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A Comparison of the Use of Home Care Services by Anglo-American and Mexican American Elders
Janice D. Crist, Seon Hye Woo and Myunghan Choi
J Transcult Nurs 2007 18: 339
DOI: 10.1177/1043659607305190

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A Comparison of the Use of Home Care Services
by Anglo-American and Mexican American Elders

JANICE D. CRIST, PHD, RN

University of Arizona
SEON HYE WOO, PHD, RN
Gyeongsang University, South Korea
MYUNGHAN CHOI, PHD, MPH, RN
Northwest Medical Center

Elders’ use of home care services varies globally. The authors
tested the relationship of cultural/ethnic, contextual, and social
structural factors with elders’ use of home care services in the
United States. Fifty-seven non-Hispanic White or “Anglo” and
56 Mexican American elders participated. Use of services
significantly correlated with Anglo and Mexican American
elders’ cultural/ethnic and contextual factors. Perceived need
and service awareness were the two factors that were signifi-
cant for both groups and that the authors believe would be
amenable to change in future transcultural nursing interven-
tions to decrease use of services disparities.
care services by two groups: non-Hispanic White (“Anglo”)
elders and Mexican American elders in the United States.
We designed a pilot study to test how factors behaved
similarly or differently in relationship to use of home care
services, for elders of Anglo- and Mexican American cul-
tures. The research questions were the following:
Research Question 1: What is the relationship of Anglo and
Mexican American elders’cultural/ethnic, contextual, and social
structural factors with elders’ use of home care services?
Research Question 2: What are the relationships among Anglo
and Mexican American elders’ cultural/ethnic, contextual, and
social structural factors?

Keywords: Mexican American; home care services; CONCEPTUAL PERSPECTIVE

utilization; Anglo-American
In this study, the term home care services refers to both
T he use of formal home care services designed to assist
skilled and supportive services. Skilled home care services
include the assessment, teaching, and substantial treatments
elders and their family caregivers varies by ethnicity. For
performed by professionally licensed providers. In the United
example, Mexican American elders use home care services
States, most private or nationally funded (Medicare or
less than non-Hispanic White elders (Centers for Medicare
Medicaid) payer regulations require home care recipients to
and Medicaid Services, 2003). Preliminary studies and other
be homebound and in need of skilled care that does not
evidence in the literature suggest that differences in use rates
exceed 28 hours per week or 8 hours per day (Montauk, 1998).
are based on cultural/ethnic, contextual, and social structural
Supportive home care services include the assistance with
factors (Andersen, Bozzette, Shapiro, & St. Clair, 2000; Crist,
activities of daily living (ADLs; e.g., bathing) and instru-
2002; Crist, García-Smith, & Phillips, 2006; Dietz, John, &
mental activities of daily living (IADLs; e.g., shopping)
Roy, 1998; Gale & Erickson, 1999; Houde, 1998; Magilvy &
performed by trained aides (Hughes, Hodgson, Muller,
Congdon, 2000; Phillips, Morrison, Andersen, & Aday, 1998;
Robinson, & McCorkle, 2000). Supportive care is funded by
Wallace, Levy-Storms, Kington, & Andersen, 1998), but they
social services for low-income elders or private pay.
have not been tested together. This article reports the results
Reasons for differences in use rates of home care services
of a pilot study that described factors affecting use of home
by Anglo- and Mexican American elders have been explored
in the southwestern United States (Crist, 2002; Crist, Garcia-
Authors’ Note: The authors wish to acknowledge the College of Nursing, The Smith, et al., 2006). Various reasons have also been reported
University of Arizona NRSA T32, Community-Based Interventions for
Underserved and Vulnerable Populations, grant for post-doctoral studies; and
by community advisers (Crist & Escandón-Dominguez, 2003)
Linda R. Phillips, PhD, RN, FAAN; ENCASA Community Advisory Council. and in the literature, but a comprehensive approach has not
been tested. A synthesis of cultural/ethnic, contextual, and
Journal of Transcultural Nursing, Vol. 18 No. 4, October 2007 339-348
DOI: 10.1177/1043659607305190 social structural factors provided the conceptual perspective
© 2007 Sage Publications of the study.

