Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2021 Jan 15.
Published in final edited form as: Res Aging. 2020 Mar 20;42(5-6):186–195. doi: 10.1177/0164027520912493

Immigrant Status, Resilience, and Perceived Oral Health Among Chinese Americans in Hawaii

Bei Wu 1, Yaolin Pei 1, Wei Zhang 2, Mary Northridge 3
PMCID: PMC7810361  NIHMSID: NIHMS1660355  PMID: 32195629

Abstract

Objectives:

This study aims to examine the associations among immigrant status, resilience, and perceived oral health for Chinese American older adults in Hawaii.

Method:

Data derived from 430 Chinese American adults aged 55 years and older residing in Honolulu, HI. We compared the self-rated oral health and oral health problems between U.S.-born Chinese Americans and foreign-born Chinese Americans by using ordered logistic regression and ordinary least squares regression models.

Results:

Findings suggest that immigrant status and lower levels of resilience are associated with poorer self-rated oral health and more oral health problems for Chinese American older adults in Hawaii. Resilience is more strongly associated with self-rated oral health for U.S.-born Chinese American than for foreign-born Chinese Americans, but this pattern was not evident for oral health problems.

Discussion:

Older Chinese American immigrants in Hawaii are disadvantaged in terms of their oral health. Understanding their susceptibilities may lead to targeted interventions.

Keywords: self-rated oral health, oral health problems, immigration, resilience, Chinese Americans

Improving oral health among U.S. older adult populations is an important public health priority (Jones & Bailey, 2012). Due to large-scale immigration in recent decades, the older immigrant population in the United States increased by 70% between 1990 and 2010 (C. N. Anderson & Kim, 2009; Sadarangani et al., 2019). The increase in the numbers of older immigrants in the United States has motivated a pressing need to better understand their perceived oral health, given that oral health is strongly associated with the overall health and well-being of older adults (Nihtilä et al., 2017).

One potential approach to address this issue is to compare differences between the older immigrants and their U.S.-born counterparts because such a comparison is useful in examining the extent to which the immigrant experience may influence oral health. Most previous research has examined oral health disparities by focusing on race/ethnicity and socioeconomic status (SES) among the foreign-born population. Nonetheless, an exclusive focus on the foreign-born neglects the opportunity to explore theoretical approaches that explain disparities in oral health between older immigrants and their native-born counterparts (Sano & Abada, 2019).

Existing studies on oral health disparities between the immigrant and the native-born population have yielded mixed results, suggesting that there is a poor understanding of the topic. In certain studies, first-generation immigrants had poorer perceived oral health than their respective Australian-, British-, Swedish-, and Canadian-born counterparts (Åstrøm et al., 2011; Kotzer et al., 2012; Steele et al., 2004). In contrast, another study indicated that Latino immigrants in the United States had better oral health–related quality of life than non-Latino Whites, even though this effect was limited to first-generation Latinos (Sanders, 2010). In addition, a study conducted among Haitian immigrants in the United States found that they had lower rates of lifetime dental caries than the U.S. national average, but their unmet dental needs were higher (Cruz, Xue, et al., 2001).

Although the topic warrants further investigation, the mixed findings may be partially explained by the fact that these comparisons were not within the same racial/ethnic group. People from different racial/ethnic groups have different diets and oral hygiene habits (Cruz et al., 2009), which are difficult to control in observational studies. Therefore, within-group comparisons may provide a better understanding of the role of immigrant status in oral health disparities (Li & Keith, 2011).

Chinese Americans are the largest subgroup of Asian Americans, and Asian Americans are the fastest growing minority group in the United States. Approximately 75% of the Asian American population is foreign-born (Pew Research Center, 2013). Despite their increasing numbers, very little is known about the oral health of Asian Americans (Wu et al., 2013). Among all the studies on immigrant/nativity status and oral health referenced above, only one of them was focused specifically on Asian Americans or Chinese Americans (Wu et al., 2013).

It is important to study the association between immigrant status and perceived oral health among Chinese Americans. Oral health is a top concern for Chinese Americans living in ethnic enclaves in New York City (Northridge et al., 2018), and Chinese adults have a worse perception of their oral health than Indian and Pakistani adults (Cruz, Galvis, et al., 2001). Older Chinese adults have also been reported to have a higher prevalence of periodontal disease and the lowest rate of dental visits when compared to other racial/ethnic adults (Luo & Wu, 2016; Weatherspoon et al., 2016). Therefore, this study conducted among Chinese Americans will provide an opportunity to better understand whether immigration status is associated with perceived oral health in the United States.

Self-rated oral health has the advantage of embodying the perspective of the participant and is considered to be a valid, reliable, and inexpensive way to measure overall oral health (Pattussi et al., 2010). Moreover, previous studies found that self-rated oral health is correlated with a range of clinically assessed measures of oral health status including untreated dental caries, tooth loss, chewing function, oral pain, and periodontal disease (Furuta et al., 2012). To better understand perceived oral health among older immigrants, this study used a sample of Chinese Americans in Honolulu, HI, to examine the associations among immigrant status, resilience, and their perceived oral health. In addition, we explored whether resilience moderates the association between immigrant status and perceived oral health.

Conceptual Framework

Guided by the social determinants of oral health framework (Watt & Sheiham, 2012) and the Reserve Capacity Model (Gallo & Matthews, 2003; Gallo et al., 2009), we speculate that immigrant status and resilience are associated with perceived oral health and that resilience modifies the association between immigrant status and perceived oral health. The social determinants of oral health framework posit that individuals with lower versus higher socioeconomic positions have limited psychological resources and lack access to dental care, resulting in worse oral health. According to the Reserve Capacity Model, it is important to consider the moderating effect of psychological resources in the association between disadvantages (i.e., SES and cultural context) and health disparities. These theories provide us with the guidance for assessing the associations among immigrant status, resilience, and perceived oral health.

Immigrant Status and Perceived Oral Health.

Compared with their native-born counterparts, foreign-born immigrants have greater exposure to socioeconomic, cultural, and political disadvantages (Sano & Abada, 2019). A large body of existing literature suggests that both general health and oral health are affected by SES, which encompasses education, occupation, and income (Watt & Sheiham, 2012). Compared with older U.S.-born natives, older immigrants often have lower levels of education thus remain economically vulnerable (Grieco et al., 2012). This economic vulnerability may lead to low levels of positive psychological resources, for example, resilience, and result in limited access to dental care. In addition, many older immigrants face legal barriers to participating in public insurance programs, such as Medicare and Medicaid, and thus experience higher out-of-pocket costs compared to older U.S.-born natives (C. N. Anderson & Kim, 2009).

