Health & Place 13 (2007) 656–671 Immigration, ethnicity, and accessibility to culturally diverse family physicians Lu Wang Department of Geography, Ryerson University, Toronto, Canada M5B 2K3 Received 19 May 2006; received in revised form 21 August 2006; accepted 10 October 2006 Abstract The study concerns ethnicity, spatial equity, and healthcare access in the context of diversity and integration. The paper first explores how Chinese immigrants in the Toronto Census Metropolitan Area choose between ethnic Chinese family physicians and other family physicians, based on a probability survey. It then applies and modifies gravity-type accessibility measures, of which a special type is the so-called floating catchment area (FCA) method, to evaluate three types of geographical accessibility in family physician utilization. The study suggests a certain degree of spatial inequality among Chinese immigrants in accessing culturally sensitive care. The paper yields important methodological and policy implications. r 2006 Elsevier Ltd. All rights reserved. Keywords: Accessibility; Family physician; Chinese immigrants; GIS; Ethnicity Introduction This paper seeks to examine the geographical accessibility of culturally disparate immigrants to family physicians who are heterogeneous in cultural background and language of practice. It has been widely acknowledged that medical care is easier to access when it is located nearby; Nugent (2000) even titles an editorial in the Journal of Thoracic and Cardiovascular Surgery ‘‘In health care, geography is destiny’’ to address the importance of geographic factors in healthcare. In Canada, where there is an absence of market mechanisms in the healthcare system, the role of geography in healthcare access is critical, but it needs to be examined carefully given its multi-ethnic context. The healthcare demand of various ethnic groups often differs culturally (e.g., different health beliefs and traditions), as does healthcare provision (e.g., physician’s language of practice). Physicians who are located in the same place but differ in ethnicity may attract immigrant patients differently. Ethnicity and culture, as well as proximity to healthcare, are important factors to consider when evaluating the accessibility of im- migrants to physicians. Accessibility generally refers to the relative ease with which individuals from one location can reach other specified zones or point locations. Accessi- bility measures range from simple cumulative opportunity measures, which count the number of potential destinations reached within a given travel time or distance (Handy and Niemeier, 1997), to more complex gravity-based (Wang and Luo, 2005) ARTICLE IN PRESS www.elsevier.com/locate/healthplace 1353-8292/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.healthplace.2006.10.001 Tel.:+1 416 979 5038; fax: +1 416 979 5362. E-mail address: [email protected].
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ARTICLE IN PRESS
1353-8292/$ - se
doi:10.1016/j.he
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Health & Place 13 (2007) 656–671
www.elsevier.com/locate/healthplace
Immigration, ethnicity, and accessibility to culturallydiverse family physicians
Lu Wang�
Department of Geography, Ryerson University, Toronto, Canada M5B 2K3
Received 19 May 2006; received in revised form 21 August 2006; accepted 10 October 2006
Abstract
The study concerns ethnicity, spatial equity, and healthcare access in the context of diversity and integration. The paper
first explores how Chinese immigrants in the Toronto Census Metropolitan Area choose between ethnic Chinese family
physicians and other family physicians, based on a probability survey. It then applies and modifies gravity-type
accessibility measures, of which a special type is the so-called floating catchment area (FCA) method, to evaluate three
types of geographical accessibility in family physician utilization. The study suggests a certain degree of spatial inequality
among Chinese immigrants in accessing culturally sensitive care. The paper yields important methodological and policy
implications.
r 2006 Elsevier Ltd. All rights reserved.
Keywords: Accessibility; Family physician; Chinese immigrants; GIS; Ethnicity
Introduction
This paper seeks to examine the geographicalaccessibility of culturally disparate immigrants tofamily physicians who are heterogeneous in culturalbackground and language of practice. It has beenwidely acknowledged that medical care is easier toaccess when it is located nearby; Nugent (2000) eventitles an editorial in the Journal of Thoracic and
Cardiovascular Surgery ‘‘In health care, geographyis destiny’’ to address the importance of geographicfactors in healthcare. In Canada, where there is anabsence of market mechanisms in the healthcaresystem, the role of geography in healthcare access iscritical, but it needs to be examined carefully given
e front matter r 2006 Elsevier Ltd. All rights reserved
its multi-ethnic context. The healthcare demand ofvarious ethnic groups often differs culturally (e.g.,different health beliefs and traditions), as doeshealthcare provision (e.g., physician’s language ofpractice). Physicians who are located in the sameplace but differ in ethnicity may attract immigrantpatients differently. Ethnicity and culture, as well asproximity to healthcare, are important factors toconsider when evaluating the accessibility of im-migrants to physicians.
Accessibility generally refers to the relative easewith which individuals from one location can reachother specified zones or point locations. Accessi-bility measures range from simple cumulativeopportunity measures, which count the number ofpotential destinations reached within a given traveltime or distance (Handy and Niemeier, 1997), tomore complex gravity-based (Wang and Luo, 2005)
ARTICLE IN PRESSL. Wang / Health & Place 13 (2007) 656–671 657
and space–time (Kwan, 1998; Weber, 2003) acces-sibility measures. The class of gravity-based mea-sures, derived from Huff’s expression of the utilitymodel in studying consumer spatial behaviour(1963, in Guy, 1983), conceptualize accessibility asa trade-off between opportunity attractiveness andspatial separation. The space–time measures evalu-ate accessibility in terms of an individual’s ability toreach activity locations given the person’s dailyactivity program and spatio-temporal constraints.In the context of healthcare utilization, much hasbeen written about geographical access to healthservices (Cromley and McLafferty, 2002; Josephand Bantock, 1982; Lin et al., 2002; Lovett et al.,2002; Martin and Williams, 1992; Parker andCampbell, 1998), including accessibility to physi-cians (Guagliardo et al., 2004; Laditka, 2004; Luoand Wang, 2003). Among the various types ofaccessibility measures, the gravity-based measuresare the most widely used. Access to physicians isgenerally regarded as influenced by physiciandistribution and where people reside—that is, thespatial structures of healthcare provision andhealthcare demand, neither of which is distributeduniformly in space. This paper focuses primarily onthe gravity-based accessibility measures.
