Racial/Ethnic Disparities in Self-Rated Health and Sense of Control for Older Adults Receiving Publicly Funded Home- and Community-Based Services

Abstract

Objectives: This study examines racial/ethnic differences in self-rated health (SRH) and sense of control among older adults receiving publicly funded home- and community-based services (HCBS) and tests the mediating role of functional, emotional, and financial stressors. Methods: Data are from 2015 National Core Indicators—Aging and Disability Survey collected from face-to-face interviews with 1936 older adults aged 65 years or older receiving HCBS in Minnesota. Path analysis based on logistic regression was used. Results: Racial/ethnic minority HCBS users had lower SRH and sense of control than white participants, with Asian participants reporting the lowest scores. Whereas functional impairment was a common explanatory factor for the racial/ethnic differences, negative mood and financial strain were mediators for Asian and Hispanic/Latino participants, respectively. Discussion: Racial/ethnic disparities in well-being exist among older HCBS users, with different mediators at play. Customized services are needed to meet diverse needs of older adults of different racial/ethnic groups.

Keywords

racial/ethnic disparities self-rated health sense of control older adults home- and community-based services

Background

Nearly 11 million older adults need long-term services and supports (LTSS) in the United States, with the number only projected to grow over time (Reaves & Musumeci, 2015). LTSS refers to a broad set of paid and unpaid services for people who need assistance because of chronic illnesses or physical or mental disabilities (Reaves & Musumeci, 2015) and consists of personal assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) (Freedman, 2014; Thomas & Applebaum, 2015). The proportion of older people who have at least one activity limitation and receive assistance ranged from less than 16% for individuals aged 65–69 years to more than 75% for those aged 90 years and older (Freedman, 2014).

LTSS can be both home- and community-based and institutional, but most older people prefer home- and community-based services (HCBS) (Wolff et al., 2008). This preference is now in part achievable because of the “rebalancing” of the long-term care system to achieve a more equitable balance between the proportions of public funding used for institutional services and that used for HCBS (Kane et al., 2006). Medicaid plays a critical role in funding HCBS in the United States, which is often achieved through HCBS waivers and Medicaid state plan (Kitchener et al., 2005). Medicaid-funded HCBS are restricted to those who have limited income and resources and need a nursing home level of care (Reaves & Musumeci, 2015). Under the HCBS waivers program, states can waive certain Medicaid program requirements and define their own requirements regarding eligibility, geographic areas or groups of beneficiaries, and service criteria (Centers for Medicare and Medicaid Services, 2019). In 2015, 55% Medicaid LTSS expenditures went to HCBS, exceeding the spending on institutional care (Eiken et al., 2017). In addition to Medicaid-funded HCBS, other funding sources such as the Older Americans Act (OAA) or state general funds are also used by states to provide LTSS for community-dwelling older adults.

A growing number of studies have shown that publicly funded HCBS are lower cost alternatives to institutional care and can prevent institutionalization or hospitalization (Pande et al., 2007; Xu et al., 2010). Yet, there is a growing talk about health outcomes for HCBS users (which are not always favorable) and the role of disparities (Wysocki et al., 2014). Besides outcomes derived from administrative data such as institutionalization or hospitalization (which only reflect the use of care), few studies have focused on self-reported outcomes among public LTSS recipients and the role of race/ethnicity for these outcomes.

Minnesota (MN) is among top states in the nation in terms of the proportion of older adults using HCBS: the percentage of older adults using HCBS increased from 40% in 2000 to 80% in 2018 (Minnesota Department of Human Services, 2015). The publicly funded HCBS for older population is managed by the MN Board on Aging and the MN Department of Human Services and administered through various aging programs, including the State Plan-Funded Home Care, Elderly Waiver Programs, Alternative Care Program, and OAA. These programs encompass a wide array of medical, personal, social, and supportive services. Minnesota spent nearly 77% of total Medicaid LTSS expenditure on HCBS in 2015 and was one of the highest in the nation (national average was 55%) (Eiken et al., 2017).