339
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340 JOURNAL OF TRANSCULTURAL NURSING / October 2007

Cultural/Ethnic Factors services (Alemán, 2000; Crist, 2002). The presence of preju-
dice and discrimination by the dominant Anglo culture of the
Cultural/ethnic factors (familism, discrimination, accultur-
United States is still in evidence (Alaimo, 2000). We expected
ation, and need for home care services, as perceived by elders)
discrimination to be negatively associated with use of home
stem from conditions, cultural norms, or experiences of being
care services.
part of an ethnic minority. Interventions must include strate-
The third cultural/ethnic factor, acculturation, is defined
gies that preserve important aspects of the populations’ culture
as changes in attitudes, behaviors, beliefs, and values of
(Leininger, 1991).
minority individuals coming into continuous and direct
The first factor, familism, is defined as elders’ and family
contact with a dominant cultural group. Acculturated people
caregivers’ beliefs that all of the elders’ needs should be met
integrate a bicultural orientation with identification and
by elders’ children, most often grown daughters, in return
comfort with both groups (Cuéllar, Arnold, & Maldonado,
for sacrifices made by their parents (Gelfand, Balcazar,
1995, p. 278). Studies show Hispanic, non–Mexican
Parzuchowski, & Lenox, 2001). This factor has not previously
American elders, and Euro-American minority elders, and
been tested in predicting Mexican American elders’ use of
their family caregivers, who are willing to use services, are
home care services. Familism has been documented as salient
more acculturated (Calderón-Rosado, Morrill, Chang, &
in many groups, including Anglo American elders, but more
Tennstedt, 2002). Level of acculturation affects other
strongly as the most important distinguishing characteristic of
minorities’ use of health care services; for example, Chinese
Mexican American culture both empirically (Luna et al., 1996;
American older women with more Chinese culture affilia-
Sábogal, Marín, & Otero-Sábogal, 1987) and theoretically
tion were less likely to have a mammogram in the last 2
(Clark & Huttlinger, 1998; Markides & Miranda, 1997),
years (Yu, Wu, & Mood, 2005). Acculturation decreases sus-
although it is found in other cultures. Familism in Mexican
picion and mistrust of outside services, increases families’
American families is even stronger than in other Hispanic
willingness to interact with outside social systems and insti-
groups (Angel & Angel, 1997). Familism is seen in developing
tutions (Rueschenburg & Buriel, 1995), and positively affects
countries and in less acculturated groups in the United States
Mexican American elders’ use of home care services
and endures as a strong value even in some groups that have
(Peragallo, Fox, & Alba, 2000).
been in the United States for multiple generations, including
The fourth cultural/ethnic factor, need for home care
American Indians in the Southwest and Mexican American
services, is defined as elders’ recognition that home care
families (Alemán, 2000). Alemán noted that Mexican
services are needed (Gelfand, 1994). This conceptualization
American family members provide care for each other with
includes comprehending how a service can be helpful in
motivations distinct from Anglo families’ “social exchange”
attaining goals and “acquiring habits of action for coping
paradigm (Dowd, 1975). Alemán instead cites the expression
with reality” (Rohrty, 1991, p. 1). Recognition of need for
“Que Dios te lo pague” (“God will reward you for it”) (p. 14),
services can be viewed as “a consensus of beliefs” constructed
as an expression of the cultural norm that family members’
as part of a group or culturally defined community (Duffy &
good deeds are appreciated, blessed, and rewarded by God
Cunningham, 1996, p. 178). We expected a positive relation-
rather than by dependent members being reciprocally
ship of need with use of home care services.
indebted to their caregivers. Familism emerged as a barrier to
elders’ use of home care services in a preliminary study (Crist, Contextual Factors
2002). The norm of familism promotes the expectations in
elders and their family caregivers that family members should Contextual factors (health status, functional status, and
be able to provide all care that is needed, family caregivers service awareness) are health-related and knowledge factors
can give better care than outsiders, elders are safer being that affect use of home care services directly. The first
cared for by family caregivers, and families present a negative factor, health status, is defined as elders’ self-reported assess-
impression if a stranger provides care to their elder (Crist, ment of their health problems. Acute or chronic declines in
García-Smith, et al., 2006). We expected a negative relation- the elders’ condition may increase the possibility of the
ship between familism and use of home care services. elders using home care services (Alkema, Reyes, & Wilber,
The second cultural/ethnic factor, discrimination, is 2006; Wallace et al., 1998). Factors such as “hospitalized
defined as “interpersonal acts and institutional arrangements within the past year,” which may have been proxies for health
that tend to denigrate individuals or groups because of ethnic status, also have been tested and found to predict use of
group affiliation” (Clark, Anderson, Clark, & Williams, 1999). home care services (Burnette & Mui, 1995). We expected a
In this study, discrimination is Mexican American people’s negative relationship between health status and use of home
perception of not being treated with dignity, respect, and care services.
personalismo (the expectation of warm, friendly, person- The second contextual factor, functional status, is defined
oriented behavior) by providers of home care services whom as elders’ ability to perform ADLs and IADLs indepen-
they expect will not speak Spanish during the delivery of dently. It is usually operationalized as functional limitations