A broader context is provided by a stream ofwriting in health geography that concerns healthservices, in particular access to and delivery andplanning of care (Anderson and Rosenberg, 1990;Rosenberg and Hanlon, 1996). Despite the richnessof this research area, Pearson (1989, in Rosenberg,1995) suggests that health geography has failed totake into account the racialized nature of health andheathcare. More than 10 years after Pearson’scomment, only cursory attention has been paid tothe role of ethnicity and race in health geography,especially the geographies of immigrant health.While the so-called new health geography (Dyckand Kearns, 1995; Gesler and Kearns, 2002;Kearns, 1993) has explored the health of immi-grants, especially immigrant women (Dyck, 2004;Meadows et al., 2001), it seldom goes beyond aqualitative examination of health experiences, leav-ing opportunities for employing GIS and quantita-tive methods to assess health and healthcarepatterns concerning ethnic minorities.
Also related to the focus of this paper is the socio-cultural literature on ethnicity and healthcareutilization (Peter, 1993; Ross et al., 1994; Stephen-son, 1995; Wen et al., 1996; Ma, 1999; Casey et al.,2004; Horne et al., 2004; Hunt et al., 2004). Cultural
differences between care providers and users maycreate barriers to effective communication andtreatment due to misinterpretation of patientsymptoms and difficulty exporting Western medicalknowledge to members of traditional ethnic com-munities (Zhang and Verhoef, 2002). Ethnoculturalaffiliation can be an important determinant ofhealthcare consumption, even after socio-economicfactors are taken into consideration (Leduc andProulx, 2004). This body of work, however, payslittle attention to the geographical barriers facingimmigrants. Conversely, the geographical work onaccess to healthcare focuses on the spatial outcomeof the uneven distribution of care providers andconsumers, paying scant attention to immigrantusers and the role of ethnicity in accessing heathservices (Lin et al., 2002; Mooney et al., 2000). Evenwhen immigrants are considered, their ethnicity isoften simplistically treated as a categorical variablein the spatial model (McLafferty and Grady, 2005;Wang and Luo, 2005), with little focus on theiractual health experiences. From this perspective,this paper fills the gap between the geographicliterature on access to healthcare and the socio-cultural approach to health.
The paper examines the experience of Chineseimmigrants in the Toronto Census MetropolitanArea (CMA) in utilizing family physicians. Cana-da’s largest ethnic minority population is Chinese,including 9% of the Toronto CMA’s population.Attention will be focused on immigrants fromMainland China and Hong Kong—respectively,the past and current top sources of immigration toCanada and the largest two Chinese immigrantsubgroups in the Toronto CMA. There is also arelatively large number of ethnic Chinese physiciansin Toronto. About 6.3% of the physicians in theToronto CMA self-report to speak Chinese. Due tothe unique ethnic and cultural identity of Chineseimmigrants, their healthcare-seeking behaviour islikely influenced by the coexistence of ethnicChinese physicians and other physicians. Specifi-cally, the paper aims to:
(1)
Explore how Chinese immigrants choose be-tween ethnic Chinese family physicians andother family physicians in the Toronto CMA.
(2)
Compute accessibility indices for Chinese im-migrants in accessing culturally diverse familyphysicians.
(3)
Explore issues on spatial equity in physicianaccess, examine whether Chinese immigrants are
ARTICLE IN PRESSL. Wang / Health & Place 13 (2007) 656–671658
well- or under-serviced compared to the generalpopulation in Toronto, and compare accessi-bility among Chinese immigrant sub-commu-nities to dialectally matched physicians.
The study yields the following contributions:
(1)
It applies and modifies the widely used gravity-based accessibility model in evaluating immi-grants’ access to family physicians and providesmethodological implications for studying equi-table access to physicians for other immigrantgroups.
(2)
It examines the role of both space and ethnicityin healthcare utilization, thus bringing newinsights to the literature on immigrants andhealth and the geographical work on access tohealth care.
(3)
It makes a contribution by considering theethnic diversity of healthcare providers, whoare frequently treated in research as ethnicallyhomogeneous spatial locations.
(4)
The lack of English-language proficiency hasbeen reported as a barrier for Mainland Chineseimmigrants in accessing immigrant settlementservices in Toronto (Lo and Wang, 2004). Thepaper sheds light on how language influencesimmigrant integration in the important domainof health.
1There is no such variable as ‘‘Chinese immigrants’’ in the
Canadian census. The ‘‘Chinese ethnicity’’ variable, however,
includes non-first-generation Chinese. The best way to approx-
imate ‘‘Chinese immigrants’’ is to sum up the number of
immigrants from Mainland China, Hong Kong and Taiwan, as
is done in this paper, while acknowledging immigrants of Chinese
ethnicity coming from places other than Mainland China, Hong
Kong, and Taiwan.
Data on population and physician distribution
Survey data
A survey administered to a random sample ofMainland Chinese (MLC) and Hong Kong Chinese(HKC) immigrants residing in two neighbourhoodsin the inner suburbs of Toronto explored immi-grants’ utilization of family physicians and theirchoices between ethnic Chinese physicians and non-Chinese physicians (see Wang, 2003, for a detaileddescription of recruitment and findings). As shownin Fig. 1, the two study areas, both with a highconcentration of Chinese immigrants, differ inphysician opportunities. The North York studyarea has few ethnic Chinese physicians, compared toan abundance of Chinese physicians in the Scarbor-ough study area. The contrasting spatial structuresof healthcare opportunities enable a comparison inphysician-seeking behaviour among Chinese withdifferent degrees of accessibility to ethnic Chinesephysicians. The survey generated 317 useful ques-
tionnaires, providing information on experiences ofusing physicians and respondents’ socio-economiccharacteristics. The sample is evenly distributedbetween the two study areas, each having about thesame number of HKC and MLC immigrants.
Population and physician data
The latest Canadian census (2001) provides geo-referenced information on the Toronto population,including Chinese immigrants1 from various sourcecountries at a census tract level. Data of a finergeographical level—dissemination area (DA), pre-viouslyknown as enumeration area (EA)—werenot used, due to the well-known problem ofrounding small numbers of ethnic minorities in aDA to zero to achieve confidentiality. The popula-tion data were incorporated into ArcGIS foraccessibility analysis.