Racial/Ethnic Differences in Self-Rated Health and Sense of Control for Older Adults

Self-rated health (SRH) and sense of control are widely used self-reported outcomes in aging research as measures of subjective well-being (Jylhä, 2009; Rodin, 1986). SRH has long been regarded as a valid and reliable indicator of well-being and a predictor of mortality and has been validated across socioeconomic strata (Winter et al., 2007; Wolinsky et al., 2008). Previous studies have documented racial/ethnic differences in SRH among non-institutionalized older adults. White older Americans consistently rated their health more positively than black, Asian, and Hispanic older adults, even after adjusting for social demographic factors, socioeconomic status, and health factors (Borrell & Dallo, 2008; Cagney et al., 2005; Liang et al., 2010; Sastry & Ross, 1998; Spencer et al., 2009; Su et al., 2013).

Sense of control, also known as perceived control or mastery, has gained increasing attention as a measure of psychological function in aging research, which refers to a person’s belief in their ability to control life events and circumstances (Fabius et al., 2019; Mitchell et al., 2016). Feeling of loss of control is common among older adults as they confront substantial changes in health status, social roles, and living arrangement in the transition to the older age (Mitchell et al., 2016). With respect to racial/ethnic differences in sense of control among older adults, black and Asian adults consistently reported a lower sense of control than white older adults (Fabius et al., 2019; Jang et al., 2003; Sastry & Ross, 1998; Shaw & Krause, 2001).

Studies examining racial/ethnic differences in SRH and sense of control primarily focused on community-dwelling older adults in general who are not receiving paid LTSS (Henning-Smith et al., 2013; Shippee et al., 2015). Studies specifically including older adults receiving publicly funded HCBS are needed because of the increasing growth of public investment in HCBS and the increasing proportions of older adults of racial/ethnic minority using publicly funded HCBS. Older recipients of publicly funded HCBS are more disadvantaged in socioeconomic and functional status than in general older adult populations (Weaver & Roberto, 2017), given the restricted eligibility of the enrollment into the HCBS programs (e.g., low income and a need for nursing home level care). In this regard, the health profile and the role of race/ethnicity may present a different picture compared with findings from non-LTSS users (Fabius et al., 2019).

To address these gaps, our study aims to (1) examine racial/ethnic differences in SRH and sense of control—two well-established measures of overall well-being, among older adults receiving publicly funded HCBS and (2) identify the mediating role of functional, emotional, and financial stressors in the relationship between race/ethnicity and these outcomes. This study can help inform national conversations about equity in LTSS quality and improving the well-being for vulnerable older adults who use LTSS.

Conceptual Work and Study Hypotheses

This study was guided by the theoretical work of Jylhä (2009) and Ross and Mirowsky (2013) on SRH and sense of control among older adults. Both SRH and sense of control are subjective assessments of well-being, which provide reflections of individuals’ physical and psychosocial states (Jylhä, 2009; Mirowsky, 2013; Ross & Mirowsky, 2002, 2013). SRH and sense of control are associated but different (Lachman & Weaver, 1998). The cognitive process of SRH often involves reviewing information regarding medical diagnoses, functional status, symptoms, and signs of diseases, while referring to personal history of health, expectations for health, and cultural norms (Jylhä, 2009). Sense of control (also known as perceived control and mastery) refers to subjective expectations regarding one’s ability to exert an influence over life circumstances and outcomes in the surrounding environment (Lachman et al., 2011; Ross & Mirowsky, 2002).

Although the empirical evidence for the predictive power of SRH for mortality has been well established (Dowd & Zajacova, 2007; Idler & Benyamini, 1997), sense of control has been predictive of outcomes such as depression, anxiety, and distress (Ross & Mirowsky, 2002, 2013). SRH and sense of control are meaningful outcomes for older adults receiving publicly funded HCBS because of likely experience of disadvantages in various aspects of life such as functional and socioeconomic status, which may present a different picture for SRH and sense of control. In addition, for older adults who are recipients of LTSS, sense of control represents the ability to have agency over their health and the context of their care and is a key indicator of HCBS quality (National Quality Forum, 2016).

