you
usually go for health care? Participants who went to the
hospital emergency room for their usual care and those who
responded that they had no usual source of care were defined
as having no usual source of health care. Having a usual
source of health care was dummy coded (1=yes; 0=no). (2)
Insurance coverage was assessed as response (yes/no) to “Are
you, yourself, now covered by any form of health insurance or
health plan?” (3) Patient-provider language concordance was
defined by two survey questions that asked about: (a) the
language that the respondent preferred for being interviewed
during the survey (English or Spanish); (b) the language in
which their appointment was usually conducted when seeing a
doctor or health-care provider. Patient-provider language
preference concordance was yes if the language preferred by
the participant for the questionnaire was the language in
which their appointment was usually conducted when visiting
the doctor; otherwise, this was coded as no language concor-
dance. (4) The measure of no information on health care received
from a doctor was based on the question asking participants
doctor or other medical professional in the past year (yes or no).
(5) We analyzed receipt of preventive services by responses to two
questions: (a) have you had your blood pressure checked by a
doctor or other health-care provider in the past 2 years? and (b)
for males aged≥35 years and for females aged≥45 years, have
you had your blood cholesterol checked by a doctor or other
health-care provider in the past 5 years?
Consistent with previous research,5we also measured
patients’ perception of care by asking, “Overall, how would
you rate the quality of medical care that you received in the
past 12 months? Was the medical care excellent, good, fair, or
poor?” Thosewho didnotreceivecarein the past12months were
excluded from the analysis for this question. This variable was
dichotomized into excellent/good and fair/poor care. Separately,
another survey question also asks participants why they think
they received poor quality of care in the past 5 years: “Do you
think you received poor quality of health care in the past 5 years
because: (a) you were unable to pay, (b) of your race or ethnic
background, or (c) of your accent or how you speak English?
Respondents answered “yes” or “no” to each possibility.
We also adjusted our multivariate models by insurance
status (1=have health insurance, 0=no insurance), having a
usual source of health care, self-rated health status (excellent,
good, fair, or poor health), and region of the country (West,
Northeast, Midwest, and South).
We investigated associations between the dependent variables
and the categorical variables on nativity/immigration status
using Rao-Scott adjustment to the Pearson χ2statistic.22
Bivariate analysis was performed to examine the associations
between the dependent variables and independent variables.
Weighted multivariate logistic was used to examine the self-
reported quality of care measures, which include having blood
Rodríguez et al.: Quality of Care Among Undocumented Latinos
pressure checked in the past 2 years, cholesterol checked in
the past 5 years, whether the patient received excellent/good
quality of care in the past year, received no health information
from their doctor, and whether there was language concor-
dance with patient language preference. In all the weighted
logistic regression models, we control for nativity/immigration
status, usual source of health care, and other sociodemo-
graphic variables. The significance of individual covariate
effects was determined by Taylor-linearized variance estima-
tion for complex survey data. In all the analyses, we used the
appropriate weights that account for the complex survey
sampling design of the Pew Hispanic Center/Robert Wood
Johnson Foundation Hispanic Healthcare Survey (Wave 1).20
Table 1 shows the descriptive characteristics of health-care
access and quality of health care received by nativity/immi-
gration status. For two health-care access variables (usual
source of health care and insurance), 74% had a usual source
of health care and 66% of the sample had health insurance
coverage. Undocumented Latinos have the lowest proportion
with usual source of health care (58%) and health insurance
(37%). For patient-provider language concordance, US-born
Latinos had the highest language preference concordance
(84%), whereas foreign-born citizens had the lowest language
preference concordance (70%).
Regarding health services received during past doctor visits
(Table 1), compared to US-born Latinos, more undocumented
Latinos received no information on health/health care from
their physicians (20% vs 40%, respectively). Significantly fewer
foreign-born permanent residents (76%) and undocumented
Latinos (67%) had their blood pressure checked during the
past 2 years, compared to the US-born (87%; P<0.01 for both).