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and has often been shown to be the strongest predictor of use
of home care services by Anglo elders (Alkema et al., 2006;
McCusker et al., 2001; Moulton, McGrane, Beck, Holland,
& Christopher, 1998) and Mexican American elders
(Burnette & Mui, 1995; Wallace et al., 1998), with a variety
of diagnoses. We expected a negative relationship between
functional status and use of home care services.
The third contextual factor, service awareness, is defined
as having an understanding about existing home care services.
The concept includes two dimensions, based on previous
theories of service awareness (Yeatts, Crow, & Folts, 1992):
(a) knowledge that home care services exist and (b) potential
to access home care services. Knowledge that home care
services exist is defined as “awareness that service is avail-
able” (Gelfand, 1994, p. 149). Elders, family caregivers, and
provider informants reported during preliminary studies that
Mexican American elders would have used home care services
more if elders and family caregivers had known that these
services existed (Crist, 2002). Awareness that services exist
does not necessarily indicate ability to access and use the
service (Krout, 1983). Potential to access home care services
is defined as “awareness of how to get service” (Gelfand,
1994, p. 149) and ability to contact home care services. We
expected a positive relationship between service awareness
and use of home care services.
Social Structural Factor
Social structural factors (financial status) make use of
home care services likely. Financial status is defined as the
elder’s ability to fund home care services. Funding in the
United States may come from (a) third-party payer coverage,
including Medicare, Medicaid, long-term care and other
health insurance, and/or eligibility to receive publicly funded
aging services, and (b) private-pay resources. Medicare
finances home care services for elders who are 65 years old,
citizens of the United States, and have paid into the Social
Security program. Home care services also may be covered
by other programs such as the Older Americans Act for low-
income people aged 60 and older. In the social structure of
the United States, for some Mexican American elders,
health insurance or other benefits are not available. Many
lack health insurance or other ways of funding home care
services (Aranda & Knight, 1999; Pol, Mueller, & Adidam,
2002). Of all Hispanic people with serious chronic condi-
tions, 71% report problems with financial access to care
(Anderson & Horvath, 2002). Financial access problems are
increased for Mexican American elders because serious
health problems occur earlier for them than the Medicare
qualifying age of 65; at the same time, working poor elders
may not qualify for funding in programs where low income
is a criterion. There is evidence in the literature that having
health insurance positively affects use of home care services
(Angel, Angel, Lee, & Markides, 1999; Crist, 2002). We
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Crist et al. / MEXICAN AMERICAN ELDERS 341
expected a positive relationship between financial status and
use of home care services.
DESIGN
This was a correlational descriptive study. Factors
expected to have a significant relationship with use of home
care services were examined using correlation coefficients.
The purpose of using correlation coefficients was twofold.
First, correlation coefficients provide a meaningful and
parsimonious explanation for observed relationships within a
theoretical framework. Second, correlation coefficients help
researchers discover relationships, associations, and strength
of the relationship among variables in the model (Hox &
Bechger, 1998; Hoyle, 1995).
Setting
The study was conducted in a southwestern city in the
United States. We recruited elders and collected their data at
senior centers, churches, and neighborhood associations, in
generally lower income neighborhoods.
Human Subjects Protection
The study was approved by the University of Arizona
Human Subjects Committee. A sample of Anglo elders and
Mexican American elders were recruited to complete a
10-page bilingual survey on the eight factors that were
proposed to have a significant relationship with use of home
care services. Questionnaires were available in Spanish or
English. The Anglo principal investigator (PI) and a bicultural
and bilingual research assistant provided assistance with
explaining the disclaimer that was required by the Human
Subjects Committee. Each elder received a copy. The PI and
research assistant assisted elders with completing the ques-
tionnaires when elders requested assistance. Questionnaires
were completed after the disclaimer was signed, during the
same session. Elders were given a $5.00 gift for completing
the questionnaires.
Measures
Measures that were selected had been translated and back
translated, and reviewed by bicultural and bilingual community
advisers. The goal was to ensure language and conceptual
equivalence for the Spanish dialect that is typically spoken
regionally (Crist, Velazquez, Ramirez Figueroa, & Durnan,
2006; Jones & Kay, 1992; Jones, Mallinson, Phillips, & Kang,
2006; Phillips, Luna de Hernandez, & Torres de Ardon,
1994).
Cultural/ethnic measures. Familism was measured by
elders’ responses to the Familism Scale (Sábogal et al., 1987).
It contains 14 items. Response choices are Likert-type,
ranging from strongly agree to strongly disagree. In previous
342 JOURNAL OF TRANSCULTURAL NURSING / October 2007
studies, Cronbach’s alpha was .64-.72 (Sábogal et al., 1987);