Different factors influence SRH and sense of control for older adults, including societal context/inequality for adults from minority racial/ethnic groups, physical, and mental health and access to resources (Mirowsky and Ross, 2003). First, one’s social status, including race/ethnicity, shapes SRH and sense of control through different exposure to resources and opportunities for older adults from different racial/ethnic groups (Ferraro et al., 2009; Mirowsky and Ross, 2003). Cumulative disadvantage framework, for example calls attention to lifetime socioeconomic status and exposure to material and social deprivation as key factors associated with worse SRH and sense of control (Ferraro et al., 2009). Older adults from racial/ethnic minority groups who use publicly funded LTSS likely experience different patterns of exposure to financial and emotional stressors, discrimination, and structural disadvantage over their life course compared with their white peers (Fabius, et al., 2019), which may result in worse SRH and lower sense of control. Based on this work, we hypothesize that (1) older adults from racial/ethnic minority groups who receive publicly funded HCBS will report lower SRH and sense of control versus their white counterparts.

Second, one’s financial status and health (functional and emotional) also impact SRH and sense of control (Mirowsky and Ross, 2003). Indeed, financial status has long been established as key outcomes of well-being, with a growing literature examining the association between perceived financial strain and SRH (Shippee et al., 2012). Financial strain has been linked to the erosion of personal control and mastery, loss of supportive social relationship, and lower SRH (Kahn & Pearlin, 2006; Shippee et al., 2012). Furthermore, functional and emotional well-being have been identified as key determinants of SRH and sense of control by prior literature (Mavaddat et al., 2011; Mirowsky, 1995). Importantly, the association between these domains of financial and physical/emotional well-being and outcomes of interest likely differs by race/ethnicity because of structural and individual barriers described earlier (Assari, 2017; Cagney et al., 2005; Moor et al., 2017; Shaw & Krause, 2001). Thus, we hypothesize that (2) functional, emotional, and financial status will mediate the relationship between race/ethnicity and these two health outcomes.

Methods

Study Design and Data Sources

This cross-sectional study used data from the 2015 MN National Core Indicators—Aging and Disability (NCI-AD) survey that were collected through face-to-face interviews with publicly funded HCBS recipients in MN. NCI-AD is a national collaborative project intended to measure and track the performance and quality of LTSS programs that serve seniors and adults with physical disabilities. The initiative was launched in June 2015 and aims to provide the crucial and often missing consumer viewpoint on state-specific quality of the LTSS services nation (National Core Indicator—Aging and Disabilities, 2017). Twenty-one states now participate in NCI-AD data collection, with more joining each year, but, despite the considerable financial and programmatic investment, to the best of our knowledge, these data have not been used in research analyses yet. MN is useful for our analysis because MN is one of the first states to implement NCI-AD data (and the data are only available on the state level; no national database at this point).

The MN NCI-AD is funded by the MN Department of Human Services and includes face-to-face interviews with older adults and younger adults with disabilities who are receiving at least one publicly funded service. The interviewers, some of whom were bilingual to assist in conducting the interviews in multiple languages, are hired and trained by a third party. Interviews are conducted at the time and location of participants’ choice. The project was approved by Institutional Review Board at the Department of Human Services. More information regarding the data collection process can be found in the state report (Minnesota Department of Human Services, 2017).

In this study, we used data for older adults because younger adults with disabilities have different health profiles and programs that serve them. Older adults are receiving services from publicly funded HCBS programs, including Elderly Waiver (including managed care organizations and fee for service), State Plan Funded Home Care, Alternative Care (for people with low income and assets who were not eligible for MN Medicaid), and OAA The MN NCI-AD project used random sampling to select eligible participants, coupled with purposive sampling from certain funding programs and racial/ethnic groups to obtain stable results for each program individually. The analytic sample for this study included 1936 adults aged 65 years and older (Minnesota Department of Human Services, 2017).

Variables and Measures

Two key dependent variables were SRH and sense of control. SRH was measured by asking participants to rate their overall health from 1 = poor to 5 = excellent. Sense of control was measured by asking participants “do you feel in control of life”. The response was 0 = no, 1 = sometimes, and 2 = often. Both of these questions are common ways to measure these constructs and have been used by previous studies (Larson, 1989; Shippee et al., 2012).