The paper focuses on the accessibility to familyphysicians, as opposed to surgeons and specialists.In the Canadian health care system, family physi-cians are extremely important. They are thephysicians that patients see for most generalpurposes and their referrals are patients’ keys tospecialist physicians. In this paper, physicians referto family physicians. The location and languageinformation on family physicians in the TorontoCMA was obtained from the annual survey of theCollege of Physicians and Surgeons of Ontario(CPSO) where the physicians self-report the lan-guages they are able to speak in addition to Englishor French, the two official languages of Canada.The six-digit postal-code data allow accurate geo-coding of physician locations to points. In somecases, multiple physicians share the same postalcode, indicating that they are likely in the samemedical building or located nearby. About 6.3% ofthe physicians in the Toronto CMA self-reported tospeak ‘‘Chinese’’ or one of these Chinese dialects:Cantonese, Fukien, Hakka, Mandarin, Swatow, orTaiwanese. Some calls were made to verify whetherthe physician practises family medicine, in cases inwhich the physician does not hold a specialty
ARTICLE IN PRESS
Fig. 1. Study areas and location of family physicians visited by survey respondents.
Table 1
Percentages of (Chinese) physicians and (Chinese immigrant) population in CSD
Census Subdivion
Area (CSD)
Ethnic Chinese family
physicians (%)
Chinese immigrants (%) All family physicians (%) Toronto population (%)
Scarborough 24.6 27.8 7.3 12.7
Toronto 23.4 14.5 52.0 14.4
Mississauga 14.2 7.9 8.0 13.1
Markham 11.2 16.6 2.3 4.5
North York 5.6 17.7 10.9 13.0
Richmond Hill 4.6 7.7 1.9 2.8
Ajax 3.0 0.2 0.9 1.6
Etobicoke 2.8 1.7 3.6 7.2
Brampton 2.3 0.7 3.3 6.9
East York 2.3 1.7 1.8 2.5
York 1.3 0.6 0.9 3.2
Oakville 1.3 0.5 2.5 3.1
The rest CSDs 3.6 2.2 4.6 15.0
Note: The shaded CSDs are in the City of Toronto and are relatively closer to downtown Toronto, compared to other suburban CSDs.
L. Wang / Health & Place 13 (2007) 656–671 659
certificate from the CPSO or a family medicinecertificate from the College of Family Physicians ofCanada. Altogether, 394 Chinese-speaking familyphysicians were identified, among whom 91 weretrained in North America and the rest had degreesfrom places such as China, Hong Kong, the UnitedKingdom, Australia, the Philippines, and Germany.Their last names indicate that they are likely ethnicChinese, although they may or may not be first-generation immigrants.
As shown in Table 1, the distribution of ethnicChinese physicians does not always correspond tothe settlement pattern of Chinese immigrants.Scarborough has the largest concentration of bothChinese immigrants (28%) and ethnic Chinesephysicians (25%). Downtown Toronto attractsmore than half of the CMA’s physicians, a muchhigher proportion than its population share, dueto the concentration of major research hospitals inthe area. In downtown Toronto there are also
ARTICLE IN PRESSL. Wang / Health & Place 13 (2007) 656–671660
proportionally more Chinese physicians than Chi-nese immigrants. It is interesting to note that NorthYork, with a fairly high concentration of Chineseimmigrants (17%), has only 6% of Chinese physi-cians. Outer suburbs such as Richmond Hill andMarkham, where relatively wealthier Chinese im-migrants settle, have similar percentages of Chinesephysicians and Chinese immigrants. Mississauga, anew and growing Chinese immigrant settlement thathosts 7% of the Chinese immigrant population, hasan overrepresentation of Chinese physicians (14%).The uneven distributions of Chinese immigrantsand ethnic Chinese physicians in the TorontoCMA suggest a need to examine the spatialequity of immigrants in accessing culturally diversephysicians.
Findings from the survey: the revealed preference for
ethnic Chinese physicians
Among survey respondents who had familyphysicians, approximately 96% were using onlyChinese physicians, most (80%) making five trips orfewer in a year to their physicians. This is a‘‘revealed preference’’ inferred from patient actualbehaviour. When asked ‘‘What ethnicity of thephysician would you prefer to see?’’ about 80%showed a ‘‘stated preference’’ for physicians ofChinese ethnicity; only one respondent preferred anon-Chinese physician, and about 20% did notstate any ethnic preference. The ‘‘revealed’’ and‘‘stated’’ preferences for Chinese physicians areconsistent and strong regardless of study area,immigration origin, income, age, and education.Proportionally, those who have spent a longer timein Canada and other Western countries tend to usenon-Chinese family physicians, although the smallsub-sample size of those who used non-Chinesephysicians does not allow for the generation ofmeaningful statistical indications. Language andculture are main reasons for using ethnic Chinesephysicians. About 93% actually spoke Chinese withtheir physicians, and 85% would prefer to commu-nicate with their physicians in Mandarin, Canto-nese, or other Chinese dialects. Many respondentsfind English ‘‘medical terminologies’’ ‘‘difficult,’’and they feel that it is easier to communicate withan ethnic Chinese physician, so that they can gain agood understanding of the physician’s instructions.In addition to the language convenience, manyWestern-trained Chinese physicians take the Chi-nese culture into account to a greater or lesser
degree—for example, how Chi or Yin-Yang is felt—in describing and discerning medical symptoms.
The algorithm in ArcInfo developed by Wang(2006) was used to compute the shortest networkdistance along the street network in order toexamine spatial physician-seeking behaviour. Thestreet network file from the DMTI Spatial hasinformation on line length, speed limit, and traveltime. On average, the North York respondentstravelled 6.99min by car (or 7.72 km) from home tophysician locations, compared to 4.15min (or4.12 km) for the Scarborough respondents. Thereis no shortage of non-Chinese physicians in eitherstudy area; North York, however, has much fewerChinese physician opportunities than does Scarbor-ough. The fact that the respondents in North Yorkovercame the friction of distance to reach ethnicallymatched physicians indicates the importance oflanguage and culture in utilizing health care.
In short, two pieces of information from thesurvey are critical in the following accessibilityanalysis. The first is the overwhelming preference ofChinese immigrants for ethnically and dialectallymatched physicians; the second is respondents’travel pattern, which is useful in calibrating theempirical parameter of the gravity model.