standardized alpha was .83 (Luna et al., 1996). In the current
study, Cronbach’s alpha was .86 for Anglo and .84 for
Mexican American responses. Discrimination was measured
using a new Perceived Experiences of Discrimination Scale
(Crist, 2004). It contained 28 items. Five response choices
were Likert-type, ranging from never to always; 20 were
dichotomous (yes/no); and one open-ended question asked
for other experiences of discrimination. In the present study,
Cronbach’s alpha was .81 for Anglo and .89 for Mexican
American responses. Acculturation was measured by elders’
responses to 10 questions, which were an adaptation of the
Acculturation Rating Scale for Mexican Americans-II
(ARSMA-II) (Cuéllar et al., 1995). In previous studies using
the complete measure, Cronbach’s alpha was .88 (Anglo)
and .81 (Mexican American); test–retest reliability was .80
(Anglo) and .72 (Mexican American) 5 weeks apart (Cuéllar
et al.). In the current study, Cronbach’s alpha was .84 for
Anglo and .72 for Mexican American responses. Need for
home care services was measured with one item asking for a
yes/no response to whether home care services were needed.
Contextual measures. Health status was measured by an
adaptation of the Older Americans Resources and Services
(OARS) Multidimensional Functional Assessment of Older
Adults (OMFAQ), Physical Health Scale (Fillenbaum,
1988). It contains 27 items. In previous studies using
the complete measure, test–retest reliability was .78-.92.
Criterion validity for Physical Health was .82 (Fillenbaum).
In the current study, Cronbach’s alpha was .76 for Anglo and
.93 for Mexican American responses. Functional status was
measured by elders’ responses to an adaptation of the Activities
of Daily Living Scale of the OMFAQ. It contains five items.
In previous studies using the complete measure, test–retest
reliability was .88-1.0, criterion validity was .89 (Fillenbaum),
and Cronbach’s alpha was .78 (Badger & Collins-Joyce,
2000). In the current study, Cronbach’s alpha was .65 for
Anglo and .74 for Mexican American responses. Service
awareness was measured by totaling scores of two questions
regarding knowledge of existing services and potential to
use services. The services named for each question were
summed. This was the first testing of this new measure;
previous psychometrics were not available. In the current
study, Cronbach’s alpha was .73 for Anglo and .62 for Mexican
American responses.
Social structural measures. Financial status was measured
by elders’ responses to two questions that were an adaptation
of the Economic Resources Scale of the OMFAQ. In previous
studies using the complete measure, intrarater reliability =
.67-.91; criterion validity = .68 (Fillenbaum). Use of home
care services was measured by one response to a yes/no
question about whether home care services were being used
or had ever been used.
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Data Analysis Plan
Data analysis was conducted using SPSS (Windows
Version 14.0). Demographic variables were compared across
groups using independent sample t tests (age, education) and
chi-square (gender, marital status, diagnoses, financial status,
insurance status) to test for significant differences in samples.
Use of home care services (a dichotomy, yes/no) was compared
across groups using correlation coefficients. To determine
relationships, Spearman’s Rho was used for nonparametric
variables. Pearson’s r (point-biserial correlation) was used for
parametric variables.
RESULTS
Sample
Inclusion criteria were community dwelling Anglo and
Mexican American elders who were 55 years of age or older.
The rationale for the age criterion of 55 years was that for
Mexican American elders, serious health problems occur
early, even in the late 40s. These serious health problems are
similar to those experienced by Anglo elders who are 65
years of age or older (Villa & Aranda, 2000).
Anglo elders (n = 57; 19.3% male and 80.7% female) and
Mexican American elders (n = 56; 19.6% male and 80.4%
female) participated (Table 1). Anglo elders’ average age
was 77.6 (ranging from 69.3 to 85.9). Mexican American
elders’ average age was 70.4 (ranging from 63.3 to 77.5)
(p = .000). Average years of education completed were 13.25
years for Anglo elders as opposed to 7.58 years for Mexican
American elders (p = .000). Anglo elders’ reports indicated
that their general health status was different from Mexican
American elders’ (p = .039). Almost one third (31.6%) of
Anglo elders and 29.6% Mexican American elders were
married. More than 12% (12.3%) of Anglo elders and 69.7%
of Mexican American elders reported they barely made ends
meet or did not have enough money to pay bills (p = .000),
and 91.2% Anglo elders and 92.9% Mexican American
elders had health insurance.
Research Question 1: Factors Significantly
Related to Use of Home Care Services
For Anglo elders, two cultural/ethnic factors were signif-
icantly correlated with use of home care services (Table 2):
more familism (r = .280, p < .05) and more need (self-
reported) for home care services (r = .477, p < .01). Two
contextual factors were significantly correlated with use of
home care services: higher functional status (r = .337, p <
.05) and more service awareness (r = .738, p < .01).
For Mexican American elders, two cultural/ethnic factors
were significantly correlated with use of home care services
(Table 3): less discrimination (r = –.285, p < .05) and more
need for home care services (r = .270, p < .05). All three
contextual factors were significantly correlated with use of
 Crist et al. / MEXICAN AMERICAN ELDERS 343

