Healthy Immigrant Effect Research Articles

Health Care Use and the Canadian Immigrant Population

Set within the "determinants of health" framework and drawing on Statistics Canada's longitudinal National Population Health Survey, this article explores health care utilization by Canada's immigrant population. Given the observed "healthy immigrant effect", whereby the health status of immigrants at the time of arrival is high but subsequently declines and converges toward that of the native-born population, does the incidence of use of health care facilities reflect greater need for care? Similarly, does the use of health care facilities by the native- and the foreign-born differ, and if so, are these differences explained primarily by socioeconomic, sociodemographic, or lifestyle factors, which may point to problems in the Canadian health care system? This study identifies trends in the incidence of physician and hospital use, the factors that contribute to health care use, and differences in health care use between the native- and foreign-born.

Racialized identity and health in Canada: Results from a nationally representative survey

This article uses survey data to investigate health effects of racialization in Canada. The operative sample was comprised of 91,123 Canadians aged 25 and older who completed the 2003 Canadian Community Health Survey. A "racial and cultural background" survey question contributed a variable that differentiated respondents who identified with Aboriginal, Black, Chinese, Filipino, Latin American, South Asian, White, or jointly Aboriginal and White racial/cultural backgrounds. Indicators of diabetes, hypertension and self-rated health were used to assess health. The healthy immigrant effect suppressed some disparity in risk for diabetes by racial/cultural identification. In logistic regression models also containing gender, age, and immigrant status, no racial/cultural identifications corresponded with significantly better health outcomes than those reported by survey respondents identifying as White. Subsequent models indicated that residential locale did little to explain the associations between racial/cultural background and health and that socioeconomic status was only implicated in relatively poor health outcomes for respondents identifying as Aboriginal or Aboriginal/White. Sizable and statistically significant relative risks for poor health for respondents identifying as Aboriginal, Aboriginal/White, Black, Chinese, or South Asian remained unexplained by the models, suggesting that other explanations for health disparities by racialized identity in Canada - perhaps pertaining to experiences with institutional racism and/or the wear and tear of experiences of racism and discrimination in everyday life - also deserve empirical investigation in this context.

Poids, santé générale et santé mentale: la situation de divers sous-groupes d’immigrants au Canada

Recent immigrants to Canada tend to be healthier than the non-immigrant population. Less is known about the health of different ethnic, cultural, and linguistic subgroups of immigrants in Canada. Data were taken from the 2005 Canadian Community Health Survey (Cycle 3.1). We used multiple logistic regression to examine associations for three immigrant characteristics (1-time since immigration, 2-visible minority status, 3-knowledge of an official language) and three health outcomes (1-self-rated general health, 2-self-rated mental health, 3-body mass index (BMI)) for Montreal, Toronto, and Vancouver, accounting for socio-demographic characteristics. Recent immigrants belonging to a visible minority have a lower likelihood of reporting poor general (OR 0.72, 95% CI 0.54-0.97) and mental (OR 0.64, 95% CI 0.43-0.96) health and BMI > or = 25 (OR 0.51, 95% CI 0.43-0.61) relative to non-immigrants. These associations were not present for recent immigrants not belonging to a visible minority. Immigrants who cannot converse in an official language have a higher likelihood of reporting poor general health (OR 1.49, 95% CI 1.06-2.10) relative to non-immigrants. In Toronto and Vancouver (but not Montreal), immigrants were less likely to have an elevated BMI. This study supports a healthy immigrant effect in Canada. However, the healthy immigrant effect is only present in certain subgroups of immigrants. These findings are important for the planning of health services targeting immigrants.

African Immigrant Health

As the number and diversity of Africans in the U.S. increases, there is a growing need to assess their health care needs and practices. Although infectious diseases have been a traditional point of contact between health care systems and African immigrants, there is a clear and unmet need to determine the risks and prevalence for chronic diseases. This review includes what has been published concerning the health of African immigrants in the U.S. and draws on European studies to supplement this assessment. While African immigrants arrive in the U.S. with some unique health problems, namely infectious diseases, they are generally healthier than African Americans of the same age. This 'healthy immigrant effect' has been well documented, but the acquisition of risk factors for chronic diseases such as coronary artery disease, hypertension, diabetes and cancer is poorly understood among African immigrants. More information must be gathered in the broad categories of chronic disease, health attitudes and health access to better promote the health of African immigrants.