Compared with White older adults, Chinese immigrants are reported to have lower self-reported prevalence of chronic disease (e.g., lower possibility of having asthma or cardiovascular disease), mainly due to their healthier behaviors (e.g., less likely to smoke, better diets, and moderate physical activity) before immigrating (Corlin et al., 2014; Jin et al., 2015). However, the widely documented healthy immigrant effect phenomenon may not extend to the area of oral health among the foreign-born older Chinese Americans.

Compared with the U.S.-born Chinese Americans, the foreign-born may have worse oral health because of the significant difference in dental health system between China and the Unites States and personal oral hygiene behaviors. For example, the prevalence of root surface caries is 43.9% in the older adult group, and adults who once visited a dentist are more likely to have root caries than those who did not because the dental visit is for treatment rather than prevention (Du et al., 2009). In terms of oral hygiene behavior, floss and mouth rinses are less commonly practiced in older Chinese immigrants (Mao et al., 2015). Therefore, we hypothesize that, compared with older U.S.-born Chinese Americans, older Chinese immigrants have poorer perceived oral health.

Resilience and Perceived Oral Health.

According to the social determinants of oral health framework, psychological factors such as resilience are important determinants of oral health (Watt & Sheiham, 2012). Resilience, a positive psychosocial resource, is an individual-level stress coping ability that enables people to overcome adversity (Connor & Davidson, 2003). Since positive psychological resources may help protect immune function and improve health behaviors, in recent years, researchers have been increasingly interested in the role of psychosocial resources that affect oral health toward better understanding documented disparities (Finlayson et al., 2010; Ickovics et al., 2006; Sano & Abada, 2019). For example, positive psychological resources, including self-esteem and mastery, have a protective effect on oral health (Finlayson et al., 2010; Locker, 2009). To date, few studies have examined whether resilience is associated with perceived oral health. One previous study conducted in Brazil found that a higher level of resilience was related to positive self-reported oral health (Martins et al., 2011). Therefore, we hypothesize that resilience is associated with better perceived oral health among Chinese Americans.

The Moderating Role of Resilience.

In comparison to their native-born counterparts, foreign-born older adults are more likely to have lower socioeconomic position, greater language barriers, and more limited access to dental care; nonetheless, they are not necessarily more likely to suffer from poorer perceived oral health. For example, first-generation Latinos were reported to have better oral health–related quality of life than U.S.-born non-Latino Whites (Sanders, 2010). In addition, the healthy immigrant effect has been shown to be robust in previous studies (Corlin et al., 2014; Gallo et al., 2009; Jin et al., 2015). Therefore, an increasing number of researchers are interested in the moderating role of resilient psychological and social resources in the association between social disadvantages and health outcomes (Elliot & Chapman, 2016; Schöllgen et al., 2011; Turiano et al., 2014).

The Reserve Capacity Model is one of the general, adaptable frameworks that may help to better understand the moderating role of individual psychological resource in the association between low social resources (i.e., low SES or born in a foreign country) and health outcomes (Gallo et al., 2009). The association between individual psychological resources and health status may be stronger among older adults with low social resources due to greater exposure to stressors over the life course (Elliot & Chapman, 2016). The utility of the Reserve Capacity Model as a guiding framework was supported in numerous empirical studies on the association between socioeconomical disadvantages and health outcomes. With more social disadvantages, psychological resources are more strongly associated with health outcomes (e.g., mortality and functional and subjective health), but less strongly related to inflammatory markers (Elliot & Chapman, 2016; Schöllgen et al., 2011; Turiano et al., 2014). Therefore, we hypothesize that resilience is more strongly associated with perceived oral health in foreign-born than in U.S.-born Chinese Americans.

However, according to the social determinants of oral health framework, resilience may be more strongly associated with perceived oral health in U.S.-born than in foreign-born Chinese Americans. The origin of this framework lies in the World Health Organization’s social determinants of health framework, which stresses the structural determinants of health outcomes. The greater social–environmental pressures that older immigrants experience may be thought of as a consistently strong situation in psychology that eliminates the influence of person-level variables (Turner, 1988). An application of this belief is that resilience is less strongly related to perceived oral health in older immigrants than in older U.S.-born natives due to the constraints of the situational and environmental disadvantages that immigrants face. These disadvantages may include limited access to dental care, fewer economic resources for oral health prevention and disease interventions, and less knowledge of how to practice appropriate oral self-care behaviors.

Rationale for the Current Study

Building on previous research, the current study examined whether immigrant status and resilience are associated with perceived oral health among Chinese Americans in Hawaii. In addition, we explored whether resilience moderates the association between immigrant status and perceived oral health. Historical reasons also account for the fact that immigrant status is an interesting and meaningful focus for older Chinese Americans in Hawaii. The Chinese American population in Hawaii includes two major groups: the descendants of early immigrants who came to the islands before the 19th century and those who arrived in Hawaii after World War II (Zhang et al., 2019). Therefore, it is feasible to examine comparisons between foreign-born Chinese Americans who arrived in Hawaii in recent decades and those offspring of earlier Chinese immigrants who were born and raised in Hawaii.

Given the greater exposure to social, economic, culture, psychosocial, and health disadvantages of older Chinese immigrants and the importance of positive psychological resources in maintaining good oral health, we therefore hypothesize the following:

Hypothesis 1: Older Chinese immigrants have poorer perceived oral health than older U.S.-born Chinese Americans.

Hypothesis 2: Higher levels of resilience are associated with better perceived oral health among Chinese Americans.

Guided by the Reserve Capacity Model, the social determines of oral health framework, and the empirical studies on the moderating role of individual psychological resource in the association between disadvantages and health outcomes, we propose the following two competing hypotheses:

Hypothesis 3a: Resilience is more strongly associated with perceived oral health in older Chinese immigrants than in older U.S.-born Chinese Americans.

Hypothesis 3b: Resilience is more strongly associated with perceived oral health in older U.S.-born Chinese Americans than in older Chinese immigrants.