TABLE 1 functional status (r = .313, p < .05), and better health status
Demographics of Anglo and Mexican American Elders with better functional status (r = .560, p < .01).
Intercorrelations among Mexican American factors
Anglo Mexican American
included less discrimination with more service awareness
Descriptor n = 57 % n = 56 % (r = –.278, p < .05) and higher financial status (r = .335,
p < .05), more need for home care services with better
Gender
Male 11 19.3 11 19.6
functional status (r = .499, p < .01), and better health status
Female 46 80.7 45 80.4 with better functional status (r = .269, p < .05) and more
χ2 = .002, p = .963 service awareness (r = .280, p < .05).
Average age 77.6 ± 8.3 70.4 ± 7.1
t = –4.930, p = .000 DISCUSSION
Years of education 13.25 ± 2.57 7.58 ± 3.52 We found that some factors that were significantly associ-
t = –9.634, p = .000
ated with use of home care services were congruent with extant
Marital status knowledge, but others were not significant or were significant
Single, widowed, in different directions than before. Intercorrelations help
separated, or explain some of the expected and unexpected significant
divorced 39 68.4 40 71.4
correlations with use of home care services. Two factors that
Married 18 31.6 16 29.6
χ2 = .121, p = .727 we believe are amenable to change were significant across
both ethnicities.
Diagnoses
Diabetes 3 5.3 13 23.2 Factors Significantly Associated With
Heart disease/ Use of Home Care Services
hypertension 17 29.8 13 23.2
Arthritis 11 19.3 5 8.9
The pilot study demonstrated that for Anglo and Mexican
Other 13 22.8 16 28.6 American elders, cultural/ethnic factors (familism, discrimi-
None 13 22.8 9 16.1 nation, and perceived need) had significant relationships with
χ2 = 10.063, p = .039 use of home care services. This finding shows that cultural/
ethnic factors are significant rather than only contextual
Financial status
factors (health status, functional status, and service awareness),
Not enough money
to pay bills 2 3.5 10 17.9
which more often have been tested and reported, in affecting
Barely making ends meet 5 8.8 29 51.8 use of home care services. Cultural/ethnic factors will be
Have enough money important to consider when designing culturally competent
to pay bills 38 66.7 11 19.6 interventions for increasing use of home care services.
Have enough money For Anglo elders, regarding cultural/ethnic factors, the
for everything 12 21.1 4 7.1 positive, rather than negative, significant correlation between
χ2 = 41.101, p = .000
the cultural/ethnic factor familism with the outcome use of
Health insurance status home care services was not congruent with current knowledge.
Yes 52 91.2 52 92.9 Familism had been conceptualized as a barrier to use of
No 5 8.8 4 7.1 home care services. Perhaps the direction of the relationship
χ2 = .102, p = .749 may be explained by Anglo elders’ believing that bringing
in services eases the work of the caregiver (Russell, 1997).
The significant relationship between Anglo elders’ perceived
need for home care services with use of home care services
is supported by extant research, as explained in the literature
home care services: better health status (r = .400, p < .01), review. The unexpected nonsignificance of Anglo elders’
better functional status (r = .341, p < .05), and more service health status with use of home care services, especially in
awareness (r = .424, p < .01). light of the intercorrelation of health status with functional
status, is not supported in the literature and needs more
Research Question 2: Intercorrelations
Among Factors investigation.
For Mexican American elders, the significant relationship
Intercorrelations among Anglo factors included more between more reported experiences of discrimination, a
familism with more acculturation (r = .357, p < .01) and better cultural/ethnic factor, with lower service awareness, a contex-
functional status (r = .302, p < .05), more need for home care tual factor, fits with current knowledge. Experiences of discrim-
services with better health status (r = .308, p < .05) and better ination could promote “mistrust of service delivery institutions”