Immigration and Selected Indicators of Health Status and Healthcare Utilization among the Chinese

We examined indicators of health status and healthcare utilization according to immigration status to assess the 'healthy immigrant effect' for Chinese adults. Data for Chinese in Taiwan (n = 15,549) were from the 2001 Taiwan National Health Interview Survey (NHIS). Data for U.S.-born Chinese (n = 964) and Chinese Immigrants in the U.S. (n = 253) were from the 1998-2004 U.S. NHIS. We used multivariate logistic regression to estimate the adjusted odds of perceived poor health, having ever smoked, and past year emergency room visits according to immigration status. For Chinese immigrants, more years in the U.S. were associated with lower odds of reporting poor health (OR = 0.4; 95% CI = 0.2-0.8) and past-year emergency room use (OR = 0.5; 95% CI = 0.3-0.9). Compared with recent Chinese immigrants (<5 years in U.S.), Chinese in Taiwan had higher odds of reporting poor health (OR = 6.2; 95% CI = 3.2-12.1) and having ever smoked (OR = 1.6; 95% CI = 1.1-2.5). Our results suggest that those who migrate have better health profiles than those who do not migrate. However, recent Chinese immigrants were not significantly different than U.S.-born Chinese.

Comparison of African American and Afro-Caribbean Older Adults' Self-Reported Health Status, Function, and Substance Use

African American and Afro-Caribbean elders differ in regard to ethnic group membership, place of birth, and years of residence in the United States. In this study, the authors compare self-rated health status, function, and reports of substance use in these two groups. Fifty low-income African American and fifty low-income Afro-Caribbean adults older than 55 were matched on gender, income, and age (within a range of 3 years) for this study. Self-reported mental and physical health (SF-8), function (basic and independent activities of daily living), and tobacco and alcohol use were measured. Significant differences between the two ethnic groups were found on four of the SF-8 domains, the physical health summary measure, and tobacco use but not on the mental health summary measure, function, or alcohol use. The differences that emerged suggest a more positive health status and healthier behavior in the immigrant Afro-Caribbean group. Results may be explained by the healthy immigrant effect relating to better health of immigrant as opposed to nonimmigrant populations.

Hospital emergency department utilisation rates among the immigrant population in Barcelona, Spain

BackgroundThe recent increase in the number of immigrants of Barcelona represents a challenge for the public healthcare system, the emergency department being the most used healthcare service by this group. However, utilisation rates in our environment have not yet been studied. We aimed to compare emergency department utilisation rates between Spanish-born and foreign-born residents in a public hospital of Barcelona.MethodsThe study population included all adults residing in the area of study and visiting the emergency department of Hospital del Mar in 2004. The emergency care episodes were selected from the Emergency Department register, and the population figures from the Statistics Department of Barcelona. Emergency care episodes were classified into five large clinical categories. Adjusted rate ratios (RR) of utilisation among foreign-born vs. Spanish-born residents were assessed through negative binomial regression.ResultsThe overall utilisation rate was 382 emergency contacts per 1,000 persons-years. The RR for foreign-born versus Spanish-born residents was 0.62 (95% CI: 0.52; 0.74%). The RR was also significantly below one in surgery (0.51, 95% CI: 0.42; 0.63), traumatology (0.47, 95% CI: 0.38; 0.59), medicine (0.48, 95% CI: 0.38; 0.59) and psychiatry (0.42, 95% CI: 0.18; 0.97). No differences were found in utilisation of gynaecology and minor emergency services.ConclusionThe overall lower utilisation rates obtained for foreign-born residents is consistent with previous studies and is probably due to the "healthy immigrant effect". Thus, the population increase due to immigration does not translate directly into a corresponding increase in the number of emergency contacts. The lack of differences in minor and gynaecological emergency care supports the hypothesis that immigrants overcome certain barriers by using the emergency department to access to health services. The issue of healthcare barriers should therefore be addressed, especially among immigrants.

Return Migration and the 'Healthy Immigrant Effect'

According to the healthy immigrant effect (HIE), immigrants upon arrival are healthier than locally born residents. However, this health advantage is supposed to diminish or even disappear over a relatively short period and the immigrants' health status is converging to that of the natives. The causes for this gradient of immigrants' health are subject to an ongoing discussion and the underlying trajectories are not yet fully understood. This paper investigates whether return migration can serve as an additional explanation for the declining health of immigrants, and thus aims at shedding some light on the trajectories underlying the HIE. The data used are drawn from 13 waves of the German Socio-Economic Panel. Using a random-effects probit model, this analysis explores the factors influencing re-migration by means of a sample of 4,426 migrants. In line with the existing literature, the study shows that e.g. having spouse and children in the home country, or being non-working or jobless yield a higher return probability, whereas all factors associated with attachment to Germany (e.g. language fluency, German citizenship,house ownership) reduce the probability of re-migration. Additionally, the results indicate that men reporting poorer health ('good', 'satisfactory', 'poor' or 'bad') are significantly less likely to return home relative to male immigrants who describe their health as 'very good'. However, for women, the effects are adverse to that of men, and none of the health coefficients for women is significant. Hence - at least for men - re-migration can be seen as an additional explanation for the HIE.