Design and Methods

Sample

Data were derived from a survey conducted in Honolulu, HI, where approximately 4.7% of the total population is comprised of immigrants, of whom 44% are adults aged 18 years and older (Tong & Sentell, 2017). Using snowball and convenience sampling, key informants were recruited from local Chinese groups, social organizations, businesses, and faith-based agencies. Key informants were selected on the basis of their capacity to access Chinese communities and their willingness to assist in recruiting Chinese older adults into the study. Researchers met with the selected key informants and described the aims of the research project and their expected responsibilities. Relying on the connections of key informants, the researchers made presentations and announcements during community meetings and worship services. The key informants also helped in distributing and collecting the survey forms and assisted in interpreting the survey questions for the participants. The inclusion criteria for the survey participants included Honolulu residents, aged 55 years and older, who self-identified as Chinese. The participants provided informed consent prior to any data collection. This study was approved by the Institutional Review Board at the University of Hawaii.

For older adults who have poor eyesight and who are unable to write, face-to-face in-depth interviews were conducted. Most older adults were able to fill out the questionnaires by themselves. We prepared questionnaires in both English and Chinese. In order to use accurate terms and languages in translation, we invited both English- and Chinese-speaking older Chinese adults to conduct some pilot interviews to brainstorm, making sure translation is accurate and survey questions are understandable. After survey questionnaires were revised and finalized based on the feedback from pilot testing, we started the data collection for this survey.

A total of 430 participants were recruited from January 2018 to September 2018. Our analytic sample is restricted to respondents who have responses in self-rated oral health, oral health problems, and immigrant status (N = 420).

Measures

Perceived oral health.

Perceived oral health was measured in two ways. Self-rated oral health was measured by one question: “How would you describe the condition of your mouth and teeth?” Responses were coded on a scale from 0 (very poor/very often) to 4 (very good/never) that was developed by the authors. Oral health problems was measured using the following three questions (Hybels et al., 2016): (a) “In the last year, have you avoided particular foods because of problems with your teeth, mouth, or dentures?” (b) “In the last year, have your teeth or gums been sensitive to hot, cold, or sweets?” and (c) “In the last year, have your gums bled when you brushed your teeth?” Responses to each of the 3 items were coded on a scale from 1 (very poor/very often) to 5 (very good/never). The Summary Scale ranged from 3 to 15, with higher scores representing better oral health. It is a reliable measure for this study (α = .81).

Immigrant status.

Immigrant status was coded as 0 for the foreign-born and 1 for the U.S.-born.

Resilience.

Resilience was measured using the Connor–Davidson Resilience Scale (CD-RISC), a 25-item scale that assesses one’s reserve capacity to overcome stress and adversity (Connor & Davidson, 2003). Sample items include “I am able to adapt when changes occur”; “I tend to bounce back after illness, injury, or other hardships”; and “I am able to handle unpleasant or painful feelings like sadness, fear, and anger.” Respondents rated how often they felt the item to be true for themselves over the past month on a scale from 0 to 4, where 0 = not true at all, 1 = rarely true, 2 = sometimes true, 3 = often true, and 4 = true. The mean score of this scale ranged from 0 to 4, with a higher score indicating greater resilience. The α value for the CD-RISC is .97, indicating that it is a very reliable measure for this sample. This valid and reliable measure of resilience has been used to assess individual resilience of Chinese Americans in prior studies (Zhang et al., 2019).

Control variables.

Control variables included demographic characteristics, educational attainment, financial strain, general health status, dental visit in the past year, significant tooth loss, health behaviors, and social support. Demographics included age in chronological years, gender (1 = female), and marital status (1 = married). Educational attainment was measured as years of schooling. Financial strain was coded as 1 = a great deal/some. General health status included self-rated health (1 = excellent/good health) and chronic condition status (1 = having at least one chronic condition). Dental visit in the past year was coded as 1 = teeth cleaned by a dentist or dental hygienist within the past year. Significant tooth loss meant that participants had lost six or more teeth (1 = yes; Gorsuch et al., 2014). Health behaviors included smoking status (1 currently smoking status (1 = currently smoking), daily fruit consumption (1 = eat fruit daily), and daily vegetable consumption (1 = eat vegetable daily). Social support included friend support and family support. Friend and family support were assessed by 3 items, which measured participants’ ability to depend on friends or extended family for emotional support, respectively. To assess friend support, participants were asked (a) how often do you talk on phone or get together with your friends, (b) how much can you rely on friends when experiencing serious problems, and (c) how much can you open up to friends and talk about worries. All items loaded on a single factor above .49, with an a reliability of .73. Family support included three parallel items in which the word friend was replaced with the phrase, “relatives who don’t live with you.” The items loaded on a single factor above .59, with an α reliability of .78. This valid and reliable measure of social support has been used to assess the social support of Asian Americans in prior studies (Zhang & Ta, 2009).

Data analysis.

Group differences in sample characteristics were compared between the foreign- and U.S.-born Chinese Americans using t tests for continuous variable and χ2 tests for categorical variables. Ordered logistic regression and ordinary least squares (OLS) regression models were used to examine whether immigrant status was associated with self-rated oral health and oral health problems, including the potential moderating effect of resilience in these associations. All analyses were conducted using STATA software (Version 15.1). A two-tailed α level of .05 was considered statistically significant, whereas .10 was considered marginally significant.

The multivariable analysis was conducted in stages. In the first stage, main effects models (Model 1) were first estimated. In the second stage, the interaction between immigrant status and resilience was added in Model 2. We examined the interaction between resilience and immigrant status mean centering to avoid multicollinearity problems (Afshartous & Preston, 2011). In the third and fourth stages, analyses were conducted in Models 3 and 4 for the foreign- and U.S.-born Chinese Americans, separately.

Significant tooth loss and dental visit in the last year were the two variables with the largest percentages of missing values, namely 15.1% and 5.1%, respectively. No other variable had a percentage of missing values that exceeded 5.0%. To reduce the bias associated with missing values, we conducted multiple imputation for the independent variables. The model results were based on 20 random, multiple-imputed replicates using all relevant variables in our analysis.

Results

Table 1 summarizes the study sample characteristics, overall and by immigrant status. On average, the U.S.-born Chinese Americans reported better self-rated oral health (mean = 2.99 vs. 2.21), fewer oral health problems (mean = 13.06 vs. 11.13), and greater resilience (mean = 3.02 vs. 2.70), than their foreign-born counterparts.