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344 JOURNAL OF TRANSCULTURAL NURSING / October 2007

TABLE 2
Relationships Among Anglo Elders’ Home Care Services Use and Specific Factors

Social
Cultural/Ethnic Contextual Structural Outcome

Health Functional Service Financial

Familism Discrimination Acculturation Need Status Status Awarenes Status Use

Cultural/ethnic
Familism 1
Discrimination –.013 1
Acculturation .357** .102 1
Need .084 .081 –.065 1
Contextual
Health status –.085 –.094 –.149 .308* 1
Functional status .302* –.028 –.064 .313* .560** 1
Service awareness –.052 .102 .118 –.122 .043 .021 1
Social structural
Financial status –.233 .190 –.040 .000 .100 .138 .021 1
Outcome
Use .280* –.006 .256 .477** .171 .337* .738** –.128 1

*Correlation is significant at the .05 level (two-tailed). ** Correlation is significant at the .01 level (two-tailed).

TABLE 3
Relationships Among Mexican American Elders’ Home Care Services Use and Specific Factors

Social
Cultural/Ethnic Contextual Structural Outcome

Health Functional Service Financial

Familism Discrimination Acculturation Need Status Status Awareness Status Use

Cultural/ethinic
Familism 1
Discrimination –.028 1
Acculturation .127 –.082 1
Need –.141 –.103 –.169 1
Contextual
Health status –.068 –.002 –.125 .084 1
Functional status –.069 .138 –.118 .499** .269* 1
Service awareness –.147 –.278* –.128 –.219 .280* –.028 1
Social structural
Financial status –.093 .335* –.190 .000 –.068 .066 –.028 1
Outcome
Use –.080 –.285* .049 .270* .400** .341* .424** –.255 1

*Correlation is significant at the .05 level (two-tailed). ** Correlation is significant at the .01 level (two-tailed).

(Calderón-Rosado et al., 2002, p. 4), resulting in reluctance
to use community services (Alaimo, 2000; Alemán, 2000;
Aranda & Knight, 1999; Crist, 2002; Romero & Roberts,
1998). It would follow that expecting to be treated unfairly
based on past experiences would preclude perceiving any
relevance of, or motivation for, learning about available
services. Although discrimination has not been tested as
predicting use of home care services outside of preliminary
studies, interventions addressing institutionalized discrimi-
nation, including providing culturally congruent services, have
been tested as strategies for increasing services use (Gelfand,
1994). It will be imperative to design interventions that increase
service awareness through culturally competent methods that
do not perpetuate perceptions of condescending and discrim-
inatory attitudes. Reframing the question also might enlighten
the interpretation; for example, could institutionalized
discrimination, in fact, cause lower use of home care services?
For example, a relationship between lack of culturally
competent outreach and services and use of home care
services should be explored.