Race/ethnicity was grouped into non-Hispanic white, non-Hispanic black, Asian, and Hispanic/Latino (Native American/American Indian older adults were not surveyed in the 2015 NCI-AD project). Three proposed mediating variables were functional, emotional, and financial status. Functional status was measured by asking participants “how much assistance with self-care do you generally need? Things like bathing, dressing, going to the bathroom, eating or moving around home.” The values ranged from 0 = none, 1 = some, and 2 = a lot. Emotional status was measured by the frequency of experiencing negative mood (i.e., lonely, sad, or depressed). The response was 0 = never or almost never, 1 = not often, 2 = sometimes, and 3 = often. In this study, we used “whether the person ever has to skip a meal due to his/her financial situation” as a proxy measure of financial status. The values range from 0 = never, 1 = sometime, and 2 = often. Assistance with self-care and the frequency of negative mood have been commonly used as global measures of functional and emotional status—two essential domains of quality of life (Shippee, Henning-Smith et al., 2015; The WHOQOL Group, 1998). Meal skipping has been used as an established measure of financial hardship by assessing minimally accepted standards of living because of insufficient resources, especially for populations with low socioeconomic status such as Medicaid beneficiaries (Rebbeck et al., 2013; Ringen, 1988).

A number of sociodemographic characteristics, including age, gender, and place of residence were considered as covariates. Age was used as a continuous variable. Place of residence was measured as a binary indicator for “living in own or family house or apartment” versus “living in group settings such as group home, adult family home, foster home, and assisted living facility.”

Data Analysis

Descriptive statistics were used to describe participant characteristics. Comparisons across racial/ethnic groups were made by using analysis of variance or chi-squared test. Path analysis was conducted separately for two outcomes to examine racial/ethnic differences and to test the mediation effect of a given mediator. Four path analysis models were built for each outcome: Model 1 includes a direct path from race/ethnicity variables to the outcome of interest, adjusting for sociodemographic characteristics, whereas Models 2–4 include an indirect path from race/ethnicity variables to the outcome via one of the three mediators, in addition to the direct path. Ordinal logistic regression was used to examine racial/ethnic differences in SRH that models the odds of rating a higher level of overall health as compared with a lower level. Binary logistic regression was used to examine racial/ethnic differences in sense of control as we recoded it as 0 = “not or sometime feel in control of life” and 1 = “often feel in control of life”.

Sample weights were applied to all regression analyses to rebalance the disproportionate representation of programs and racial/ethnic groups in the sample. This allows generalizing the results to older HCBS users in MN. All path analyses were conducted in Mplus version 8 (Muthén & Muthén, 2017). The mean- and variance-adjusted weighted least squares estimator in Mplus version 8 was used because of the inclusion of categorical variables as dependent variables. In our study, SRH and sense of control had 1.54% and 7.74% missing data, respectively. Mplus, by default, uses the full-information maximum likelihood estimator to address missing data (Muthén & Muthén, 2017).

Results

Of 1936 participants, 72.6% were white older adults. Table 1 displays descriptive statistics by racial/ethnic groups. Racial/ethnic differences existed in all sociodemographic characteristics except for gender. Black older adults were the youngest among the participants. Whereas most older adults lived in their own house or apartment, white and Hispanic/Latino older adults were more likely to live in group settings than black and Asian older adults. With respect to functional, emotional, and financial status, black older adults were more likely to skip a meal because of financial worries and Asian older adults were more likely to need a lot of assistance with self-care and experienced negative mood more often than others.

Table 1.

Sample Characteristics by Racial/Ethnic Groups.