Table 1.

Descriptive Characteristics of the Chinese Study Sample Aged 55 Years and Older, Overall and by Immigrant Status, Honolulu, HI, 2018.

Total Sample Foreign-Born U.S.-Born
Variables Valid N Mean, % (SD) Valid N Mean, % (SD) Valid N Mean, % (SD)
Self-rated oral health 420 2.42 (0.90) 306 2.21 (0.81) 114 2.99*** (0.89)
Oral health problems 420 11.66 (2.62) 306 11.13 (2.70) 114 13.06*** (1.78)
U.S.-born 420 27.14%
Resilience 414 2.78 (0.71) 302 2.70 (0.75) 112 3.02*** (0.52)
Age (years) 420 73.55 (9.93) 306 72.32 (9.30) 114 76.86*** (10.82)
Female 414 59.42% 302 58.61% 112 61.6%
Married 411 69.83% 297 73.74% 114 59.6%**
Education (years) 412 11.63 (4.99) 298 10.01 (4.57) 114 15.84*** (3.30)
Some financial strain 415 21.21% 301 26.58% 114 7.0%***
Self-rated health (excellent/good health) 415 62.41% 301 53.82% 114 85.1%***
Any chronic disease 420 70.95% 306 66.01% 114 84.2%***
Dental visit last year 405 65.19% 292 56.16% 113 88.5%***
Significant tooth loss 363 30.03% 255 36.08% 108 15.7%***
Smoke 415 4.10% 303 4.62% 112 2.68%
Eat fruit daily 414 53.62% 300 57.33% 114 43.86%*
Eat vegetable daily 414 61.35% 300 67.67% 114 44.74%***
Friend support 400 6.43 (1.90) 293 6.48 (1.78) 107 6.30 (2.18)
Family support 407 6.49 (2.02) 298 6.45 (1.88) 109 6.60 (2.38)
Open in a new tab

Note. SD standard deviation.

†

p < .1.

*

p < .05.

**

p < .01.

***

p < .001.

When compared to their foreign-born Chinese Americans, the U.S.-born were also on average older (mean = 77 vs. 72 years), less likely to be married (59.6% vs. 73.74%), and more likely to have higher levels of education (mean = 15.84 vs. 10.01 years). U.S.-born Chinese Americans were less likely to have financial strain (7.0% vs. 26.6%), enjoy better self-rated health (85.1% vs. 53.8%), more likely to have a dental visit in the past year (88.5% vs. 56.2%), and less likely to have significant tooth loss (15.7% vs. 36.1%). Of note, however, the U.S.- born Chinese Americans were more likely to have at least one chronic condition than were immigrants (84.2% vs. 66.0%). The U.S.-born were less likely to have daily fruit consumption (43.9% vs. 57.3%) and daily vegetable consumption (44.7% vs. 67.7%) than their foreign-born counterparts.

Results from the collinearity diagnostics test suggest that tolerance for all variables was greater than 0.2, indicating no multicollinearity issues in these models (Hair et al., 2010). Table 2 presents the multivariable ordered logistic regression results for self-rated oral health. The main effects equation in Model 1 showed that Chinese Americans who were foreign-born had worse self-rated oral health than their U.S.-born counterparts (B = 1.443, p < .001); resilience was positively associated with self-rated oral health (B = 0.593, p < .001). In Model 2, a positively significant interaction was found between immigrant status and resilience (B = 0.865, p < .05), suggesting that resilience is associated with better self-rated oral health among the U.S.-born Chinese Americans than their foreign-born counterparts. When we conducted the analysis by immigrant status, resilience was significantly associated with self-rated oral health among both foreign-born Chinese Americans (B = 0.502, p < .01) and their U.S.-born counterparts (B = 1.185, p < .01).

Table 2.

Unstandardized Coefficients From Ordered Logistic Regression Models for Self-Rated Oral Health, Honolulu, HI, 2018.

Total Foreign-Born U.S.-Born
Model 1 Model 2 Model 3 Model 4
Variables B (SE) B (SE) B (SE) B (SE)
U.S.-born (reference = foreign-born) 1.443*** (0.312) 1.244*** (0.326)
Resilience 0.593*** (0.156) 0.464** (0.165) 0.502** (0.174) 1.185** (0.414)
Age −0.003 (0.012) −0.002 (0.012) 0.004 (0.014) −0.014 (0.023)
Female (reference = male) −0.191 (0.222) −0.211 (0.223) −0.395 (0.271) 0.110 (0.432)
Married (reference = unmarried) −0.679** (0.238) −0.742** (0.240) −0.833** (0.299) −0.708 (0.468)
Education −0.013 (0.027) −0.011 (0.027) −0.022 (0.030) −0.030 (0.066)
Have some financial strain (reference = no) −0.306 (0.262) −0.276 (0.263) −0.243 (0.292) −0.411 (0.786)
Excellent/good health (fair/bad/poor health) 0.501* (0.233) 0.520* (0.233) 0.541* (0.267) 0.541 (0.571)
Any chronic disease (reference = no) 0.104 (0.233) 0.111 (0.233) 0.145 (0.267) −0.121 (0.590)
Dental visit last year (reference = no) 0.360 (.234) 0.383 (0.234) 0.368 (0.262) 0.956 (0.652)
Significant tooth loss (reference = no) −1.684*** (0.274) −1.722*** (0.276) −2.045*** (0.340) −1.277* (0.602)
Currently smoking (reference = no) −0.254 (0.488) −0.300 (0.490) −0.625 (0.575) −0.009 (1.237)
Eat fruit daily −0.193 (0.278) −0.198 (0.279) −0.206 (0.334) −0.090 (0.593)
Eat vegetable daily 0.458 (0.291) 0.431 (0.293) 0.335 (0.357) 0.692 (0.563)
Friend support −0.121† (0.067) −0.115† (0.067) −0.051 (0.084) −0.201 (0.126)
Family support 0.072 (0.060) 0.073 (0.060) −0.044 (0.082) 0.261* (0.107)
Interaction
 U.S.-Born × Resilience 0.865* (0.397)
 Pseudo R2 .192 .200 .154 .141
Open in a new tab
†

p < .1.

*

p < .05.

**

p < .01.

***

p < .001.