The refined gravity-based accessibility measures
The model
The gravity accessibility measure generally con-sists of two components, as shown in (1).
Ai ¼X
j
W jf ðdijÞ. (1)
Ai refers to the geographical accessibility ofindividual i or individuals at location i (e.g. census
tract i). W j refers to the number of opportunitiesand, in a more general sense, represents theattractiveness of destination j with regard tofeatures such as facility size or number of servicetypes. f ðdijÞ is the impedance function, whichmeasures the disincentives to reach a destinationrepresented by journey distance, driving time, ormonetary cost.
The merit of measure (1) lies in its ability to assessthe interaction between destination attractivenessand spatial separation in examining travel beha-viour, as well as its capacity to use the impedancefunction to weigh nearby opportunities moreheavily than remote ones. However, one major
ARTICLE IN PRESSL. Wang / Health & Place 13 (2007) 656–671 661
limitation is that it focuses only on the supply sideand overlooks how demand from origin and, inparticular, competition among users determine tripdistribution. Hence, some refinements were made toinclude demand competition to the measure (Josephand Bantock, 1982; Luo and Wang, 2003; Shen,1998), which can be written as
Ai ¼Xn
j¼1
W jf ðdijÞPmk¼1pkf ðdikÞ
. (2)
Ai is the gravity-based accessibility of population incensus tract i. f ðdijÞ is the distance impedancefunction. In the context of accessing physicians, dij
represents spatial separation from population incensus tract i to physician location j, normally in theform of distance or travel time. Wj measures theattractiveness of physician location j, with regard tofeatures such as the number of physicians atlocation j. Pk is the population size in census tractk. n and m are the total numbers of physicianlocations and census tracts, respectively.
Essentially, the refined gravity-type accessibilitymeasure consists of two sets of calculations. First,for each physician, it considers the demand compe-tition from all census tracts. Nearby tracts are givena heavier weight as defined by the distanceimpedance function f ðdijÞ. The results of the firstset of calculations represent the so-called physician-to-population ratio that reflects the competitivenessfor physicians. In the second set of calculations, forthe population in each given tract, all physicians areconsidered, while nearby physicians are weightedmore heavily than are more distant ones. It isimportant to note that the distance impedancefunction performs as a scale and assigns variousweights to destination attractiveness (Wj) anddemand (Pk) based on spatial separation. Normally,after reaching a certain distance or travel time, thedistance impedance function approaches zero andremote physicians or census tracts have littleinfluence on the calculated accessibility scores.
Relationship to the FCA model
A simpler version of the refined gravity-basedaccessibility measure is the two-step floating catch-ment area (FCA) method (Luo, 2004; Luo andWang, 2003; Wang and Luo, 2005). The FCAmethod replaces the continuous distance impedancefunction with a dichotomous travel impedance
that is predefined by patient travel threshold orphysician catchment area.
AFCAi ¼
Xj2ðdijpd0Þ
W j=X
k2ðdikpd0Þ
Pk
!. (3)
AFCAi is the FCA accessibility index for population in
census tract i. d0 is the radius of the physiciancatchment area, or the population travel time/distancethreshold. Similar to the refined gravity-accessibilitymeasure, the calculation of the FCA accessibility alsoinvolves two steps (see Wang and Luo, 2005, for adetailed description of the FCA method).
Compared to the refined gravity measure, theFCA measure is arbitrary in the sense that the travelthreshold draws an artificial line between accessibleand inaccessible physicians. For example, physi-cians outside the threshold are simply treated asinaccessible. Despite the limitation, the FCAmethod is relatively easy to implement in the GISand does not involve the selection of travel frictioncoefficient for the impedance function, which can betroublesome (Wang and Luo, 2005). Given theirrespective advantages in conceptualization andcomputation, the paper applies both methods tomeasure accessibility to physicians.
Accessibility concerning population and physician
subgroups
For Chinese immigrants, as newcomers in theiradopted Canadian home, having access to physi-cians who can speak Chinese and have somecultural understanding of their health traditionsand beliefs plays an important role in achieving agood quality of life. Given the importance oflanguage and culture in physician utilization, it isboth important and methodologically interesting toexplore the accessibility of population subgroups(e.g., Chinese immigrants or MLC immigrants) tophysician subgroups (e.g., ethnic Chinese physiciansor Mandarin-speaking Chinese physicians).
Sub-accessibility I: accessibility of Chinese
immigrants to ethnic Chinese physicians
Measuring accessibility concerning population andopportunity subgroups is by no means a straightfor-ward process. Different subgroups usually competewith each other for opportunities, and differentopportunity groups may attract people from variouspopulation subgroups. Past studies (Shen, 1998; Wang
ARTICLE IN PRESSL. Wang / Health & Place 13 (2007) 656–671662
and Minor, 2002) use the gravity-based accessibilitymeasure improved by Shen (1998) to evaluateaccessibility to employment opportunities for groupswith different transportation modes. Different dis-tance friction parameters and impedance functions areapplied to different modal groups. The situation inthis study is far more complicated. Unlike the twostudies in which each pre-defined modal group(e.g. auto drivers or public transit riders) uses oneand only one transportation mode (e.g. auto or publictransit) to access employment opportunities, in thispaper, both population and physician opportunitiesmay have subgroups defined by language, and there isno one-to-one relationship between any populationsubgroup and opportunity subgroup. For example,while Chinese immigrants prefer to use ethnic Chinesephysicians, ethnic Chinese physicians are open topeople from all ethnic groups and non-Chinesepopulations are not restricted to non-Chinese physi-cians. Thus, the method to developed by Shen (1998)and Wang and Minor (2002) to measuring accessi-bility concerning population and opportunity sub-groups is not applicable in this study.