	Non-Hispanic White (n = 1405, 72.57%)	Non-Hispanic Black (n = 246, 12.71%)	Asian (n = 133, 6.87%)	Hispanic/Latino (n = 152, 7.85%)	Full Sample (n = 1936)	p
Dependent variables
Self-rated health (%)
Poor	12.05	15.00	25.38	17.33	13.75	<.001
Fair	30.01	47.50	32.31	38.00	33.00
Good	37.95	28.75	33.08	33.33	36.10
Very good or excellent	19.98	8.75	9.23	11.34	17.16
Feel in control of life (%)
No	4.69	5.75	20.95	7.58	6.00	<.001
Sometimes	11.81	8.85	17.14	19.70	12.33
Yes	83.50	85.40	61.90	72.73	81.67
Independent variables
Age (mean + SD)	79.61 ± 8.6	73.48 ± 8.6	77.71 ± 7.4	77.71 ± 8.6	78.56 ± 8.6	<.001
Female (%)	76.35	71.95	69.92	70.39	74.88	.107
Place of residence (%)
Own or family house or apartment	72.87	89.75	93.23	82.67	77.18	<.001
Group setting (i.e., group home, foster home, and assisted living facility)	27.13	10.25	6.77	17.33	22.82
Assistance with self-care (%)
None	44.71	17.96	15.91	26.49	37.90	<.001
Some	33.83	39.59	30.30	35.10	34.42
A lot	21.46	42.45	53.79	38.41	27.67
Feel lonely, sad, or depressed (%)
Never or almost never	33.74	32.74	19.27	39.85	33.18	<.001
Not often	22.29	19.91	12.84	15.79	20.93
Sometimes	33.21	34.51	24.77	30.83	32.68
Often	10.77	12.83	43.12	13.53	13.21
Having to skip a meal because of financial worries (%)	4.51	16.05	9.23	14.00	7.03	<.001

Note. Chi-squared test was used for categorical variables measured with percentage; analysis of variance was used for continuous variables measured with mean and standard deviation. SD = standard deviation

Racial/ethnic minority older adults had lower SRH than white older adults. As shown in Table 1, more than half of minority older adults rated their health as poor or fair (i.e., 62.5% for black older adults, 57.69% for Asian older adults, and 55.33% for Hispanic/Latino older adults) as compared with 42% among white older adults. When asked “do you feel in control of life”, more than 80% black and white older adults reported they often felt in control of life, whereas about 61.9% Asian and 72.7% Hispanic/Latino older adults did so. Racial/ethnic differences in SRH and sense of control remained statistically significant for Asian and Hispanic/Latino older adults after controlling for sociodemographic characteristics (see Model 1 in Tables 2 and 3).

Table 2.

Racial/Ethnic Differences in Self-Rated Health—Testing Meditating Effects of Functional, Emotional, and Financial Status.

Dependent Variable: Self-Rated Health	Model 1		Model 2		Model 3		Model 4
Dependent Variable: Self-Rated Health	B	SE	B	SE	B	SE	B	SE
Race (Ref = Non-Hispanic white)
Non-Hispanic black	−.169	(.117)	.087	(.129)	−.165	(.122)	−.068	(.124)
Asian	−.324***	(.113)	−.066	(.124)	−.168	(.121)	−.308*	(.122)
Hispanic/Latino	−.245*	(.108)	−.092	(.119)	−0.248*	(.11)	−.142	(.121)
Age	.009*	(.004)	.013**	(.005)	.007	(.005)	−.001	(.006)
Female	−.009	(.083)	.063	(.083)	.061	(.087)	−.030	(.091)
Living in own or family house or apartment versus group setting	−.324***	(.091)	−.437***	(.096)	−.361***	(.097)	−.081	(.128)
Mediator
Need some or a lot assistance with self-care			−.320***	(.05)
Experiencing negative mood sometimes or often					−.331***	(.05)
Having to skip a meal because of financial worries							−.232**	(.077)

Dependent variable: one of the three mediators	Need some or a lot assistance with self-care		Experiencing negative mood sometimes or often		Experiencing negative mood sometimes or often
Race (Ref = Non-Hispanic white)
Non-Hispanic black	.826***	(.138)	.040	(.13)	.456**	(.161)
Asian	.859***	(.164)	.522**	(.155)	.103	(.201)
Hispanic/Latino	.518***	(.132)	.031	(.129)	.473**	(.155)
Age	.013*	(.006)	−.008	(.005)	−.042***	(.008)
Female	.228*	(.1)	.214*	(.102)	−.089	(.156)
Living in own or family house or apartment versus group setting	−.304**	(.107)	−.060	(.109)	1.082***	(.176)