Table 3 presents the multivariable OLS regression models for oral health problems. The main effects equation in Model 1 showed that Chinese Americans who were foreign-born had worse oral health problems than their U.S.-born counterparts (B = 1.119, p < .01); resilience was positively associated with oral health problems (B = 0.395, p < .05). In Model 2, we didn’t find a significant interaction between immigrant status and resilience. When we conducted the analysis by immigrant status, resilience was not significantly associated with oral health problems among both the foreign-born Chinese Americans and the U.S.-born Chinese Americans.

Table 3.

Unstandardized Coefficients From Ordinary Least Squares Regression Models for Oral Health Problems, Honolulu, HI, 2018.

Total Foreign-Born U.S.-Born
Model 1 Model 2 Model 3 Model 4
Variables B (SE) B (SE) B (SE) B (SE)
U.S.-born (reference = foreign-born) 1.119*** (0.344) 1.039** (0.362)
Resilience 0.395* (0.180) 0.342† (0.194) 0.299 (0.213) 0.667† (0.359)
Age 0.002 (0.013) 0.002 (0.013) 0.002 (0.018) −0.001 (0.019)
Female (reference = male) 0.028 (0.254) 0.017 (0.255) 0.063 (0.328) −0.155 (0.380)
Married (reference = unmarried) −0.609* (0.282) −0.634* (0.284) −0.824* (0.371) −0.070 (0.414)
Education −0.009 (0.031) −0.009 (0.031) −0.019 (0.037) 0.034 (0.057)
Have some financial strain (reference = no) −0.997** (0.299) −0.985** (0.300) −0.937** (0.346) −1.491* (0.725)
Excellent/good health (fair/bad/poor health) 0.782** (0.270) 0.789** (0.270) 0.927** (0.328) 0.032 (0.505)
Any chronic disease (reference = no) −0.032 (0.266) −0.029 (0.267) 0.082 (0.324) −0.273 (0.497)
Dental visit last year (reference = no) 0.281 (0.275) 0.287 (0.275) 0.409 (0.320) −0.441 (0.576)
Significant tooth loss (reference = no) −1.303*** (0.309) −1.317*** (0.311) −1.379*** (0.370) −1.268* (0.550)
Currently smoking (reference = no) 0.571 (0.583) 0.545 (0.584) 0.554 (0.712) 1.371 (1.142)
Eat fruit daily −0.131 (0.327) −0.137 (0.327) −0.335 (0.411) 0.186 (0.509)
Eat vegetable daily 0.720* (0.342) 0.715* (0.343) 1.027 (0.444) 0.160 (0.468)
Friend support −0.064 (0.076) −0.060 (0.077) −0.107 (0.102) 0.015 (0.106)
Family support 0.012 (0.070) 0.012 (0.070) 0.016 (0.096) −0.010 (0.090)
Interaction
 U.S.-Born × Resilience 0.350 (0.455)
 R2 .278 .279 .213 .194
Open in a new tab
†

p < .1.

*

p < .05.

**

p < .01.

***

p < .001.

Discussion

Using a sample of older Chinese Americans in Honolulu, HI, this study examined the association between immigrant status, resilience, and perceived oral health and the role of resilience in the association between immigrant status and oral health. The first hypothesis (Hypothesis 1) that older Chinese immigrants have poorer perceived oral health than older U.S.-born Chinese Americans was supported. Although younger than the U.S.- born Chinese Americans, older immigrants still had poorer self-rated oral health and more oral health problems than older U.S.-born Chinese Americans. Consistent with Sano and Abada (2019), this finding highlights immigrant status as a social determinant of oral health among Chinese Americans. This may be because compared with the U.S.-born Chinese Americans, the foreign-born Chinese Americans had poorer oral health before immigration due to the different health care systems in China and the United States. Oral health status is an accumulative process. Poor oral health status in early life can affect oral health status in later life. Meanwhile, after immigration, the oral health of the foreign-born Chinese Americans could have further deteriorated due to structural factors including language barriers, unfamiliarity with the U.S. health care system, and lack of access to dental care (Ge et al., 2018; Sano & Abada, 2019). Finally, foreign-born Chinese Americans generally have low levels of acculturation, thereby impeding the utilization of oral health services, and in turn resulting in a lack of oral health literacy and poorer oral health (Guo et al., 2018; Mao et al., 2015).

Our second hypothesis (Hypothesis 2) that higher levels of resilience were related to better perceived oral health was supported. We found that higher levels of resilience were associated with poorer self-rated oral health and fewer oral health problems in the total sample, and among the foreign-born Chinese Americans, and the U.S.-born Chinese Americans. This finding is consistent with previous studies in other populations, which found that positive psychological resources such as resilience, self-esteem, and mastery were associated with better perceived oral health (Finlayson et al., 2010; Martins et al., 2011). This may be because that positive psychological resources could protect immune function by reducing the exposures to stress and promote healthy behaviors (Finlayson et al., 2010; Ickovics et al., 2006; Sano & Abada, 2019). This finding highlights the importance of resilience in the association with oral health among Chinese Americans.

The hypothesis that resilience is more strongly associated with perceived oral health in older foreign-born Chinese Americans than in older U.S.-born Chinese Americans (Hypothesis 3a) is not supported. In contrast, we found that the association between individual resilience and self-rated oral health was stronger for the U.S.-born than for the foreign-born, which partially support Hypothesis 3b. This finding is consistent with the results from a recent study, which found that an individual’s resilience was more strongly associated with psychological distress in the U.S.-born than in the foreign-born among Chinese Americans (Zhang et al., 2019). This may be partially due to the fact that older adults’ immigrant status is closely related to language barriers, lower levels of acculturation, and socioeconomic disadvantages, which may affect their ability to seek dental care and integrate resources to deal with accumulative oral health problems that are salient in later life (R. A. Anderson et al., 2019; Guo et al., 2018). This finding also suggests that immigrant status may limit an individual’s resilience to adversity because the foreign-born and the U.S.-born do not have the same opportunity for resilience in an unequal social, economic, and political structure (Gallo et al., 2009; Meyer, 2015). This is the first study of which we are aware that considered the role of resilience in the association between immigrant status and oral health outcomes. Future studies are needed to better understand the role of resilience in the association between immigrant status and oral and general health outcomes.

