A low response rate does not necessarily indicate non-response bias in gastroenterology survey research: a population-based study

Aim

To estimate the potential for response bias in standard mailed questionnaires used in surveys of GI symptoms in a community.

Subjects and methods

Validated self-report tools have been developed to measure functional gastrointestinal (GI) disorders but response rates in community surveys have been rapidly declining in many parts of the world. Whether a lower community response rate introduces significant response bias in GI survey research is unknown. A questionnaire was mailed to a total of 5,069 randomly selected subjects. The overall response rate was 52 %. A random sample of 723 of these subjects (428 responders and 295 non-responders, stratified by age and gender) was selected for medical record abstraction (including both inpatient and outpatient history).

Results

The odds for response increased in those with a higher body mass index (odds ratio (OR):1.02 [95 % CI: 1.01, 1.03]), more health care seeking behavior for non-GI problems (OR: 1.97 [95 % CI: 1.43, 2.72]), and for those who had responded to a previous survey (OR: 4.84 [95 % CI: 2.84, 8.26]). Responder status was not significantly associated with any GI symptoms or a diagnosis of GI or non-GI disease (with two exceptions, diverticulosis and skin disease).

Conclusions

Despite a response rate of only 52 %, the results of a community-based GI survey do not appear to be impacted by non-response bias in a major way. A low survey response rate does not necessarily indicate non-response bias.     

Are community-living and institutionalized dementia patients cared for differently? Evidence on service utilization and costs of care from German insurance claims data

Background

The validity of survey-based health care utilization estimates in the older population has been poorly researched. Owing to data protection legislation and a great number of different health care insurance providers, the assessment of recall and non-response bias is challenging to impossible in many countries. The objective of our study was to compare estimates from a population-based study in older German adults with external secondary data.

Methods

We used data from the German KORA-Age study, which included 4,127 people aged 65–94 years. Self-report questions covered the utilization of long-term care services, inpatient services, outpatient services, and pharmaceuticals. We calculated age- and sex-standardized mean utilization rates in each domain and compared them with the corresponding estimates derived from official statistics and independent statutory health insurance data.

Results

The KORA-Age study underestimated the use of long-term care services (?52%), in-hospital days (?21%) and physician visits (?70%). In contrast, the assessment of drug consumption by postal self-report questionnaires yielded similar estimates to the analysis of insurance claims data (?9%).

Conclusion

Survey estimates based on self-report tend to underestimate true health care utilization in the older population. Direct validation studies are needed to disentangle the impact of recall and non-response bias.     

Assessing population-wide behaviour change: concordance of 10-year trends in self-reported and observed sun protection

Objectives

Increases in socially desirable responses in self-reports might occur in the context of ongoing public education. We examine concordance of trends in two long-term studies monitoring population impact for SunSmart.

Methods

One study employed telephone interviews of Melbourne residents; the other entailed observations at public recreation venues across Melbourne. The studies assessed people’s sun protection on identical weekend dates (Nw = 33 dates). Data from five summers between 1992 and 2001 (n ~ 23,000 individuals) were analysed. A body cover index score was calculated for participants on each date. Outcomes were aggregated separately for Saturdays and Sundays by date and year. Regression analyses tested whether these trends differed by survey method.

Results

The pattern of change in body cover over time was similar for both surveys. Self-reported body cover was consistently higher than observed body cover, suggesting that social desirability bias may be present. Regression analyses showed no divergence between self-reported and observed trends in mean body cover, suggesting no evidence of significant increased social desirability bias in self-reporting over time.

Conclusion

Findings suggest that self-report offers a valid means of assessing change in a population’s sun protection compliance over time, at least when self-reports are precisely focussed for time and activity context.     

Migration and depressive symptoms in migrant-sending areas: findings from the survey of internal migration and health in China

Objectives

China has experienced large-scale internal migration and growing mental health disorders. Limited research has examined the relationship between the two processes. We examined the association between labor out-migration and depressive symptoms of family members left behind in migrant-sending areas.

Methods

We conducted a multistage probability sample survey of Chinese adults in 2008 (“Internal Migration and Health in China”), including 787 people in rural migrant-sending areas. To study whether adults in out-migrant households were more likely to experience depressive symptoms (CES-D) than were adults in non-migrant households, we used multivariate regressions and adjusted for a wide range of confounding factors and for the complex sampling design.