The same pattern existed for having had cholesterol tested in
the past 5 years for males (aged≥35 years) and females
(aged≥45 years), where 71% of the foreign-born permanent
residents and 56% of the undocumented Latinos reported
being tested for cholesterol levels, compared to 83% of US-born
Latinos reporting the same. Undocumented residents reported
the lowest percentage of perceived excellent/good quality of
care received (76% vs 80% US-born) in the past year.
The reasons for perceived poor quality of care received in the
exclusive; more than one reason can be given. Among the US-
unable to pay, in contrast to foreign-born permanent residents
(39%) and the undocumented (45%). A significantly higher
proportion of foreign-born permanent (38%) and undocumented
(39%) residents believed that they received poor care due to their
ethnic background, in contrast to the US-born (25%). Among the
US-born, a significantly lower percentage (14%) thought they
received poor care because of their accent, in contrast to foreign-
the undocumented (48%). The logistic regressions for these
perceived reasons for poor care provided similar results after
adjusting for age, sex, education, and insurance.
Using multivariate analysis (Table 3), foreign-born citizens
(OR=0.57; 95% CI, 0.42–0.77), foreign-born permanent resi-
dents (OR=0.60; 95% CI, 0.43–0.82), and the undocumented
(OR=0.60; 95% CI, 0.43–0.84) were less likely to have their
blood pressure checked in the past 2 years compared to US-
born Latinos. Other factors independently associated with
blood pressure check include being female, older age, high
educational attainment, poorer self-reported health, or having
a usual source of health care. For cholesterol checked in the
past 5 years, the undocumented were less likely to have been
tested for blood cholesterol (OR=0.62; 95% CI, 0.39–0.99)
compared to US-born Latinos. Participants who were female,
older, had health insurance, or were from the northeast region
of the US were also more likely to have been tested for
cholesterol levels (data not shown).
For perceived quality of care received in the past year, after
adjustment for other covariates, the undocumented (OR=0.56;
95% CI, 0.39–0.77) were less likely to report having received
excellent/good quality of care in the past year compared to US-
born Latinos. The results for no health/health-care informa-
tion received from doctors show that after adjustments,
foreign-born citizens (OR=1.43; 95% CI, 1.11–1.84), foreign-
born permanent residents (OR=1.58; 95% CI, 1.22–2.05), and
the undocumented (OR=1.43; 95% CI, 1.13–2.05) were more
Table 1. Descriptive Characteristics of Health-care Access to and Perceived Quality of Health Care Received by Nativity/Immigration Status
Have usual source of health care
Have insurance coverage
Patient-provider language concordance
services received during doctor visit
No health/health-care information received
Blood pressure checked (past 2 years)
Test for cholesterol (past 5 years for
males≥35 years, ≥45 years for females,
Perceived quality of care received
(past year, N=3,590)*
28% 20%28% 35%40%<0.001
*Those who did not receive care in the past 12 months were excluded from this analysis
Rodríguez et al.: Quality of Care Among Undocumented Latinos
likely to report that they received no health/health-care
information from their doctors.
With respect to language concordance, where the language
of care is concordant to the patient’s language preference,
foreign-born citizens (OR=0.45; 95% CI, 0.34–0.58) and
foreign-born permanent residents (OR=0.62; 95% CI, 0.45–
0.83) were less likely to report having received care in their
language of preference than undocumented Latinos and
compared to US-born Latinos.
