摘要：Objectives. We examined individual-, environmental-, and policy-level correlates of US farmworker health care utilization, guided by the behavioral model for vulnerable populations and the ecological model. Methods. The 2006 and 2007 administrations of the National Agricultural Workers Survey (n = 2884) provided the primary data. Geographic information systems, the 2005 Uniform Data System, and rurality and border proximity indices provided environmental variables. To identify factors associated with health care use, we performed logistic regression using weighted hierarchical linear modeling. Results. Approximately half (55.3%) of farmworkers utilized US health care in the previous 2 years. Several factors were independently associated with use at the individual level (gender, immigration and migrant status, English proficiency, transportation access, health status, and non-US health care utilization), the environmental level (proximity to US–Mexico border), and the policy level (insurance status and workplace payment structure). County Federally Qualified Health Center resources were not independently associated. Conclusions. We identified farmworkers at greatest risk for poor access. We made recommendations for change to farmworker health care access at all 3 levels of influence, emphasizing Federally Qualified Health Center service delivery. US farmworkers face significant disease burden 1 and excessive mortality rates for some diseases (e.g., certain cancers and tuberculosis) and injuries. 2 Disparities in health outcomes likely stem from occupational exposures and socioeconomic and political vulnerabilities. US farmworkers are typically Hispanic with limited education, income, and English proficiency. 3 Approximately half are unauthorized to work in the United States. 3 Despite marked disease burden, health care utilization appears to be low. 1 , 4 – 9 For example, only approximately half of California farmworkers received medical care in the previous year. 6 This rate parallels that of health care utilization for US Hispanics, of whom approximately half made an ambulatory care visit in the previous year, compared with 75.7% of non-Hispanic Whites. 10 Disparities in dental care have a comparable pattern. 6 , 8 , 11 , 12 However, utilization of preventive health services is lower for farmworkers 5 , 7 , 13 , 14 than it is for both US Hispanics and non-Hispanic Whites. 15 , 16 Farmworkers face numerous barriers to health care 1 , 4 , 17 : lack of insurance and knowledge of how to use or obtain it, 6 , 18 cost, 5 , 6 , 12 , 13 , 18 – 20 lack of transportation, 6 , 12 , 13 , 19 – 21 not knowing how to access care, 6 , 18 , 20 , 21 few services in the area or limited hours, 12 , 20 , 21 difficulty leaving work, 19 lack of time, 5 , 13 , 19 language differences, 6 , 8 , 18 – 20 and fear of the medical system, 13 losing employment, 6 and immigration officials. 21 Few studies have examined correlates of health care use among farmworkers. Those that have are outdated or limited in representativeness. 5 , 7 , 14 , 22 , 23 Thus, we systematically examined correlates of US health care use in a nationally representative sample of farmworkers, using recently collected data. The sampling strategy and application of postsampling weights enhance generalizability. We selected correlates on the basis of previous literature and the behavioral model for vulnerable populations. 24 The behavioral model posits that predisposing, enabling, and need characteristics influence health care use. 25 The ecological model, which specifies several levels of influence on behavior (e.g., policy, environmental, intrapersonal), 26 provided the overall theoretical framework. To our knowledge, we are the first to extensively examine multilevel correlates of farmworker health care use. We sought to identify farmworkers at greatest risk for low health care use and to suggest areas for intervention at all 3 levels of influence so that farmworker service provision can be improved.