Results

Adults in households with labor out-migrants were more likely to report depressive symptoms than those in households without out-migrants, presumably a result of the absence of family members. However, monetary remittances from labor migrants buffered the mental health costs of out-migration.

Conclusions

Labor out-migration has important consequences for the mental health in migrant-sending communities. There is an urgent need to address the psychological costs of migration and to promote regular remittances.     

Catastrophic healthcare payments and impoverishment in the occupied Palestinian territory

Background

Financial protection from the risks of ill health has globally recognized importance as a principal performance goal of any health system. This type of financial protection involves minimizing catastrophic payments for healthcare and their associated impoverishing effects. Realization of this performance goal is heavily influenced by factors related to the overall policy environment and sociopolitical context in each country.

Objectives

To examine the incidence and intensity of catastrophic and impoverishing healthcare payments borne by Palestinian households between 1998 and 2007. The incidence and intensity of these effects are examined within the historically unique policy and socioeconomic context of the occupied Palestinian territory.

Methods

A healthcare payment was considered catastrophic if it exceeded 10% of household resources, or 40% of resources net of food expenditures. The impoverishing effect of healthcare was examined by comparing poverty incidence and intensity before and after healthcare payments. The data source was a series of annual expenditure and consumption surveys covering 1998 and 2004–7, and including representative samples of Palestinian households (n = 1231–3098, per year). Total household expenditure was used as a proxy for household level of resources; and the sum of household expenses on a comprehensive list of medical goods and services was used to estimate healthcare payments.

Results

While only around 1% of the surveyed households spent ≥40% of their total household expenditures (net of food expenses) on healthcare in 1998, the percentage was almost doubled in 2007. In terms of impoverishing effect, while 11.8% of surveyed households fell into deep poverty in 1998 due to healthcare payments, 12.5% of households entered deep poverty for the same reason in 2006. Over the same period, the monthly amount by which poor households failed to reach the deep poverty line due to healthcare payments increased from $US9.4 to $US12.9.

Conclusions

The inability of the Palestinian healthcare system to protect against the financial risks of ill health could be attributed to the prevailing sociopolitical conditions of the occupied Palestinian territory, and to some intrinsic system characteristics. It is recommended that pro-poor financing schemes be pursued to mitigate the negative impact of the recurrent health shocks affecting Palestinian households.     

A randomised controlled trial to determine the effect on response of including a lottery incentive in health surveys [ISRCTN32203485]

Background

Postal questionnaires are an economical and simple method of data collection for research purposes but are subject to non-response bias. Several studies have explored the effect of monetary and non-monetary incentives on response. Recent meta-analyses conclude that financial incentives are an effective way of increasing response rates. However, large surveys rarely have the resources to reward individual participants. Three previous papers report on the effectiveness of lottery incentives with contradictory results. This study aimed to determine the effect of including a lottery-style incentive on response rates to a postal health survey.

Methods

Randomised controlled trial. Setting: North and West Birmingham. 8,645 patients aged 18 or over randomly selected from registers of eight general practices (family physician practices). Intervention: Inclusion of a flyer and letter with a health questionnaire informing patients that returned questionnaires would be entered into a lottery-style draw for £100 of gift vouchers. Control: Health questionnaire accompanied only by standard letter of explanation. Main outcome measures: Response rate and completion rate to questionnaire.

Results

5,209 individuals responded with identical rates in both groups (62.1%). Practice, patient age, sex and Townsend score (a postcode based deprivation measure) were identified as predictive of response, with higher response related to older age, being female and living in an area with a lower Townsend score (less deprived).

Conclusion

This RCT, using a large community based sample, found that the offer of entry into a lottery style draw for £100 of High Street vouchers has no effect on response rates to a postal health questionnaire.     

Association between blood lead and mercury levels and periodontitis in the Korean general population: analysis of the 2008–2009 Korean National Health and Nutrition Examination Survey data

Objectives

We present data from the Korean National Health and Nutrition Examination Survey 2008–2009 regarding the association between blood lead and mercury levels and periodontitis in a representative sample of the adult South Korean population.

Methods

The analysis was restricted to participants ≥20 years of age who completed the health examination survey, including blood lead, cadmium, and mercury measurements (n = 3,966). Odds ratios (ORs) for periodontitis were calculated for log-transformed blood metal levels and quartiles thereof after covariate adjustment.