To assess the accessibility of Chinese immigrantsto ethnic Chinese physicians, modifications weremade to general accessibility measures Ai and AFCA
i .The idea is that Chinese immigrants compete witheach other for Chinese physicians, and thereforetheir accessibility to Chinese physicians is influencedby the demand of co-ethnic residents for Chinese-speaking physicians and the supply of the Chinesephysicians available within the travel threshold.Note that it is not just the absolute size of Chinesepopulation nor the number of Chinese-speakingphysicians in the area that dictates the accessibilityof Chinese immigrants to ethnic Chinese physicians,but the relatively abundance of ethnic Chinesephysicians and share of Chinese immigrants in thearea, as described in (4)
ACi ¼ Ai
PjCW jf ðdijÞPjTW jf ðdijÞ
!, PkCPkf ðdikÞPkTPkf ðdikÞ
� �: (4)
The FCA-based accessibility submeasure is
ACFCAi ¼ AFCA
i
Pj2ðdif pd0Þ
CW jPj2ðdijpd0Þ
TW j
!, Pk2ðdikpd0Þ
CPkPk2ðdikpd0Þ
TPk
!,
(5)
ACi and ACFCAi represent, respectively, the gravity-
type accessibility submeasure and the FCA-typeaccessibility submeasure for Chinese immigrants incensus tract i to ethnic Chinese physicians. Ai and
AFCAi are the general accessibility of residents,
including Chinese immigrants, in census tract i toall physicians based on measures (2) and (3),calculated based on measure (2). CW j is the numberof Chinese physicians in location j. TW j is thenumber of all physicians in location j. CPk refers tothe number of Chinese immigrants in census tract k.TPk is the total population in census tract k.
There are two assumptions underlying measures(4) and (5). First, Chinese immigrants prefer ethnicChinese physicians, as shown by the survey results.Although the survey participants were drawn fromtwo small study areas, it is reasonable to assume thata similar preference for ethnic Chinese physiciansholds for Chinese immigrants in other locations, asthe literature suggests the importance of languageand culture in healthcare delivery and consumption(Blackemore, 2003; Dyck, 2004; Ma, 1999). Thesecond assumption concerns physicians who are self-employed and are essentially open to patients fromall ethnic groups. While some Chinese physicianslocated in certain Chinese residential areas attract alarge proportion of Chinese patients, non-Chinesepatients may also access these Chinese physicians.Given the lack of data on the ethnic mix of theclientele of Chinese and non-Chinese physicians, itmakes sense to assume that the potential demand forChinese ethnic physicians comes from the overallpopulation in the physician service area.
In measures (4) and (5), sub-accessibility iscalculated on the basis of general accessibility andis a function of Chinese immigrant population shareand ethnic Chinese physician share in the physicianservice area. Taking the FCA sub-accessibility as anexample, if the Chinese immigrant population sharein the physician catchment area is the same as theshare of ethnic Chinese physicians, the accessibility ofimmigrants to Chinese physicians remains the sameas general accessibility—that is, the opportunity for aChinese immigrant to get a Chinese family physicianis the same as the opportunity for any resident in theneighbourhood to get a family physician. If theChinese immigrant population share is higher thanthe Chinese physician share, sub-accessibility is lowerthan general accessibility, as Chinese immigrants willcompete with each other for Chinese physicians. Ifthe Chinese immigrant population share is smallerthan the Chinese physician share within the patienttravel threshold, immigrants will face a relativelyabundant supply of Chinese physicians and theiraccessibility to Chinese physicians will be higher thantheir general accessibility to all physicians.
ARTICLE IN PRESSL. Wang / Health & Place 13 (2007) 656–671 663
Sub-accessibility II: accessibility of Chinese
immigrant subgroups to Mandarin- and
Cantonese-speaking physicians
The survey reveals that Chinese immigrants havea strong preference for dialectally matched Chinesephysicians. About 95% of the respondents whospoke Cantonese at home communicated with theirphysicians in Cantonese. These immigrants cameprimarily from Hong Kong. Similarly, over 81% ofthose whose home language is Mandarin and whoimmigrated primarily from Mainland China usedphysicians who can speak some Mandarin. Thisreflects the variances in the broadly labelled Chineseimmigrant community in Toronto in terms ofimmigration origin and dialect, as well as thedialectal differences among ethnic Chinese physi-cians. For new Chinese immigrants with pooraccessibility to physicians who speak their Chinesedialect, obtaining quality care may become one ofthe greatest challenges that they face in Canada, aspeople speaking different Chinese dialects canhardly understand each other. Hence, it is impor-tant to further evaluate the accessibility of MLCimmigrants to Mandarin-speaking physicians andthe accessibility of HKC immigrants to Cantonese-speaking physicians.
Using a similar conceptual framework for sub-accessibility I, sub-accessibility II measures areformulated as
AMi ¼ Ai
PjMW j f ðdij ÞPjTW jf ðdij Þ
� �P
kðMLPkþTWPkÞf ðdikÞP
kTPkf ðdikÞ
� � , (6)
AMFCAi ¼ AFCA
i
Pj2ðdif pd0 Þ
MW jPj2ðdijpd0Þ
TW j
!P
k2ðdikpd0 ÞðMLPkþTWPkÞP
k2ðdikpd0 ÞTPk
� � , (7)
AHi ¼ Ai
PjCTW jf ðdijÞP
jTW jf ðdijÞ
!, PkHKPkf ðdikÞP
kTPkf ðdikÞ
� �,
(8)
AHFCAi ¼ AFCA
i
Pj2ðdif pd0Þ
CTW jPj2ðdijpd0Þ
TW j
!, Pk2ðdikpd0Þ
HKPkPk2ðdikpd0Þ
TPk
!.
(9)
AMi and AMFCAi refer, respectively, to the gravity-
type and FCA measures of accessibility of MLC
immigrants in census tract i to Mandarin-speakingChinese physicians. MWj is the number of Mandar-in-speaking physicians at location j. MLPk and arethe number of MLC immigrants and of TaiwaneseChinese immigrants, respectively, in census tract k.AHi and AHFCA
i are the accessibility of HKCimmigrants to Cantonese-speaking physicians usinggravity-type and FCA measures, respectively. CTWj
is the number of Cantonese-speaking physicians atlocation j. HKPk is the number of HKC immigrantsin census tract k. As mentioned earlier, the Chineseimmigrants in this paper are divided into those whowere born in Mainland China, Hong Kong, andTaiwan. While HKC immigrants speak Cantonese,the majority of Mainland and Taiwanese Chineseimmigrants speak Mandarin; thus, they compete forthe services of Mandarin-speaking physicians.