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The nonsignificance of two cultural/ethnic and one social
structural factor, for Mexican American elders, did not fit
with extant literature. First, the nonsignificant relationship of
Mexican American elders’ reported levels of familism with
elders’ use of home care services did not fit with current
evidence. In light of the cultural norm that Mexican American
children care for their elders, we expected a significant,
negative relationship (that the higher the familism, the lower
the use of home care services; Crist, 2002; Crist, García-
Smith, et al., 2006). An explanation may be that Mexican
American elders may perceive use of home care services as
a support to elders and caregivers, rather than the affront to
the traditional family. Second, the unexpected lack of a
significant correlation between acculturation and Mexican
American elders’ use of home care services may be related to
the measure used. Language spoken at home and language
read were used as proxies for acculturation. Measures that
capture the complexity of acculturation should be used
(Portillo et al., 2001). Using the well-established ARSMA-II
(Cuéllar et al., 1995) or newer measures such as the Strength
of Cultural Affiliation Scale (Yu et al., 2005) might yield
significant results in future studies.
Third, a reason for the nonsignificant relationship between
Mexican American elders’ financial status and their use of
home care services, when Mexican American elders are less
likely than Anglo elders to have private health insurance
(Angel, 2006), may be a measurement error. The two-item
measure for financial status, which consisted of one question
about whether the elder had health insurance and one question
rating how well elders’ income met their needs, may not have
been adequately sensitive. In future studies, the health insur-
ance and income questions on more detailed instruments,
for example, the complete financial section of the well-
tested OMFAQ (Fillenbaum, 1988), may be more likely to
be adequately sensitive. Although a statistically significant
relationship was not found in this pilot study between the
social structural factor with use of home care services, such
factors as financial access must continue to be examined.
Culturally focused interventions alone cannot reduce dis-
parities if economic and other societal realities are not
addressed (Portillo, 2003).
Intercorrelations Among Factors
The positive intercorrelation between Anglo elders’
higher levels of familism and being more acculturated is
not explained in the literature. Strong family norms are
usually associated with traditional, less acculturated,
immigrant cultures, including Italian American and other
southern European Catholic cultures (Bellah, Madsen,
Sullivan, Swidler, Tipton, 1996; McGoldrick, 1993), and
Greek American (Tripp-Reimer & Sorofman, 1998) and Irish
American cultures (Wilson, 2003). Regarding contextual
factors for Anglo elders, the significant intercorrelation
between functional status and service awareness with use of
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Crist et al. / MEXICAN AMERICAN ELDERS 345
home care services is congruent with extant knowledge; that
is, the more severe elders’ functional impairment and the more
they know about home care services, the more likely they
will be to use them. The significant intercorrelations of func-
tional status with perceived need for home care services, and
with health status, are consistent with the literature that has
demonstrated that health problems increase perceptions of
need for home care services (Wallace et al., 1998).
The significant positive intercorrelation of Mexican
American elders’ discrimination with financial status is at
first counterintuitive, but it may indicate that more finan-
cially successful Mexican American elders are more aware
of discriminatory behaviors, less likely to attribute discrimina-
tory behaviors as deserved, and more willing to report
discriminatory practices (Aranda & Knight, 1999). Other
significant intercorrelations among factors were Mexican
American elders’ perceived need for home care services with
functional status and health status with service awareness.
These factors are conceptually related, in that more health
problems and diagnoses and more help needed with ADLs
logically relate to increased need for home care services.
Indeed, some researchers use health status as a proxy to rep-
resent need for services (Wallace et al., 1998). The signifi-
cant relationship of health status with service awareness may
relate to information about home care services that dis-
charge planners and/or primary care practitioners provide in
a more acute phase of the elder’s trajectory, for example, if
the elder is hospitalized. An acute event—for example, car-
diovascular accident (stroke) with hemiparesis, acute hypo-
glycemia, broken hip, heart attack with surgery, new ostomy,
or knee surgery—often requires rapid planning to place
skilled and supportive services in the home (Magilvy &
Congdon, 2000).
Significant Factors Across Two Ethnic Groups
Three factors were significant across both groups; however,
we believe that only two would be amenable to change. More
need (as perceived by elders), a cultural/ethnic factor, was
significantly associated with use of home care services by
both Anglo and Mexican American elders; better functional
status and more service awareness, contextual factors, were
significantly associated with use of home care services by
both groups. We believe that perceived need and service
awareness are the only factors across ethnicities that would
be amenable to change (Stewart & Archbold, 1992). Our
interventions will not likely be able to change contextual
“givens” such as functional status but can change percep-
tions of need for, and awareness of, home care services. Service
awareness is a complex construct and should be examined
more extensively in future studies. In fact, it should be
conceptualized to include perception of need (Crist, Michaels,
Gelfand, & Phillips, 2007). Intercorrelations indicating that
service awareness may be related to both how elders physi-
cally feel and perceive their abilities and how much assistance
346 JOURNAL OF TRANSCULTURAL NURSING / October 2007
they believe they need support adding perceived need as a
third dimension of service awareness.
Regarding other significant factors, research programs
with the goal of reducing health care disparities should attend
to the significant cultural/ethnic factor findings as interven-