Results

In a logistic regression analysis using log-transformed blood lead and mercury levels as independent variables after covariate adjustment, including blood lead, mercury, and cadmium, the ORs and 95 % CI values in men for having periodontitis with doubling of blood lead and mercury were 1.699 (1.154–2.503) and 1.394 (1.057–1.838), respectively. Furthermore, in a logistic regression analysis using tertiles of blood lead and mercury as independent variables after covariate adjustment, the ORs and 95 % CIs of men for having periodontitis in the highest tertile were 1.756 (1.184–2.604) and 1.575 (1.507–2.347), respectively. ORs in the logistic regression analysis for men using log-transformed blood cadmium or the tertile of blood cadmium as independent variables after covariate adjustments were not statistically significant in either model. Unlike men, ORs in the logistic regression analyses for women using the same independent variables after covariate adjustment were not statistically significant in any blood metal analysis.

Conclusions

The association between blood lead and mercury levels and periodontitis was significant regardless of the type of variable (continuous or categorical) in the Korean male population.     

Out-of-pocket expenditures on traditional and Western medicine in Taiwan

Objectives

Coexistence of traditional and modern medicine is common in Asian countries. This paper investigates out-of-pocket expenditures on traditional medicine, traditional medical service, and Western medicine by households in Taiwan.

Methods

Using a national sample of 13,765 households, the three expenditure equations are estimated with a censored system procedure. Effects of socio-demographic variables are explored by calculating marginal effects on probabilities and levels of medical expenses.

Results

Different types of medical expenditures are correlated. Households with higher income and more aging members use more traditional medicine than others, as do households in agricultural sector and in urban areas. In addition, households living in rural areas relative to those in the cities are more likely to use and also spend more on traditional service. Regional disparity of health care utilization is found.

Conclusions

Higher income households spend more on traditional medicine, likely due to the fact that patients usually pay out-of-pocket for herbal materials needed in preparation of traditional medicine. To ensure equity in health care utilization, establishment of hospitals and clinics in rural areas should be considered.     

Household crowding and psychosocial health among Inuit in Greenland

Objectives

Poor housing conditions experienced by many Indigenous peoples threaten their health and well-being. This study examines whether household crowding is associated with poorer psychosocial health among Greenlanders, and the mediating role of social support. It also assesses whether Inuit men and women are differently influenced by their housing conditions.

Methods

Data on more than 3,000 Inuit aged 18 years and older are from the Inuit health in transition Greenland survey. Associations between household crowding and composition, and mental well-being and binge drinking were examined using logistic regression models, adjusting for individuals’ characteristics.

Results

Household crowding was associated with poorer mental well-being. Binge drinking was more common among people living in households without children. These effects were more important for women than for men. The association between household crowding and mental well-being was significantly mediated by social support. This suggests that having a strong social network may buffer the deleterious impacts of household crowding.

Conclusions

Targeting housing conditions and fostering social support as part of population health interventions might contribute to improving psychosocial health and well-being in Greenland.     

Coverage and beliefs about temephos application for control of dengue vectors and impact of a community-based prevention intervention: secondary analysis from the Camino Verde trial in Mexico

Background

Temephos in domestic water containers remains a mainstay of Latin American government programmes for control of Aedes aegypti and associated illnesses, including dengue. There is little published evidence about coverage of routine temephos programmes. A cluster randomised controlled trial of community mobilisation in Mexico and Nicaragua reduced vector indices, dengue infection, and clinical dengue cases. Secondary analysis from the Mexican arm of the trial examined temephos coverage and beliefs, and the impact of the trial on these outcomes.

Methods

The trial impact survey in December 2012, in 10,491 households in 45 intervention and 45 control clusters, asked about visits from the temephos programme, retention of applied temephos, and views about temephos and mosquito control. Fieldworkers noted if temephos was present in water containers.

Results

Some 42.4% of rural and 20.7% of urban households reported no temephos programme visits within the last 12 months. Overall, 42.0% reported they had temephos placed in their water containers less than 3 months previously. Fieldworkers observed temephos in at least one container in 21.1% of households. Recent temephos application and observed temephos were both significantly more common in urban households, when other household variables were taken into account; in rural areas, smaller households were more likely to have temephos present.Most households (74.4%) did not think bathing with water containing temephos carried any health risk. Half (51%) believed drinking or cooking with such water could be harmful and 17.6% were unsure.Significantly fewer households in intervention sites (16.5%) than in control sites (26.0%) (Risk Difference ? 0.095, 95% confidence interval ? 0.182 to ?0.009) had temephos observed in their water; more households in intervention clusters (41.8%) than in control clusters (31.6%) removed the applied temephos quickly. Although fewer households in intervention sites (82.7%) compared with control sites (86.7%) (RD -0.04, 95% CI -0.067 to ?0.013) agreed temephos and fumigation was the best way to avoid mosquitoes, the proportion believing this remained very high.