Selecting an impedance function
Kwan (1998) identifies the three most commonimpedance functions for gravity-type accessibilitymeasures:
f ðdijÞ ¼ d�bij Inverse power function;
f ðdijÞ ¼ e�bdij Exponential function;
f ðdijÞ ¼ e�d2ij=b Gaussian function;
where b is an empirical parameter that representsdistance friction. The inverse-power impedancefunction and the exponential impedance functionhave been widely applied in gravity-type accessi-bility models (Cervero et al., 1999; Luo and Wang,2003; Shen, 1998; Talen and Anselin, 1998).However, as Guy (1983) and Kwan (1998) pointout, these two impedance functions decline toosteeply close to the trip origin and produceunrealistic accessibility patterns. As shown inFig. 2, the Gaussian measure, resembling the bell-shape normal distribution curve, drops gradually atfirst, then more abruptly as the distance increasesfrom origin. It appears the most appropriate amongthe three measures in the context of urbanhealthcare access.
Calibrating distance friction parameter b
The distance friction parameter b in the impe-dance function was estimated based on the re-vealed travel behaviour of survey respondents. The
ARTICLE IN PRESS
0
0.2
0.4
0.6
0.8
1
1 615141312111
d (distance)
f(d)
Power Measure
Exponential Measure
Gaussian Measure
Fig. 2. Impedance functions for three commonly used gravity-
type geographical accessibility measures.
2The City of Toronto, known as Metropolitan Toronto before
the 1998 amalgamation, includes six municipalities (Toronto,
North York, Scarborough, Etobicoke, York, and East York).
The areas outside of the City of Toronto are often regarded as
Toronto’s suburbs, although municipalities inside the City, such
as North York and Scarborough, are sometimes referred to as the
inner suburbs. In this paper, the City refers to the City of
Toronto.
L. Wang / Health & Place 13 (2007) 656–671664
majority of the survey respondents (97%) spent15min in accessing physicians. Hence, 15min wasused as a cut-off point in defining b. Kwan (1998)suggests 0.01 as a critical value of the Gaussianimpedance function approaching zero. Based onsome simple calibration exercises, with a value of50, b gives a 0.01 value of the impedance function atthe travel time of 15min.
It is acknowledged that the threshold travel timemay vary for non-Chinese populations and forChinese immigrants living in different parts ofToronto. Ideally, the impedance function parameterb itself should be a variable when travel patternschange. It is also acknowledged that the underlyingassumption of any gravity-type accessibility mea-sure is a fixed-travel behavioural pattern forindividuals in different locations, as evidenced bya fixed distance friction parameter. Due to the lackof information on the revealed spatial behaviour ofpopulation at different locations, b is treated as aconstant in this study. Because in Toronto there aremore non-Chinese physicians in proportion to non-Chinese populations than Chinese physicians inproportion to Chinese immigrants, applying b tostudying the accessibility of the Toronto generalpopulation represents a relatively safe approach inthe sense that the maximum travel time for theToronto general population would likely fall withinthe time frame defined by b.
Spatial patterns of accessibility
General accessibility to all physicians
The refined gravity-type accessibility measure (2)and the FCA measure (3) were used to calculategeneral accessibility from all population centroids to
all physician locations, regardless of the ethnicity ofresidents and physicians. The calculation of theshortest street network driving time is also based onthe algorithm developed by Wang (2006). Fig. 3shows the spatial pattern of FCA accessibility scoreusing the natural break method in ArcGIS. Thepattern, as expected, is centrifugal, with accessibilitydecreasing from the city core, where hospitals andphysicians are concentrated, to the suburbs. Thedistribution of the gravity-type accessibility scores issimilar to that of the FCA scores shown in Fig. 3,although on average, the gravity-type scores are alittle higher and the gravity-type measure revealsmore details in accessibility variation in the City ofToronto2 than does the FCA measure.
Sub-accessibility I: accessibility to ethnic Chinese
physicians
Measures (4) and (5) were used to assess thegravity-type and FCA sub-accessibility I – ease ofaccess by Chinese immigrants to ethnic Chinesephysicians. Regardless of the measure used, sub-accessibility I scores increase from the City ofToronto to the outer suburbs, opposite to thegeneral accessibility pattern (due to space limit, onlythe FCA accessibility pattern is reported in Fig. 4).This result is not surprising. The calculation of sub-accessibility I is based on general accessibility to allphysicians and is positively related to the propor-tion of Chinese physicians and negatively related tothe Chinese immigrant population share within thetravel threshold. Although there are a large numberof Chinese physicians in the City of Toronto,especially in the downtown area, the size of theChinese immigrant population is also large, whichmeans that competition for ethnic Chinese physi-cians is also great. Anecdotal evidence indicates thatethnic Chinese physicians in the City are rarecommodities. In some places, a wait time of 3months before seeing a Chinese family physician forthe first time was observed. Being surrounded by alarge number of Chinese physicians in the City doesnot necessarily guarantee good accessibility to them,
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Fig. 3. FCA general accessibility to all family physicians.
L. Wang / Health & Place 13 (2007) 656–671 665
simply because of the high demand from co-ethnicresidents.
As noted by Wang and Luo (2005), accessibilitypatterns near the edge of the study area need to beinterpreted with caution because people living inthese areas may seek healthcare opportunities out-side the study area. In this study, areas near the edgeof the Toronto CMA generally have a small numberof residents and physicians. In some edge tracts, inwhich there are few Chinese immigrants (e.g., asmall denominator in measures (4) and (5)) andethnic Chinese physicians are the only physiciansavailable (e.g. a large numerator in measures 4 and5), the accessibility scores become extremely high,which enlarges the variance of the accessibilityscores in the CMA as a whole and creates someextreme spatial patterns. For both accessibilitymeasures, more details of the variations of accessi-bility are revealed when these edge tracts areremoved, especially in areas of low physician access(see the FCA accessibility map in Fig. 4 for an
example). A few pockets in outer suburbs such asBrampton, Mississauga, Aurora, and Newmarketare associated with relatively high accessibilityscores. In the City of Toronto, accessibility in-creases toward the west, while areas with a largenumber of Chinese immigrants (e.g., Scarboroughand North York) tend to have relatively lowaccessibility scores.