Several limitations of this study merit consideration regarding the validity and interpretation of the findings. First, a geographically restricted small sample with nonprobability sampling was used. Therefore, the findings cannot be generalized to the Chinese American population overall. Future studies with representative samples are needed to reduce selection bias. However, since all the study participants were recruited from local communities, meaning that both the immigrants and U.S.-born native respondents were involved in some of the same organizations and share similar community resources, the comparisons may be more meaningful to a certain extent. Second, given the cross-sectional design of the study, it is impossible to identify causal relations. Longitudinal studies are needed to follow immigrants when they immigrate to the United States and natives throughout the life course to better observe the consequential perception of oral health and its implications. Third, the decision to distinguish between older Chinese Americans solely on the basis of immigrant status may oversimplify the true heterogeneity of the Chinese population. For example, compared to older adults who emigrated from mainland China, immigrants from Hong Kong are more likely to have higher levels of dental service utilization (Lai & Hui, 2007). Future studies with sufficient sample sizes are needed to compare differences of Chinese immigrants based on their region of birth and emigration. Such studies should also consider how age at migration and length of residence may influence the perception of oral health in older immigrants. Fourth, this study did not assess oral health status from clinical examinations. Nonetheless, perceived oral health status is an important topic of study in its own right and is a good indicator of general oral health status (Wu et al., 2011). Future studies using clinical oral health data may lead to a better understanding of the association between immigrant status and oral health. Finally, given the important role of acculturation and insurance status on oral health, we need to include these covariates in future studies.

Despite these limitations, this study is among the first to use the determinants of oral health framework to examine whether immigrant status and resilience are associated with poorer perceived oral health within the same ethnicity. Through the comparison between older immigrants and older U.S.-born natives among Chinese Americans, this study illustrates how immigrant status is associated with the perceived oral health in later life. Although the study used a small sample of older Chinese Americans who were recruited in Honolulu, HI, the results are relevant to other ethnic groups who are experiencing similar economic, social, cultural, and political disadvantages in their host countries (Sano & Abada, 2019). Our study shows that resilience is associated with both self-rated oral health and oral health problems, and the association between immigrant status and self-rated oral health is stronger in the U.S.-born Chinese Americans than in foreign-born Chinese Americans. This finding suggests that the oral health disadvantages conferred by immigrant status may limit individual resilience to adversity. More studies need to be conducted in other ethnic groups to better understand the oral health needs of older immigrants in general.

Taken together, the findings reported here have important implications for public health systems charged with improving the oral health of older immigrants. The results presented here suggest that older immigrants are more susceptible to perceived oral health than older U.S.-born natives. Dental care providers need to provide culturally sensitive services to older foreignborn populations in the context of the predominantly biomedical model of care (Smith et al., 2013). Public health systems also need to take account of the socioeconomic and political disadvantages linked to immigration. As dental insurance is important in accessing dental care, U.S. policy makers need to seek long-term solutions to eliminate inequities and provide affordable services for older immigrants. Finally, oral health care needs to be better integrated with medical care, as poor self-rated health is also associated with poor self-rated oral health and oral health problems (Griffin et al., 2012).

Resilience was found to be more strongly associated with self-rated oral health in older U.S.-born natives than in older immigrants, suggesting that immigration-related disadvantage limits individual resilience to adversity. Rather than focusing on interventions that aim to improve older immigrants’ resilience, strategies need to focus on providing better environments and improving access to care for disadvantaged groups. Future studies are needed to better understand the role of individual resilience in the association between immigrant status and health outcomes.

In summary, recognition of the fact that older immigrants have poorer oral health than older U.S.-born natives should lead to the delivery of more effective and affordable services to those who are most in need. Health care providers that provide services regardless of immigrant status or the ability to pay for services, such as those who practice in Federally Qualified Health Centers, ought to provide culturally tailored educational materials to improve oral health knowledge among older Chinese immigrants of lower SES.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Bei Wu received support from the Rutgers University Asian Resource Centers for Minority Aging Research Center under NIH/NIA Grant P30-AG0059304. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Author Biographies

Bei Wu is dean’s professor in Global Health at the Rory Meyers’ College of Nursing, New York University. She is also a co-director of the NYU Aging Incubator.

Yaolin Pei is postdoctoral associate at the Rory Meyers’ College of Nursing, NYU.

Wei Zhang is the chair and professor at the Department of Sociology, University of Hawaii at Mānoa.

Mary Northridge is research associate professor at Hansjorg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine.

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.