Conclusion

Coverage with the government temephos programme was low, especially in rural areas. Despite an intervention encouraging non-chemical mosquito control, most households continued to believe that chemicals are the best control method.

Trial registration

ISRCTN:27581154.

     

The impact of being the intermediate caring generation and intergenerational transfers on self-reported health of women in Ireland

Objectives

To investigate the associations with being the “sandwich generation” in older women in Ireland and its impact on self-reported health.

Methods

Analysis of 3,196 women from wave 1 of the Irish Longitudinal Study on Ageing (TILDA) was undertaken. Poisson regression was used to determine whether intergenerational transfers, were associated with self-rated physical health and depression, when controlling for other socio-demographic variables.

Results

Multivariate analysis found that women in the sandwich generation who financially supported their children had better self-rated physical health (poor/fair health relative to excellent; RR 0.84, 95 % CI 0.72–0.97). Conversely, the women who provided other care for their children showed evidence of poorer mental health (case-level depression, RR 1.35, 95 %CI 1.05–1.73). Providing financial support for parents was associated with case-level depression (RR 2.21, 95 %CI 1.26–3.86).

Conclusions

Supporting two generations was associated with both better self-rated health and poorer mental health, depending on the type and direction of the transfers. This generation of women have substantial caring responsibilities. Strategies to address the stresses associated with bi-directional intergenerational transfers are needed.     

Disease-Specific Impoverishment Impact of Out-of-Pocket Payments for Health Care: Evidence from Rural Bangladesh

Background

Analysing disease-specific impoverishment impact of out-of-pocket (OOP) payments for health care is crucial for priority setting in any informed policy discussion. Lack of evidence, particularly in the Bangladesh context, motivates our paper.

Objective

To examine disease-specific impoverishment impact of OOP payments for health care.

Methods

The paper estimates the poverty impact of OOP payments by comparing the difference between the average level of headcount poverty and poverty gap with and without health care payments. We used primary data drawn from 3,941 households, distributed over 120 villages of seven districts in Bangladesh during August–September 2009.

Findings

We find that OOP outlays annually push 3.4 % households into poverty. The corresponding figures for those who had non-communicable diseases (NCDs), chronic illness, hospitalization and catastrophic illness were 4.61, 4.65, 14.53 and 17.33 %, respectively. Note that NCDs are the principal reason behind the latter two situations (about 88 % and 85 % of cases, respectively). Looking into individual categories of NCDs we found that major contribution to headcount impoverishment arose out of illnesses such as cholecystectomy, mental disorder, kidney disease, cancer and appendectomy. The intensity of impoverishment is the largest among the hospitalized patients, and more individually among cancer patients.

Conclusions

The poverty impact of OOP outlays for health care, in general, is quite high. However, it is especially high for NCDs, particularly for chronic NCDs and those requiring immediate surgical procedures. Hence, these illnesses should be given more priority for policy framing. In addition to suggesting some ex-ante measures (e.g. raising awareness regarding the risk factors causing NCDs), the paper argues for reforms to enhance efficiency in the public health care facilities and increasing the quality of public health care.     

SF-36v2 norms and its’ discriminative properties among healthy households of tuberculosis patients in Malaysia

Background

The aim of the study was to obtain norms of the SF-36v2 health survey and the association of summary component scores with socio-demographic variables in healthy households of tuberculosis (TB) patients.

Design

All household members (18 years and above; healthy; literate) of registered tuberculosis patients who came for contact tracing during March 2010 to February 2011 at the respiratory clinic of Penang General Hospital were invited to complete the SF-36v2 health survey using the official translation of the questionnaire in Malay, Mandarin, Tamil and English. Scoring of the questionnaire was done using Quality Metric’s QM Certified Scoring Software version 4. Multivariate analysis was conducted to uncover the predictors of physical and mental health.