Sub-accessibility II: accessibility of Chinese
immigrant subgroups to dialectally diverse ethnic
Chinese physicians
Measures (6)–(9) were used to calculate theaccessibility of MLC immigrants to Mandarin-speaking physicians and the accessibility of HKCimmigrants to Cantonese-speaking physicians.The share of Chinese immigrant subgroups, com-bined with the share of Mandarin-speaking andCantonese-speaking physicians available within thetravel threshold specified by the model, decide
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Fig. 4. FCA accessibility of Chinese immigrants to ethnic Chinese family physicians (sub-accessibility I).
3Census tracts that are on the edge of the study area and have
no presence of Chinese immigrants were excluded in Tables 1
and 2.
L. Wang / Health & Place 13 (2007) 656–671666
whether sub-accessibility II in a given census tract ishigher or lower than general accessibility. Thespatial patterns of sub accessibility II scorescalculated by the two different measures areconsistent. Using HKC immigrants as an example,Fig. 5 shows the spatial variations of theiraccessibility to Cantonese-speaking family physi-cians based on the FCA and gravity-type measures.Those living in the western part of the City ofToronto (including some parts of downtown) anda few pockets of the suburbs enjoy higher accessi-bility to Cantonese-speaking physicians. Comparedto HKC immigrants, MLC immigrants in theCity of Toronto generally have lower accessibilityscores than do those living in the suburbs. Similarto the sub-accessibility I pattern, for both groups,the western inner suburbs, such as Bramptonand Mississauga, are associated with higher acces-sibility scores. In areas in which both immigrantgroups are concentrated (e.g., Scarborough, NorthYork, and Markham), the accessibility scores aregenerally low.
Statistical analysis of accessibility indices: is the
Chinese community in Toronto well serviced?
In terms of mean and median, the accessibility ofChinese immigrants to ethnic Chinese physicians(sub-accessibility I) and to dialectally matchedChinese physicians (sub-accessibility II) is higherthan the general accessibility to all physicians.3 Forexample, with regard to FCA measure, the mean ofgeneral accessibility scores is 0.001451, as comparedto the mean of sub-accessibility I scores (0.001872)and sub-accessibility II scores for HKC immigrants(0.004251). The standard deviations of sub-accessi-bility I and II are relatively large, suggesting acertain degree of variation in accessibility in somecensus tracts.
The calculated accessibility of HKC immigrantsto Cantonese-speaking physicians (AHi and
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Fig. 5. Accessibility of Hong Kong Chinese immigrants to Cantonese-speaking family physicians (sub accessibility II).
L. Wang / Health & Place 13 (2007) 656–671 667
AHFCAi ) is the highest among all the accessibility
indices, while the accessibility of MLC immigrantsto Mandarin-speaking physicians (e.g. the mean ofAMFCA
i is 0.001479) is only slightly higher than thegeneral accessibility scores. The difference in sub-accessibility II between MLC and HKC immigrantshas to do with the relative abundance of Cantonese-speaking physicians in Toronto. The majority(81%) of the ethnic Chinese physicians in theToronto CMA speak Cantonese, while only halfspeak Mandarin (some speak both), partly due tothe relatively long immigration history of HKC andthe recent arrival of MLC in Canada. Anotherexplanation for the high sub-accessibility II scoresof HKC immigrants is provided by looking at theshares of HKC immigrants and Cantonese-speakingphysicians available within the travel threshold. Asshown in Fig. 6, the percentage of HKC immigrantsper census tract is always associated with a higher
percentage of Cantonese-speaking physicians withinthe travel threshold from the centroid weighted bythe impedance function, although there are somefluctuations in the percentage of Cantonese-speak-ing physicians. The division of these two percen-tages is thus larger than one, amplifying the generalaccessibility scores.
Table 2 summarizes the correlations amongvarious accessibility indices and the size of theChinese immigrant (sub)population in each censustract. In measuring the three types of accessibility,scores based on the gravity-type and FCA measuresare significantly correlated in a positive way,indicating the internal consistency of the twomethods. The FCA accessibility of Chinese immi-grants to Chinese physicians (sub-accessibility I) issignificantly and negatively correlated to FCAgeneral accessibility, which explains the decreasinggeneral accessibility from the City to the suburbs
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Fig. 6. Percentages of Hong Kong Chinese immigrants in a census tract and Cantonese-speaking Chinese family physicians available in
the service area weighted by the impedance function.
Table 2
Correlations among accessibility indices and Chinese immigrant (sub)population in each census tract
General accessibility Sub-accessibility I Sub-accessibility II Chinese immigrant population
Ai AFCAi
ACi ACFCAi
AMi AMFCAi
AHi AHFCAi
Total MLC HKC
Ai 1
AFCAi
.676** 1
ACi .019 �.157** 1
ACFCAi
�.005 �.002 .340** 1
AMi �.039 �.226** .546** .170** 1
AMFCAi
�.092** �.071* .312** .940** .240** 1
AHi .338** .156** .845** .236** .158** .150** 1
AHFCAi
.372** .449** .164** .720** .020 .570** .312** 1
Total �.030 �.072* �.187** �.283** �.172** �.243** �.148** �.306** 1
**Correlation is significant at the 0.01 level 2-tailed.
*Correlation is significant at the 0.05 level 2-tailed.
L. Wang / Health & Place 13 (2007) 656–671668
and the opposite pattern for FCA sub-accessibilityI. When comparing the accessibility of HKCimmigrants to Cantonese-speaking physicians andthe general accessibility, the correlation is positivelysignificant, corresponding to their common spatialpatterns with accessibility decreasing from the Citytoward the (western) suburbs. The accessibility ofMLC immigrants to Mandarin-speaking physicians
is negatively and significantly related to generalaccessibility; this is consistent with their contrastingspatial pattern—when moving outward from theCity, sub-accessibility II for MLC immigrantsdecreases and general accessibility increases.