Results of the Recent Immigrant Pregnancy and Perinatal Long-term Evaluation Study (RIPPLES)

People who immigrate to Western nations may experience fewer chronic health problems than original residents of those countries, which raises concerns about long-term environmental or lifestyle factors in those countries. We tested whether the "healthy immigrant effect" extends to the risk of placental dysfunction during the short interval of pregnancy. We conducted a population-based retrospective cohort study of data for 796 105 women who had a first documented obstetric delivery in Ontario between 1995 and 2005. Recency of immigration was determined for each woman as the time from her enrolment in universal health insurance to her date of delivery, classified as less than 3 months, 3-5 months, 6-11 months, 12-23 months, 24-35 months, 36-47 months, 48-59 months and 5 years or more (the referent). The primary composite outcome was maternal placental syndrome (defined as a diagnosis of pre-eclampsia or eclampsia, placental abruption or placental infarction). The mean age of the women was 28.8 years. Maternal placental syndrome occurred in 45 216 women (5.7%). The risk of this outcome was lowest among the women who had immigrated less than 3 months before delivery (3.8%) and highest among those living in Ontario at least 5 years (6.0%), for a crude odds ratio (OR) of 0.62 (95% confidence interval [CI] 0.54-0.71). After adjustment for maternal age, income status, pre-existing hypertension, diabetes mellitus, multiple gestation and receipt of prenatal ultrasonography, the risk of maternal placental syndrome was correlated with the number of months since immigration in a gradient manner (OR, 95% CI): less than 3 months (0.53, 0.47-0.61), 3-5 months (0.68, 0.61-0.76), 6-11 months (0.67, 0.63-0.71), 12-23 months (0.69, 0.66-0.73), 24-35 months (0.75, 0.70-0.79), 36-47 months (0.75, 0.70-0.80) and 48-59 months (0.82, 0.77-0.87). There was a progressively lower risk of maternal placental syndromes associated with recency of immigration. The "healthy immigrant effect" may extend to common placental disorders, diminishes with the duration of residency and underscores the importance of nongenetic determinants of maternal health accrued over a brief period.

Healthier on arrival? Further insight into the "healthy immigrant effect"

In this issue Ray and colleagues[1][1] explore the relation between immigration to Canada (Ontario specifically) and the risk of placental dysfunction. Quantifying a triad of obstetric complications (pre-eclampsia or eclampsia, placental abruption and placental infarction), the study team observed

Chronic Conditions and the Healthy Immigrant Effect: Evidence from Canadian Immigrants

The literature suggests that the foreign-born, and especially recent arrivals, enjoy better health than their Canadian-born counterparts, as measured by a number of health outcomes including self-assessed health and chronic conditions. Using data drawn from Statistics Canada's longitudinal National Population Health Survey (NPHS), the paper evaluates the so-called ‘healthy immigrant effect’ with respect to chronic conditions. Specifically, it evaluates the presence, number and type of chronic conditions (heart disease, asthma, arthritis, diabetes) within the immigrant population, with comparisons made to the native-born population. Native- and foreign-born prevalence rates for chronic conditions are also age–sex standardised to aid comparison. Evidence from both descriptive and multivariate analysis supports the healthy immigrant effect with respect to chronic conditions. Strong evidence of health disparities across arrival cohorts is also found.

Unhealthy assimilation: Why do immigrants converge to American health status levels?

It is well documented that immigrants are in better health upon arrival in the United States than their American counterparts but that this health advantage erodes over time. We study the potential determinants of this "healthy immigrant effect, " with a particular focus on the tendency of immigrants to converge to unhealthy American BMI levels. Using data from the National Health Interview Survey, we find that average female and male immigrants enter the United States with BMIs that are approximately two and five percentage points lower than native-born women and men, respectively. Consistent with the declining health status of immigrants the longer they remain in the United States, we also find that female immigrants almost completely converge to American BMIs within 10 years of arrival, and men close a third of the gap within 15 years.

Structural and behavioural determinants of immigrant and non-immigrant health status: Results from the Canadian community health survey

The purpose of this paper, which utilizes data from the Canadian Community Health Survey (CCHS-Cycle 1.1), is threefold. The first is to examine the health of Canadian immigrants in relation to non-immigrants, focusing on the relationship between key health determinants and health status. Second, it tests whether these data support the well-documented ‘healthy immigrant effect’. The third is to evaluate the usefulness of using a large national database to study ‘special populations’ such as immigrants. Through a comparison of findings from previous studies, the authors highlight the strengths and weaknesses of different datasets for investigating immigrant health and, by extension, the health of other unique populations in Canada.