Results

A total of 649 eligible respondents were approached, while 525 agreed to participate in the study (response rate = 80.1 %). Out of consenting respondents, 46.5 % were male and only 5.3 % were over 75 years. Internal consistencies met the minimum criteria (α > 0.7). Reliability coefficients of the scales were always less than their own reliability coefficients. Mean physical component summary scale scores were equivalent to United States general population norms. However, there was a difference of more than three norm-based scoring points for mean mental component summary scores indicating poor mental health. A notable proportion of the respondents was at the risk of depression. Respondents aged 75 years and above (p = 0.001; OR 32.847), widow (p = 0.013; OR 2.599) and postgraduates (p < 0.001; OR 7.865) were predictors of poor physical health while unemployment (p = 0.033; OR 1.721) was the only predictor of poor mental health.

Conclusion

The SF-36v2 is a valid instrument to assess HRQoL among the households of TB patients. Study findings indicate the existence of poor mental health and risk of depression among family caregivers of TB patients. We therefore recommend that caregivers of TB patients to be offered intensive support and special attention to cope with these emotional problems.     

Assessing the use of the neighborhood method to estimate the prevalence of child separation: a pilot in North Kivu,DRC

Background

This article reports on the use of the ‘neighborhood method’ to measure the prevalence and basic characteristics of children who became separated from their parents or usual caregivers subsequent to an attack by the M23 militia group in North Kivu, Democratic Republic of the Congo.

Methods

A two-stage household cluster survey was conducted in 522 households in North Kivu in August 2014. Heads of households were asked about separated children in their household, as well as the households of their two closest neighbors. Separation was tracked in terms of children who arrived into the households after the M23 attacks and children who departed from the households after the recall event without their parent(s) or usual caregiver. For a subset of 44 neighbor pairs, respondents were asked to report on the same household to assess inter-rater reliability. Data about primary respondents and their neighbors were assessed to determine whether the neighborhood method was a comparable, reliable and efficient alternative to a traditional household survey about separated children.

Results

The prevalence of separated children who arrived was 8.52 % [95 % CI: 6.75–10.75] in primary households and 4.46 % [95 % CI: 3.60–5.52] in neighbors’ households (p-value?=?0.0000). The prevalence of separated children who departed was 4.98 % [95 % CI: 3.45–7.19] in primary households and 3.19 % [95 % CI: 2.27–4.48] in neighbors’ households (p-value?=?0.0110). Kappa coefficients for the neighbor pairs indicated fair to moderate agreement for most demographic variables, but agreement was generally higher for variables related to current characteristics of the households than for variables describing the household in the past, especially before the M23 attack. Compared to a traditional household survey with similar power, the neighborhood method reduced data collection time by 50 % and lowered costs by 36 %.

Conclusion

This pilot showed that, for measuring separated children in North Kivu, the results from neighbor households significantly underestimated the prevalence of separation when compared to data collected from respondents directly. Reliability was mixed. Although the neighborhood method did not yield valid results in this setting, given the potential the method holds to save scarce resources in humanitarian settings, additional pilots to refine and evaluate its validity and reliability in settings with shorter recall periods are recommended.

     

The age-dependent influence of self-reported health and job characteristics on retirement

Objectives

Social scientists and economists doubt the usefulness of self-reported health status as an indicator of overall health status. Self-reported health acts as a justification for retirement when this decision is in reality driven by other reasons. In this study, we looked at income, job satisfaction, and job status.

Methods

We introduce a survival model (Cox model) that simultaneously includes both health and job characteristics as independent variables. We also take the age-dependent character of these effects into account.

Results

An analysis of the European Community Household Panel data did not validate the justification bias with respect to these variables. The addition of job characteristics had no influence on the effect estimates of self-reported health.

Conclusions

We found significant effects for self-reported health as well as for objective health measures. The addition of job characteristics did not contribute to the explanation of the effect of self-reported health falsifying the justification bias hypothesis.     

Geschlechtsspezifische Verzerrungen bei der Erfassung von Depressivität

Background

Aspects of mental health are often assessed in population surveys. However, especially answers to sensitive questions can be biased. For this reason, a validation of the used instruments with regard to potential bias is of high relevance.

Objectives

This paper addresses the potential existence of gender bias in a commonly used questionnaire assessing depressive symptoms. It is hypothesized that gender differences in depressiveness to the disadvantage of women can be traced back to some extent to the survey mode as well as to the depressiveness instrument itself.