References

  1. Afshartous D, & Preston RA (2011). Key results of interaction models with centering. Journal of Statistics Education, 19(3), 1–24. 10.1080/10691898.2011.11889620 [DOI] [Google Scholar]
  2. Anderson CN, & Kim H (2009). An examination of older immigrants’ use of dental services in the United States. Journal of Aging & Social Policy, 22(1), 18–32. 10.1080/08959420903385593 [DOI] [PubMed] [Google Scholar]
  3. Anderson RA, Wang J, Plassman BL, Nye K, Bunn M, Poole PA, Drake C, Xu H, Ni Z, & Wu B (2019). Working together to learn new oral hygiene techniques: Pilot of a carepartner-assisted intervention for persons with cognitive impairment. Geriatric Nursing, 40(3), 269–276. 10.1016/j.gerinurse.2018.11.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Åstrøm AN, Ekback G, Ordell S, & Unell L (2011). Social inequality in oral health-related quality-of-life, OHRQoL, at early older age: Evidence from a prospective cohort study. Acta Odontologica Scandinavica, 69(6), 334–342. 10.3109/00016357.2011.568965 [DOI] [PubMed] [Google Scholar]
  5. Connor KM, & Davidson JRT (2003). Development of a new resilience scale: The Connor-Davidson Resilience Scale (CD-RISC). Depression and Anxiety, 18(2), 76–82. 10.1002/da.10113 [DOI] [PubMed] [Google Scholar]
  6. Corlin L, Woodin M, Thanikachalam M, Lowe L, & Brugge D (2014). Evidence for the healthy immigrant effect in older Chinese immigrants: A cross-sectional study. BMC Public Health, 14(1), 603 10.1186/1471-2458-14-603 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Cruz GD, Chen Y, Salazar CR, & Le Geros RZ (2009). The association of immigration and acculturation attributes with oral health among immigrants in New York City. American Journal of Public Health, 99(S2), S474–S480. 10.2105/AJPH.2008.149799 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Cruz GD, Galvis DL, Kim M, Le-Geros RZ, Barrow SL, Tavares M, & Bachiman R (2001). Self-perceived oral health among three subgroups of Asian-Americans in New York City: A preliminary study. Community Dentistry and Oral Epidemiology, 29(2), 99–106. 10.1111/j.1600-0528.2001.290204.x [DOI] [PubMed] [Google Scholar]
  9. Cruz GD, Xue X, LeGeros RZ, Halpert N, Galvis DL, & Tavares M (2001). Dental caries experience, tooth loss, and factors associated with unmet needs of Haitian immigrants in New York City. Journal of Public Health Dentistry, 61(4), 203–209. 10.1111/j.1752-7325.2001.tb03392.x [DOI] [PubMed] [Google Scholar]
  10. Du M, Jiang H, Tai B, Zhou Y, Wu B, & Bian Z (2009). Root caries patterns and risk factors of middle-aged and elderly people in China. Community Dentistry and Oral Epidemiology, 37(3), 260–266. 10.1111/j.1600-0528.2009.00461.x [DOI] [PubMed] [Google Scholar]
  11. Elliot AJ, & Chapman BP (2016). Socioeconomic status, psychological resources, and inflammatory markers: Results from the MIDUS study. Health Psychology, 35(11), 1205–1213. 10.1037/hea0000392 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Finlayson TL, Williams DR, Siefert K, Jackson JS, & Nowjack-Raymer R (2010). Oral health disparities and psychosocial correlates of self-rated oral health in the national survey of American life. American Journal of Public Health, 100(S1), S246–S255. 10.2105/AJPH.2009.167783 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Furuta M, Ekuni D, Takao S, Suzuki E, Morita M, & Kawachi I (2012). Social capital and self-rated oral health among young people. Community Dentistry and Oral Epidemiology, 40(2), 97–104. 10.1111/j.1600-0528.2011.00642.x [DOI] [PubMed] [Google Scholar]
  14. Gallo LC, & Matthews KA (2003). Understanding the association between socioeconomic status and physical health: Do negative emotions play a role? Psychological Bulletin, 129(1), 10–51. 10.1037/0033-2909.129.1.10 [DOI] [PubMed] [Google Scholar]
  15. Gallo LC, Penedo FJ, Espinosa de los Monteros K, & Arguelles W (2009). Resiliency in the face of disadvantage: Do Hispanic cultural characteristics protect health outcomes? Journal of Personality, 77(6), 1707–1746. 10.1111/j.1467-6494.2009.00598.x [DOI] [PubMed] [Google Scholar]
  16. Ge S, Wu B, & Dong X (2018). Associations between acculturation and oral health among older Chinese immigrants in the United States. Gerontology and Geriatric Medicine, 4, 1–10. 10.1177/2333721418778197 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Gorsuch MM, Sanders SG, & Wu B (2014). Tooth loss in Appalachia and the Mississippi Delta relative to other regions in the United States, 1999–2010. American Journal of Public Health, 104(5), e85–e91. 10.2105/AJPH.2013.301641 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Grieco EM, Acosta YD, de la Cruz GP, Gambino C, Gryn T, Larsen LJ, Trevelyan EN, & Walters NP (2012). The foreign-born population in the United States: 2010 (Report No. ACS-19). U.S. Census Bureau. http://www.census.gov/library/publications/2012/acs/acs-19.html
  19. Griffin SO, Jones JA, Brunson D, Griffin PM, & Bailey WD (2012). Burden of oral disease among older adults and implications for public health priorities. American Journal of Public Health, 102(3), 411–418. 10.2105/AJPH.2011.300362 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Guo M, Stensland M, Li M, Dong X, & Tiwari A (2018). Is migration at older age associated with poorer psychological well-being? Evidence from Chinese older immigrants in the United States. The Gerontologist. 10.1093/geront/gny066 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Hair JF, Black WC, Babin BJ, & Anderson RE (2010). Multivariate data analysis: A global perspective (7th ed.). Pearson Education. [Google Scholar]
  22. Hybels CF, Bennett JM, Landerman LR, Liang J, Plassman BL, & Wu B (2016). Trajectories of depressive symptoms and oral health outcomes in a community sample of older adults. International Journal of Geriatric Psychiatry, 31(1), 83–91. 10.1002/gps.4292 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Ickovics JR, Milan S, Boland R, Schoenbaum E, Schuman P, & Vlahov D (2006). Psychological resources protect health: 5-Year survival and immune function among HIV-infected women from four US cities. AIDS, 20(14), 1851–1860. 10.1097/01.aids.0000244204.95758.15 [DOI] [PubMed] [Google Scholar]
  24. Jin K, Ding D, Gullick J, Koo F, & Neubeck L (2015). A Chinese immigrant paradox? Low coronary heart disease incidence but higher short-term mortality in western-dwelling Chinese immigrants: A systematic review and meta-analysis. Journal of the American Heart Association, 4(12), e002568 10.1161/JAHA.115.002568 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Jones JA, & Bailey WD (2012). Burden of oral disease among older adults and implications for public health priorities. American Journal of Public Health, 102(3), 411–418. 10.2105/AJPH.2011.300362 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Kotzer RD, Lawrence HP, Clovis JB, & Matthews DC (2012). Oral health-related quality of life in an aging Canadian population. Health and Quality of Life Outcomes, 10(50), 1–12. 10.1186/1477-7525-10-50 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Lai DWL, & Hui NTA (2007). Use of dental care by elderly Chinese immigrants in Canada. Journal of Public Health Dentistry, 67(1), 55–59. 10.1111/j.1752-7325.2007.00009.x [DOI] [PubMed] [Google Scholar]