tions are designed. For example, preserving familiar cultural
components such as familism can be achieved by including
caregivers in the intervention, and avoiding the promotion of
societal realities such as perceived discrimination can be
improved by incorporating personalismo into the manner in
which the intervention is presented. Interventions that include,
for example, using a telenovela, a dramatized story (Crist,
2005), and including the family with each contact may be more
effective with Mexican American elders and their caregivers
for transmitting information and promoting understanding,
compared to mainstream Anglo-based individualistic, fact-
oriented interactions such as offering written brochures.
A consideration in interpreting the study is the allocentric
cultural norms of Mexican American compared with the
individualistic cultural norms of Anglo U.S. society (Landrine,
1992). Regardless of resource availability for elders, many
Mexican American elders tend to be more concerned with
other family members than their own health needs. Cultural
values are important factors that influence elders’ perceptions
regarding the need for, and use of, home care services. The val-
ues that affirm and sustain elders’ cultural identities not only
influence elders’ decision making but also affect their ability to
remain in the home. Service awareness may be influenced at a
group level including the family, especially the elders’ primary
caregivers. Caregivers report burden, although interpreted dif-
ferently within different cultures, but which might prompt
seeking information about services (Bass & Noelker, 1987;
Choi & Harwood, 2004; Crist, 2002; Crist, García-Smith, et
al., 2006; Houde, 1998). Caregivers may also feel that profes-
sional assistance would improve their ability to care for their
loved ones. Understanding the cultural assumptions that guide
Mexican American elders’ behaviors is imperative while facil-
itating elders’ decision making to use appropriate home care
resources to continue healthy aging at home.
LIMITATIONS AND RESEARCH IMPLICATIONS
A potential limitation was possible sample bias. The
significant differences in years of education and financial
status may have affected some of our comparisons. These
differences may have been affected by one of our recruitment
sites. Although most of the sample was recruited at the same
senior sites in neighborhoods known for lower socioeco-
nomic status, some Anglo elder participants were recruited
at a housing apartment in a more affluent neighborhood than
other Anglo or the Mexican American participants. The pilot
study demonstrates that future recruitment should be designed
to locate participants from similar sites with similar variables
of socioeconomic status.
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Another potential limitation was that the samples were
largely drawn from senior meal sites. This pilot study revealed
to us that recruitment procedures may have resulted in samples
that were more connected with services and community
health infrastructures and that did not reflect the presence of
more marginalized elders. In future studies, efforts should be
made to recruit more broadly, to include elders who are more
socially isolated, less healthy, and of lower financial status, to
improve generalizability.
The pilot study also was effective in illustrating measures
that need to be evaluated for use in our populations of interest.
For example, Cronbach’s alpha of the OMFAQ functional
status (Fillenbaum, 1988) and the new Service Awareness
Scale were low. These measures either need to be further
developed or replaced.
CONCLUSION
In the United States, 10% of people 65 years and older
and 50% of people 85 years and older have some functional
disability. Family members provide more than 70% of care
received by noninstitutionalized elders (Family Caregiver
Alliance, 2001). Mexican American families adhere to cultural
norms to keep elders at home regardless of sacrifices (Crist,
2002). Dedicated family caregivers may sacrifice their own
potential employment in well-paying jobs, thus enabling
the cycle of poverty by being willing to provide home care,
to the detriment of their own potential employment in well-
paying jobs (Purdy & Arguello, 1992).
Pilot studies provide a means to test theories and new
instruments before planning larger scale studies (Gardner,
Gardner, MacLellan, & Osborne, 2003; Prescott & Soeken,
1989). Pilot tests with two ethnic groups revealed varying
strengths of cultural/ethnic and contextual factors’ signifi-
cant relationships with use of home care services. These
relationships and varying intercorrelations among factors
within the two groups can inform new interventions to
increase both groups’ understanding about using home care
services. This pilot study will guide future studies and offer
insight into transcultural nurses’ approaches to elders when
recommending use of home care services. As conceptual-
ized by Purnell (2003), incorporating cultural competence
within presentations of these services to families that could
use support in the home will be essential. Measures should
be refined for use in future studies. Specific interventions to
improve utilization of home care services by Mexican
American elders must include culture care (Leininger,
1991, 1997).
Nursing should design outreach and education to address
significant cultural/ethnic issues while promoting the contex-
tual factor service awareness. In this way, transcultural
nurses may improve equity in health care delivery for elders
of vulnerable populations who are not aware of, or using,
home care services.

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Janice D. Crist, RN, PhD, is an assistant professor in the
College of Nursing at the University of Arizona, Tucson. Her
research interests focus on designing interventions to reduce health
and health care disparities, especially for Latino populations.
Seon Hye Woo, PhD, RN, is a professor in the Department of
Nursing at Gyeongsang University in South Korea. Her research
focuses on home health care, comparison study of international
home health care, and developing health promotion models for
older adults using home health care. She was a visiting scholar at
the University of Arizona.
Myunghan Choi, PhD, MPH, RN, is a nurse scientist at
Northwest Medical Center, Oro Valley, Arizona. Her research
focuses on women’s responses to domestic violence, developing
models of acculturation with domestic violence, the impact of
acculturation and Hwabyung among married Korean immigrants,
and Yin-Yang instrument development.