Figures 1 and 2 show the adjusted percentages of partici-
pants receiving the recommended blood pressure and choles-
terol checks by nativity/immigration status, stratified by usual
source of health care. Figure 1 illustrates that those who had a
usual source of health care were more likely to have had blood
pressure checks in the past 2 years compared to those who
had no usual source of health care (P<0.05). In the group with
a usual source of health care, all foreign-born residents
(citizens, legal permanent residents, and the undocumented)
had significantly lower predicted rates of blood pressure
checks compared to US-born Latinos (P<0.05). In the group
with no usual source of health care, foreign-born citizens,
permanent residents, and the undocumented had significantly
lower predicted rates of blood pressure checks compared to
US-born Latinos (P<0.05). Figure 2 also demonstrates that
those with a usual source of health care were more likely to
have had a blood cholesterol test compared to those with no
usual source of health care (P<0.05). In the group with a usual
source of health care, the undocumented were significantly
less likely to have had a blood cholesterol test compared to US-
born Latinos (P<0.05). We found the same pattern for those
with no usual source of health care. The undocumented
Latinos were significantly less likely to have had a blood
cholesterol test compared to US-born Latinos (P<0.05).
To our knowledge, this is the first study using nationally
representative data reporting on perceived quality of care and
receipt of selected preventive care among Latinos in the US by
nativity/immigration status. Our study demonstrates that
perceived quality of care as well as receipt of health/health-
care information, blood pressure, and cholesterol screening by
Latino immigrants is lower than that of US-born Latinos.
Similarly, the proportion with health insurance and a usual
source of health is lower among Latino immigrants. For most
of the measures, the trend is one of improved parameters that
parallel the range of immigration status from lack of docu-
mentation to US-born.
In addition to the differences in receipt of preventive care and
different by nativity/immigration status, but the magnitude of
might explain why they reported disproportionately less preven-
and also lower perceived quality of care ratings. As many
undocumented Latinos have recently arrived to the US, they
may use different standards to evaluate the quality of health care
and rate certain health services higher than Latinos who have
been living in the country longer.
Ourstudy alsoprovides perspectives regardingthe reasonsfor
poor quality of care among Latinos and how these perspectives
vary by nativity/immigration status and country of origin. Our
findings support those of other researchers who found that
undocumented Latinos were more likely to report that ability to
pay and racial/ethnic background were reasons for perceived
proficiency may help explain why the undocumented were most
likely to report receiving no information on health from their
Table 2. Reasons for Perceived Poor Quality of Care Received in the
Past 5 Years, by Nativity/Immigration Status and Country of Origin
Accent or how
By nativity/immigration status:
By country of origin:
*P<0.05, significantly different from US-born Latinos
Table 3. Multivariate Analysis of Perceived Quality of Care Outcomes US-born and Foreign-born Latinos
esident OR (95%CI)
Blood pressure checked in the past
Cholesterol checked in the past
Received excellent/good quality of
care in the past yearH,I
No information on health/health-care received
from doctor in the past yearH
Reference group 0.57 (0.42–0.77)* 0.60 (0.43–0.82)* 0.60 (0.43–0.84)*
Reference group1.38 (0.95–2.00) 0.89 (0.60–1.31) 0.62 (0.39–0.99)*
Reference group 0.99 (0.76–1.31) 0.79 (0.59–1.05)0.56 (0.39–0.77)*
Reference group 1.43 (1.11–1.84)*1.58(1.22–2.05)* 1.43 (1.13–2.05)*
Reference group0.45 (0.34, 0.58)* 0.62 (0.45, 0.83)*0.72 (0.50, 1.03)
*Significant at P<0.05
HAdjusted for sex, income, age, education, marital status, health status, health insurance, usual source of care, and region
IAnalysis included only males aged≥35 years and females aged≥45 years
Rodríguez et al.: Quality of Care Among Undocumented Latinos
doctor and least likely to feel reassured that they could manage
their own health. Not surprisingly, almost half of undocumented
Latinos who reported poor care in the past 5 years attributed
their poor care to their accent or how well they speak English.
Receipt of preventive care is influenced by Latino patients’ ability
to speak English24presumably because of the diminished
communication between patients and their doctors and the
doctors limited ability to address patients’ health-care needs.