Materials and Methods

In order to examine this hypothesis, data from the pretest and the main survey of the German lidA-study is used. Within the survey the simplified Beck-Depression-Inventory (BDI-V) is applied for the measurement of depressive symptoms. Two survey modes were used in the pretest to measure depressiveness. Using mean comparisons and factor analyses, stratified for gender, possible gender bias is examined.

Results and Discussion

The results show evidence of gender bias with regard to the survey mode. Factor analyses show that symptoms for depressiveness have a different relevance and are structured differently for men and women. This should be taken in account when assessing depressiveness.

     

Chronic health conditions and work ability in the ageing workforce: the impact of work conditions,psychosocial factors and perceived health

Purpose

The aim of this study was to determine the influence of work conditions, psychosocial factors and perceived health on the association between the presence of a chronic health condition and (single-item) work ability among workers aged 45 years and older. In addition, we aimed to examine variables associated with work ability for workers with and without a chronic health condition separately.

Methods

The data of this cross-sectional study were obtained from 5,247 workers aged 45 years and older in five different work sectors. Work ability was assessed with the first item of the Work Ability Index. The presence of a chronic health condition was assessed by self-report. Independent variables in the multivariable linear regression analysis were work conditions, psychosocial factors and perceived health status.

Results

The presence of a chronic health condition was negatively associated with work ability (B = ?0.848). The strength of this association slightly attenuated after subsequently adding individual characteristics (B = ?0.824), work conditions (B = ?0.805) and more so after adding psychosocial factors (B = ?0.704) and especially perceived health variables (B = ?0.049) to the model. Variables associated with work ability for workers with and without a chronic health condition were similar.

Conclusion

Perceived health and psychosocial factors, rather than work conditions, explained the association between the presence of a chronic health condition and work ability. Substantial differences in variables associated with work ability for workers with and without a chronic health condition were not found. Based on the lower mean scores for workers with a chronic health condition and work ability as well for predictors, these workers might have the most benefit by a policy focussing on enhancing these associated variables.     

Parent and Adolescent Report of the Forms and Functions of Aggression: Associations with Delinquency,CU Traits,and Dysregulation

Background

The purpose of this study is to provide an examination of the psychometric properties and correlates of a parent-report measure of the forms and functions of aggression.

Objective

We sought to explore the potential independent association of parent-reported forms and functions of aggression to several important variables commonly associated with aggression (i.e., callous and unemotional traits, delinquency, and emotional and behavioral dysregulation) while controlling for self-reported aggression. Further, we examined whether parent-reported reactive and proactive aggression showed similar divergent correlates as self or other reports of aggression.

Methods

141 community youth aged 11–17 (mean age = 13.55; SD = 2.18; 51 % female) and their parents/guardians participated in the study. Parent and self-report questionnaire data were collected during a laboratory visit.

Results

Results suggest that parent-reported aggression was associated with adolescent adjustment variables while controlling for self-reported aggression, and that parent-reported reactive and proactive aggression showed divergent associations with adjustment correlates similar to those often found for self-reported reactive and proactive aggression.

Conclusions

This study provides a promising initial examination of the utility of a parent-report measure of forms and functions of aggression in adolescents. These findings have implications for the assessment of the forms and functions of aggression in adolescents and suggest that using parents as informants (in addition to other reporters) provides useful information about youths’ behavior.     

Nativity and cognitive disability among children: a unique comparison with reduced selection bias

Objectives

We examined the impact of nativity on self-reported cognitive disability by comparing children who were born outside of the USA (first-generation immigrants) with US-born offspring (second-generation immigrants) of foreign-born parents.

Methods

We analyzed a diverse, nationally representative, sample of 77,324 first-generation immigrant and second-generation immigrant children (aged 5–17 years) from the 2009 American Community Survey. Multivariate logistic regression was used to assess the association between nativity and self-reported cognitive disability after adjustment for demographics and household characteristics.

Results

Self-reported cognitive disability was observed in 1.7 % of the sample. The prevalence was higher among first second-generation immigrants than among second first-generation immigrants (1.9 vs 1.1 %, p < 0.001). After multivariate adjustment, the advantage of being foreign-born remained (OR = 0.63, 95 % CI = 0.53–0.75). Further analysis revealed effect modification of the immigrant health advantage by household income (p = 0.003).

Conclusions

We observed an immigrant advantage in self-reported cognitive disability; however, it was only evident among economically disadvantaged children. Future research should examine the contribution of the accumulation of poverty over time to the relationship between nativity and children’s health.