The generally high scores of sub-accessibility Iand II, compared to the general accessibility scores,seem to indicate that Chinese immigrants are
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relatively well serviced in accessing culturallydiverse physicians in the Toronto CMA, comparedto Toronto residents in getting family physicians.A closer look at the correlation scores suggests asomewhat different picture. In Table 2, correlationsbetween Chinese immigrant (sub) group size andaccessibility scores to (dialectally matched) Chinesephysicians are overwhelmingly negative and signifi-cant, suggesting a certain degree of spatial mismatchbetween immigrant healthcare demand and thesupply of culturally diverse physicians. In Figs. 4and 5, most of the well-serviced areas in terms ofaccessibility I and II scores have relatively smallChinese immigrant communities (e.g., Aurora andBrampton), whereas many relatively under-servicedareas are heavily populated with Chinese immi-grants (e.g., Scarborough and North York). Areaswith a high concentration of Chinese suffer frompoorer access to Chinese family physicians, mainlydue to the competition among the Chinese residentsfor Chinese physicians. This reflects a spatialinequity in utilizing physician services for Chineseliving in different census tracts. The patteris contrary to the general accessibility pattern(Fig. 3) where the general accessibility scoresdecrease from more populated central Toronto tothe suburbs; high-density areas enjoy better accessto physicians when ethnicity of patients andphysicians are not considered. The implication isthat for Chinese immigrants, accessing familyphysicians is easier when living in the City. But iflanguage of the physician is considered, accessingethnic Chinese physician is actually easier for thoseliving in suburbs with less fellow Chinese.
Summary and avenues for future research
Building upon the geographical work on accessi-bility and the socio-cultural literature on ethnicityand health, the paper explores immigrants’ utiliza-tion of and access to family physicians in amulticultural city where both the demand for andprovision of family medicine care are culturallydefined with spatial variations. The paper firstexplores the revealed preference of Chinese immi-grants between ethnic Chinese family physiciansand other physicians, based on a probability surveyin Toronto. The overwhelmingly strong preferenceof the survey respondents for ethnically anddialectally matched physicians and the travel effortthat immigrants made to access Chinese physiciansprovide the rationale for calculating the accessibility
of Chinese immigrants to culturally and linguisti-cally diverse family physicians. Specifically, thestudy applies and modifies the widely used gravity-type accessibility measures, of which a special typeis the so-called floating catchment area (FCA)method, in evaluating three types of geographicalaccessibilities in a GIS environment: (1) the generalaccessibility of Toronto residents to family physi-cians; (2) the accessibility of Chinese immigrants toethnic Chinese physicians (sub-accessibility I); and(3) the accessibility of MLC immigrants to Man-darin-speaking Chinese physicians and the accessi-bility of HKC immigrants to Cantonese-speakingChinese physicians (sub-accessibility II). Whilegeneral accessibility decreases from city core to theouter suburbs, due to the concentration of physi-cians and major hospitals in the City, sub-accessi-bility I increases when moving toward the suburbs.The competition among co-ethnic residents in theCity reduces the likelihood of accessing Chinesephysicians, even though Chinese physicians have afairly heavy presence in the City. In the Chineseimmigrant community, HKC immigrants enjoy thehighest accessibility to Cantonese-speaking physi-cians and MLC immigrants have relatively lowaccessibility to Mandarin-speaking physicians. Thisis due to the relative abundance of Cantonese-speaking Chinese physicians in Toronto.
Previous work on Toronto’s immigrant settle-ment services (Lo and Wang, 2005) finds thatimmigrants, including MLC immigrants, in the Cityof Toronto have much better access to socialservices that assist with initial settlement of im-migrants than do those in the suburbs. This papersuggests a different picture when it comes to anothertype of social service—healthcare. Canada’s health-care system is ‘‘a group of socialized healthinsurance plans that provides coverage to allCanadian citizens’’ (http://www.canadian-healthcare.org), implying an equal access of all individuals tocare. However, the spatial outcomes of physicianand immigrant distribution suggest inequality forculturally disparate immigrants in utilizing ethni-cally and dialectally matched physicians. Althoughthe average scores of sub-accessibility I and II arehigher than the general accessibility scores, a largeproportion of Chinese immigrants are relativelyunder-serviced in accessing culturally diverse physi-cians. Most of the census tracts in the TorontoCMA with higher accessibility scores are associatedwith small Chinese immigrant populations, andmost census tracts with low accessibility scores are
ARTICLE IN PRESSL. Wang / Health & Place 13 (2007) 656–671670
heavily populated by Chinese immigrants; thisimplies a certain degree of spatial mismatch betweenthe delivery of and demand for healthcare that isappropriate to Chinese immigrants. The overwhel-mingly strong preference of Chinese immigrants forethnically and dialectally matched family physi-cians, as revealed by the survey, points out the needfor physicians and clinicians to enhance theircultural understanding of immigrant patients. Italso points out the need to address issues related totraining and licensing of foreign-trained physicianswho are linguistically and culturally favoured bymany immigrant patients but face numerous ob-stacles to practising medicine in Canada. Finally,physicians and clinicians need to enhance theircultural understanding of immigrant patients, whichis a critical factor in addressing the health needs ofimmigrant populations.
Proceeding from this study, there are severalimportant directions that future research can take.First, as used in this paper and other studies, thegravity-type accessibility measures assume a fixedtravel threshold defined by the impedance functionparameter, which is a constant. However, people indifferent locations are likely surrounded by differentsets of physician opportunities and the transporta-tion network; thus, they may exhibit differentiatedtravel patterns in accessing physicians. The gravitymeasure can be improved by surveying residents indifferent locations and treating the impedancefunction parameter as a variable in future work onaccessibility. Second, more work is called forcomparing the experiences of different ethnicgroups with accessibility to physician utilization inmulticultural cities such as Toronto, where sizableethnic communities and culturally diverse physi-cians exist (e.g., Chinese and South Asian commu-nities and physicians). Third, due to datalimitations, the paper does not consider the spatialvariations of immigrants in terms of socio-economicstatus such as income and age. More comprehensivegeo-referenced census data will enable researchers touncover the relationships among immigrant socio-economic characteristics, residential location, andgeographical accessibility to physicians.
Acknowledgement
I would like to express my gratitude to Dr. LuciaLo who contributed to and financially supported thesurvey. I would also like to thank the two anony-mous reviewers whose comments and suggestions
have greatly improved the paper. Lastly, I wouldlike to thank the respondents who participatedin the survey on immigrant physician experienceand wish them well in building their new livesin Canada.
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