Consistent with previous studies,6undocumented Latinos were
leastlikely tohavea usualsource ofhealthcare, whichaccording
to other studies is associated with a higher likelihood that a
patient will report positive health-care communication.25
Our findings suggest that foreign-born Latinos, especially
the undocumented, face serious financial and linguistic con-
straints to access health care. These findings help increase our
understanding of the heterogeneity among Latinos and why
reporting results by immigration status is important. Consis-
tent with other studies, we found that usual source of health
care is a significant predictor17,26–28in determining whether
adults receive recommended screening and preventive ser-
vices. This underscores the fact that having a usual source of
health care is a critical element of a medical home, regardless
of nativity/immigration status and insurance status.
One study limitation is that we focused on a single measure of
perceived quality of care, which may not reflect other dimen-
sions of quality of care. Homogeneous rankings of health-care
quality may be responsible for averaging the perception of
health-care services that are not directly comparable. A
distinction by type of service in the ranking of health-care
quality might have been useful to address this issue. In
addition, the respondents to our survey may have perceived
poor quality from the provider, although treatment could have
been adequate. Self-reported data for other variables, such as
blood pressure checked in 2 years and cholesterol checked in 5
years, are also subject to respondent’s memory and understand-
ing of tests being taken during preventive care examinations.
with being undocumented, accuracy and/or reliability response
could be adversely impacted. To address this limitation, partici-
pants were categorized as undocumented by exclusion, and
intensive interviewer training included safeguards of confidenti-
ality and privacy to help develop rapport during the interviews.
Nonetheless, it is possible that some respondents misplaced
themselves in another category, resulting in a potential under-
Figure 1. Blood pressure checked in the past 2 years, by usual source of health care+. *P<0.05, significant difference between having usual
source of health care and no usual source of health care. **P<0.05, significant difference compared to US-born. FB = foreign-born.+Adjusted
for sex, income, age, education, marital status, health status, health insurance, and region.
Figure 2. Blood cholesterol checked in the past 5 years, by usual source of health care+. *P<0.05, significant difference between having
usual source of health care and no usual source of health care. **P<0.05, significant difference compared to US-born. FB = foreign-born.
+Adjusted for sex, income, age, education, marital status, health status, insurance, and region.
Rodríguez et al.: Quality of Care Among Undocumented Latinos
count of undocumented and more conservative estimates. A
related concern is that the survey missed those without phones,
underrepresenting the most vulnerable with worse quality of
services, thereby reducing the size of differences detected.
An additional limitation is the inclusion of barriers to
health-care quality linked only to inability to pay, racial/ethnic
background, and ability to speak English. In contrast with
other health-care surveys (MEPS, CHIPS) where barriers such
as cost or distance to the health-care provider are included,
our dataset had limited information available on such barriers
to quality of care. The limited range of alternatives might have
influence participant response by causing respondents to
endorse the few barriers at increased levels.
Previous research on the perceived quality of care among Latinos
has focused on either health-care quality differentials across
racial/ethnic categories or studied specific quality issues among
all Latinos, with limited distinction of nativity or immigration
status. While all foreign-born categories of Latinos were less likely
than US-born Latinos to have their blood pressure assessed or
receive any information on health or health-care from their
doctors, undocumented Latinos were the only group to also report
lower odds of cholesterol screening and worse perceived health-
care quality than US-born Latinos. Undocumented Latinos are
also the subgroup with the highest proportion reporting that their
supporting increased access to affordable culturally and linguis-
tically competent services could be beneficial to improve the
among Latinos by both nativity and immigration status under-
score the importance of future studies of Latinos appropriately
collecting29and reporting results by immigration status.
Acknowledgments: This project was supported by the Network for
Multicultural Research on Health and Healthcare, Department of
Family Medicine—UCLA David Geffen School of Medicine, funded by
the Robert Wood Johnson Foundation.
Corresponding Author: Michael A. Rodríguez, MD, UCLA Depart-
ment of Family Medicine, 10880 Wilshire Blvd #1800, Los Angeles,
CA 90024, USA (e-mail: firstname.lastname@example.org).
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