RMSEA	<.001	<.001	<.001	<.001
SRMR	<.001	<.001	<.001	<.001
CFI	1.000	1.000	1.000	1.000

Note. RMSEA = root mean square error of approximation; SRMR = standardized root mean square residual; CFI = comparative fit index; *p < .05, **p < .01, ***p < .001.

Table 3.

Racial/Ethnic Differences in Sense of Control—Testing Meditating Effects of Functional, Emotional, and Financial Status.

Dependent Variable: Self-Rated Health	Model 1		Model 2		Model 3		Model 4
Dependent Variable: Self-Rated Health	B	SE	B	SE	B	SE	B	SE
Race (Ref = Non-Hispanic white)
Non-Hispanic black	.154	(.164)	.371*	(.184)	.180	(.173)	.264	(.176)
Asian	−.657***	(.161)	−.458**	(.169)	−.507**	(.177)	−.652***	(.165)
Hispanic/Latino	−.285*	(.136)	−.160	(.146)	−.292	(.154)	−.182	(.147)
Age	.014*	(.007)	.018*	(.007)	.012	(.007)	.005	(.008)
Female	−.178	(.12)	−.124	(.126)	−.111	(.124)	−.204	(.126)
Living in own or family house or apartment versus group setting	.334**	(.129)	.267*	(.133)	.334*	(.133)	.596**	(.179)
Mediator
Need some or a lot assistance with self-care			−.258***	(.07)
Experiencing negative mood sometimes or often					−.367***	(.071)
Having to skip a meal because of financial worries							−.234*	(.102)

Dependent variable: one of the three mediators	Need some or a lot assistance with self-care		Experiencing negative mood sometimes or often		Having to skip a meal because of financial worries
Race (Ref = Non-Hispanic white)
Non-Hispanic black	.825***	(.138)	.041	(.13)	.457**	(.161)
Asian	.858***	(.164)	.523**	(.155)	.099	(.201)
Hispanic/Latino	.519***	(.132)	.032	(.129)	.472**	(.155)
Age	.013*	(.006)	−.008	(.005)	−.042***	(.008)
Female	.228*	(.1)	.214*	(.102)	−.09	(.156)
Living in own or family house or apartment versus group setting	−.304**	(.107)	−.06	(.109)	1.082***	(.176)

RMSEA	<.001	<.001	<.001	<.001
SRMR	<.001	<.001	<.001	<.001
CFI	1.000	1.000	1.000	1.000

Note. RMSEA = root mean square error of approximation; SRMR = standardized root mean square residual; CFI = comparative fit index; *p < .05, **p < .01, ***p < .001.

Table 2 demonstrates the path analysis models for testing the mediation effects of functional, emotional, and financial status separately on racial/ethnic differences in SRH. The difference in SRH between Asian and white older adults was fully explained by assistance with self-care and negative mood, as the coefficient of the path from race/ethnicity to SRH was no longer statistically significant after adding the mediation path. The difference in SRH between Hispanic/Latino and white older adults was fully explained by assistance with self-care and meal skipping.

Table 3 demonstrates the path analysis models for testing the mediation effects of functional, emotional, and financial status separately on racial/ethnic differences in the sense of control. The difference in the sense of control between Asian and white older adults was partially explained by assistance with self-care and negative mood, as the coefficient of the path from race/ethnicity to sense of control decreased in effect size but remained statistically significant after adding the mediation path. The difference in the sense of control between Hispanic/Latino and white older adults was fully explained by assistance with self-care and meal skipping, as the coefficient of the path from race/ethnicity to sense of control became statistically insignificant after controlling for the mediation path. Note that black older adults report significantly better scores on sense of control than white older adults only after controlling for assistance with self-care.