  28. Li Q, & Keith LG (2011). The differential association between education and infant mortality by nativity status of Chinese American Mothers: A life-course perspective. American Journal of Public Health, 101(5), 899–908. 10.2105/AJPH.2009.186916 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Locker D (2009). Self-esteem and socioeconomic disparities in self-perceived oral health. Journal of Public Health Dentistry, 69(1), 1–8. 10.1111/j.1752-7325.2008.00087.x [DOI] [PubMed] [Google Scholar]
  30. Luo H, & Wu B (2016). Acculturation and dental service use among Asian immigrants in the US. American Journal of Preventive Medicine, 51(6), 939–946. 10.1016/j.amepre.2016.07.041 [DOI] [PubMed] [Google Scholar]
  31. Mao W, Wu B, & Chi I (2015). Oral health among older Chinese immigrants and implications for social work practice. Health & Social Work, 40(3), e75–e82. 10.1093/hsw/hlv035 [DOI] [Google Scholar]
  32. Martins AB, Dos Santos CM, Hilgert JB, de Marchi RJ, Hugo FN, & Pereira Padilha DM (2011). Resilience and self-perceived oral health: A hierarchical approach. Journal of the American Geriatrics Society, 59(4), 725–731. 10.1111/j.1532-5415.2011.03350.x [DOI] [PubMed] [Google Scholar]
  33. Meyer IH (2015). Resilience in the study of minority stress and health of sexual and gender minorities. Psychology of Sexual Orientation and Gender Diversity, 2(3), 209–213. 10.1037/sgd0000132 [DOI] [Google Scholar]
  34. Nihtilä A, Tuuliainen E, Komulainen K, Autonen-Honkonen K, Nykänen I, Hartikainen S, Ahonen R, Tiihonen M, & Suominen AL (2017). Preventive oral health intervention among old home care clients. Age and Ageing, 46(5), 846–851. 10.1093/ageing/afx020 [DOI] [PubMed] [Google Scholar]
  35. Northridge ME, Metcalf SS, Yi S, Zhang Q, Gu X, & Trinh-Shevrin C (2018). A protocol for a feasibility and acceptability study of a participatory, multi-level, dynamic intervention in Urban Outreach centers to improve the oral health of low-income Chinese Americans. Frontiers in Public Health, 6, 29 10.3389/fpubh.2018.00029 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Pattussi MP, Peres KG, Boing AF, Peres MA, & Da Costa JSD (2010). Self-rated oral health and associated factors in Brazilian elders. Community Dentistry and Oral Epidemiology, 38(4), 348–359. 10.1111/j.1600-0528.2010.00542.x [DOI] [PubMed] [Google Scholar]
  37. Pew Research Center. (2013). The rise of Asian Americans. Population Reference Bureau Pew Research Center. https://www.pewsocialtrends.org/wp-content/uploads/sites/3/2013/04/Asian-Americans-new-full-report-04-2013.pdf
  38. Sadarangani TR, Trinh-Shevrin C, Chyun D, Yu G, & Kovner C (2019). Cardiovascular risk in middle-aged and older immigrants: Exploring residency period and health insurance coverage. Journal of Nursing Scholarship 10.1111/jnu.12465 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Sanders AE (2010). A Latino advantage in oral health-related quality of life is modified by nativity status. Social Science & Medicine, 71(1), 205–211. 10.1016/j.socscimed.2010.03.031 [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Sano Y, & Abada T (2019). Immigration as a social determinant of oral health: Does the ‘healthy immigrant effect’ extend to self-rated oral health in Ontario, Canada? Canadian Ethnic Studies, 51(1), 135–156. 10.1353/ces.2019.0005 [DOI] [Google Scholar]
  41. Schöllgen I, Huxhold O, Schüz B, & Tesch-Römer C (2011). Resources for health: Differential effects of optimistic self-beliefs and social support according to socioeconomic status. Health Psychology, 30(3), 326 10.1037/a0022514 [DOI] [PubMed] [Google Scholar]
  42. Smith A, MacEntee MI, Beattie BL, Brondani M, Bryant R, Graf P, Hornby K, Kobayashi K, & Wong ST (2013). The influence of culture on the oral health-related beliefs and behaviours of elderly Chinese immigrants: A meta-synthesis of the literature. Journal of Cross-Cultural Gerontology, 28(1), 27–47. 10.1007/s10823-013-9187-4 [DOI] [PubMed] [Google Scholar]
  43. Steele JG, Sanders AE, Slade GD, Allen PF, Lahti S, Nuttall N, & Spencer AJ (2004). How do age and tooth loss affect oral health impacts and quality of life? A study comparing two national samples. Community Dentistry and Oral Epidemiology, 32(2), 107–114. 10.1111/j.0301-5661.2004.00131.x [DOI] [PubMed] [Google Scholar]
  44. Tong M, & Sentell T (2017). Insights in public health: Challenges investigating health outcomes in Chinese Americans using population-based survey data. Hawaii Journal of Medicine & Public Health, 76(1), 27–32. [PMC free article] [PubMed] [Google Scholar]
  45. Turiano NA, Chapman BP, Agrigoroaei S, Infurna FJ, & Lachman M (2014). Perceived control reduces mortality risk at low, not high, education levels. Health Psychology, 33(8), 883–890. 10.1037/hea0000022 [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Turner RH (1988). Personality in society: Social psychology’s contribution to sociology. Social Psychology Quarterly, 51(1), 1–10. 10.2307/2786979 [DOI] [Google Scholar]
  47. Watt RG, & Sheiham A (2012). Integrating the common risk factor approach into a social determinants framework. Community Dentistry and Oral Epidemiology, 40(4), 289–296. 10.1111/j.1600-0528.2012.00680.x [DOI] [PubMed] [Google Scholar]
  48. Weatherspoon DJ, Borrell LN, Johnson CW, Mujahid MS, Neighbors HW, & Adar SD (2016). Racial and ethnic differences in self-reported periodontal disease in the Multi-Ethnic Study of Atherosclerosis (MESA). Oral Health & Preventive Dentistry, 14(3), 249–257. 10.3290/j.ohpd.a35614 [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Wu B, Liang J, Landerman L, & Plassman B (2013). Trends of edentulism among middle-aged and older Asian Americans. American Journal of Public Health, 103(9), e76–e82. 10.2105/AJPH.2012.301190 [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Wu B, Plassman BL, Liang J, Remle RC, Bai L, & Crout RJ (2011). Differences in self-reported oral health among community-dwelling black, Hispanic, and white elders. Journal of Aging and Health, 23(2), 267–288. 10.1177/0898264310382135 [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Zhang W, Liu S, Zhang K, & Wu B (2019). Neighborhood social cohesion, resilience, and psychological well-being among Chinese older adults in Hawai’i. The Gerontologist. 10.1093/geront/gnz104 [DOI] [PubMed] [Google Scholar]
  52. Zhang W, & Ta VM (2009). Social connections, immigration-related factors, and self-rated physical and mental health among Asian Americans. Social Science & Medicine, 68(12), 2104–2112. 10.1016/j.socscimed.2009.04.012 [DOI] [PubMed] [Google Scholar]

RESOURCES