Discussion

This was the first study investigating the SRH and sense of control for community-dwelling older adults receiving publicly funded LTSS—an understudied population that is only projected to grow. We used a unique dataset: National Core Indicators—Aging and Disabilities Survey for MN to assess the well-being and sense of control by race/ethnicity. Our study revealed that racial/ethnic minority older adults enrolled in publicly funded HCBS had lower SRH and sense of control than their white counterparts, with Asian older adults having the lowest scores. One exception was that black older adults had higher sense of control than white older adults. The explanatory pathways for the racial/ethnic differences appeared to be similar for two outcome variables but varied across different minority racial/ethnic groups.

Our findings about racial/ethnic differences in well-being are aligned with previous studies which show that white adults in general are advantaged in well-being in later life (Sarkin et al., 2013). However, our study examined the role of race/ethnicity for older population already receiving publicly funded HCBS; even among those with access to HCBS, racial/ethnic disparities in outcomes remain. Although racial/ethnic differences in SRH continue to exist among US adult population, the difference has been diminishing over the past decades (Sarkin et al., 2013). Sarkin et al. (2013) reported that the difference in SRH between black and white adults declined from .37 in 1972 to .18 in 2008. However, we found the racial/ethnic differences were much greater among older adult populations receiving publicly funded HCBS. Using the same scaling (5-level Likert scale), SRH of white older adults was .40, .35, and .27 higher than that of Asian, black, and Hispanic/Latino older adults, respectively. It is noteworthy that Asian older adults were the most disadvantaged with respect to SRH and sense of control, which challenged the notion of “model minority” for older Asian adults. This may be partially because Asian adults in our study were primarily immigrants with low income and assets, who came to the United States as refugees from war-torn areas (Migration Policy Institute, 2005). This finding is also supported by studies reporting high unmet needs among community-dwelling Asian older adults and their caregivers (Li, 2004).

Previous studies consistently reported that black older adults had lower sense of control than white older adults and the difference persisted across all age groups (Assari, 2017; Shaw & Krause, 2001). However, our study observed higher sense of control among black older adults receiving publicly funded HCBS compared with white older adults, after controlling for functional status. This inconsistency may be due to different samples studied. While previous studies focused on community-dwelling adults among which white adults consistently reported higher socioeconomic status (Assari, 2017; Shaw & Krause, 2001), our study exclusively included older adults receiving publicly funded HCBS. Older adults in our sample were income limited, to qualify for public assistance and, thus, may remain disadvantaged in socioeconomic status and in other factors associated with sense of control. In addition, our study found Hispanic/Latino older adults had significantly lower sense of control than white older adults. Yet, a scarcity of research on racial/ethnic differences in the sense of control for Hispanic/Latino older adults hindered the comparison of our findings with other studies. More research is needed on racial/ethnic disparities in measures of psychosocial well-being such as sense of control, especially among older adults using LTSS.

We found that functional status, measured with assistance with self-care, is a common mediator explaining racial/ethnic differences in the two outcomes for Asian and Hispanic/Latino older adults. Previous literature has documented that physical function was one of the determinants of SRH among community-dwelling older population (Arnadottir et al., 2011; Cott et al., 1999). Studies also pointed out that independence in performing daily life activities ensured autonomy and control over one’s own life, which was greatly associated with experiences of well-being in older people (Ebrahimi et al., 2015; Johnson & Wolinsky, 1993). Indeed, we found high levels of functional impairments among minority older adults versus white adults, which affected racial/ethnic disparities in SRH and sense of control. Higher functional needs for minority older adults need the attention of HCBS providers with respect to providing sufficient assistance in ADLs and IADLs to sufficiently meet the needs of minority older adults. In addition, different living experiences and psychosocial responses to managing functional impairments for older adults with different cultural backgrounds underscore the importance for providing culturally sensitive HCBS for these populations.

Emotional status was a unique explanatory factor for the differences in SRH and sense of control between Asian and white older adults. It appeared that poorest SRH and lowest sense of control among Asian older adults were strongly associated with their frequent experience of negative mood. The relationship between SRH and negative mood such as loneliness and depression was well documented in previous studies (Han & Jylha, 2006; McHugh & Lawlor, 2016). Asian older adults living in community were usually characterized by low English proficiency, proximity of adult children, dependence on adult children, and immigration in later life (Kuo et al., 2008; Mui & Kang, 2006). These unique sociodemographic characteristics were assumed to make them particularly susceptible to the development of negative mood (Kuo et al., 2008; Mui & Kang, 2006). In our sample, about 60% Asian older adults were non-English speakers and spoke Hmong, and nearly 70% lived with non-spouse family members (primarily adult children). By contrast, the proportions of non-English speakers and those living with non-spouse family members were 7% and 11%, respectively, among white older adults. Whether these characteristics contributed to a frequent experience of negative mood and in turn resulted in low SRH and sense of control among Asian older adults needs further investigation. Nonetheless, our findings are consistent with other studies, which document the higher prevalence of depressive symptoms and mental distress among immigrant and refugee community-dwelling Asian older adults, including Hmong older adults, coupled with low health literacy and low use of mental health services (Khuu et al., 2018; Sorkin et al., 2011; Yang & Mutchler, 2019).

Financial status played a unique role in explaining racial/ethnic differences in SRH and sense of control for Hispanic/Latino older adults as compared with their white counterparts. Our findings are consistent with a recent systematic literature review, which indicated that material, psychosocial, and behavioral factors were important pathways contributing to the explanation of socioeconomic inequalities in SRH (Moor et al., 2017). Material factors such as income and financial problems were found to have most impact among these factors, as they had both independent and shared effects through psychosocial and behavioral factors on SRH (Moor et al., 2017). Financial status as an important determinant of perceived control was also documented in empirical research (Lachman & Weaver, 1998) and theoretical work (Heckhausen & Schulz, 1995; Lachman, 2006; Ross & Mirowsky, 2013). Using meal skipping as a proxy measure of financial hardship, we assumed that financial difficulties in paying the necessities would also reflect disadvantages in other material factors such as income, housing conditions, and neighborhood conditions that may collectively influence the well-being of older adults residing in community. In addition, skipping meals likely exacerbates various nutrition-related problems such as malnutrition, weight loss, and diabetes that were associated with the individual’s negative experience of health and control of life.

Limitations

Some limitations of this study need to be noted. First, our key variables were measured with a single question because of data availability, which may introduce potential measurement errors. Future research should consider using more comprehensive instruments to measure these key constructs related to well-being for older populations. Second, because of the sample restriction, we were not able to include Native American/American Indian older adults who may face significant disparities in health and need to be included in future studies. Still, this study moves beyond the typical white/black disparities analysis that has been commonly performed. Third, our conclusions are limited by the cross-sectional nature of the data, which prevented us from establishing the causal pathways between these variables. Future studies need to apply longitudinal design to further test the causal relationships between variables identified in this work. Finally, our data came from one state, which limits the generalizability of this study.

Despite these limitations, our study was the first to examine SRH and sense of control for older adults receiving publicly funded HCBS, and our findings identify racial/ethnic disparities in these two established measures of well-being among this population. The divergent explanatory pathways toward these disparities for different minority older adults indicated that publicly funded HCBS should be tailored to meet diverse needs (physical and psychosocial) of older adults of different racial/ethnic groups.

Conclusion

Older adults receiving publicly funded HCBS experienced significant racial/ethnic disparities in well-being. Minority older adults had lower SRH and sense of control than white older adults, with Asian adults reporting the lowest scores. Functional, emotional, and financial stressors played different roles in explaining these disparities for different minority older adults. Whereas functional impairment was a common explanatory factor for racial/ethnic differences in SRH and sense of control, negative mood and financial strains were unique mediators for Asian and Hispanic/Latino older adults, respectively, in explaining lower SRH and sense of control as than white older adults. Our findings provide empirical implications for care providers and policymakers to develop customized services for older adults of different races/ethnicities and to eliminate the racial/ethnic disparities in well-being.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Minnesota Department of Human Services.

ORCID iD

Tetyana P. Shippee

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