IMMIGRANT GENERATIONAL STATUS AND ETHNIC DIFFERENCES IN HEALTH

We read with interest 2 recent reports using population-level epidemiological data to make inferences about ethnic differences in illicit drug use status1 or health status.2 Both reports were remiss in not attributing more importance to the influence of immigration history and immigrant generational status. Particularly for countries of origin distant from the United States and Canada and from which most immigrants came voluntarily (as opposed to immigrating as refugees), immigrants tend to have better health status and better health practices than is the norm either in their country of origin or among second-generation or later-generation persons sharing their national heritage.3 This phenomenon is known as the “healthy immigrant” effect.4,5 We applaud Delva and associates’ examination of the effects of acculturation, in which the authors used a question about first language spoken as a child (English or Spanish) as a proxy for acculturation status. First-generation immigrants are more likely to use a language other than English in the home than second or later generations.6 However, we take issue with the authors’ inclusion of respondents of Cuban and Puerto Rican origin in this examination. Most Cuban immigrants have come to the United States as refugees, and Puerto Rican immigrants have had many rights of US citizenship and much exposure to US culture before immigrating to the continental United States. Not surprisingly, Delva and associates found that only for Mexican Americans and “other Latin American” students was the language question a significant predictor of marijuana use or heavy drinking. Consistent with the healthy immigrant effect, use of Spanish in these populations was associated with a reduced likelihood of reporting marijuana use or heavy alcohol drinking. To their credit, Wu and Schimmele did incorporate a dummy variable called “immigrant,” reflecting whether a respondent had been born in Canada or not.7 Again, consistent with the healthy immigrant effect, they found functional health to be greater in first-generation Canadians than in Canadians who were born in Canada. This effect has elsewhere been observed to be particularly pronounced in Blacks, resulting in 7.8 to 9.4 years of extra longevity for first-generation immigrant Blacks compared with native-born Blacks.7 Wu and Schimmele should be more cautious in their speculative explanation for the superior functional health status of Canadian Blacks compared with the health of US Blacks. It would be more parsimonious to attribute the observed national differences in Black mortality rates to national differences in immigration history than to national differences in access to health care. Researchers examining racial/ethnic health disparities in countries characterized by substantial recent immigration should consider and report both immigration history and immigrant generational status because of these factors’ high potential for confounding with ethnicity as contributors to observed disparities in health status.

The effect of immigrant generation on smoking

Immigrants to the US are not only an increasingly significant demographic group but overall they also have lower socioeconomic status (SES) than the native-born. It is known that tobacco use is a major health risk for groups that have low SES. However, there is some evidence that tobacco use among certain immigrant groups is lower than among the respective native-born ethnic group, and that immigrant assimilation is positively related to tobacco use. We investigated the relationship between immigrant generation and daily smoking, using the Tobacco Use Supplement of the Current Population Survey (TUS-CPS), 1995–96, a national data set representative of the US general and immigrant populations. Our multivariate logistic regression analysis of the relationship between immigrant generation and daily smoker status ( n = 221 , 798 ) showed that after controlling for age, gender, race/ethnicity, SES variables (i.e. equivalized household income, education, occupation), and central-city residence, the odds of being a daily smoker were highest among US-born individuals of US-born parents (reference group) and lowest among foreign-born individuals (95% CI: 0.54–0.62). Being a second-generation immigrant (i.e. US born) with two immigrant parents also conferred a protective effective from smoking (95% CI: 0.64–0.77). However, having only one foreign-born parent was not protective against smoking. Testing for interaction effects, we also found that being foreign born and being second generation with two immigrant parents were especially protective against smoking among females (vis-à-vis males); racial/ethnic minorities (vis-à-vis whites); and low-income individuals (vis-à-vis high-income individuals). We discuss possible mechanisms that may explain the protective effect against smoking of being foreign born and being second generation with two immigrant parents, including differences in the stage of the tobacco epidemic between immigrants’ countries of origin and the US, the “healthy immigrant effect”, and anti-smoking socialization in immigrant families.

The Healthy Immigrant Effect

The Healthy Immigrant Effect

Unhealthy Assimilation: Why Do Immigrants Converge to American Health Status Levels?

It is well documented that immigrants are in better health upon arrival in the United States than their American counterparts, but that this health advantage erodes over time. We study the potential determinants of this healthy immigrant effect, with a particular focus on the tendency of immigrants to converge to unhealthy American BMI levels. Using data from the National Health Interview Survey, we find that the average female and male immigrants enter the U.S. with BMIs that are approximately two and five percentage points lower than native-born women and men, respectively. And, consistent with the declining health status of immigrants the longer they remain in the United States, we also find that female immigrants almost completely converge to American BMIs within ten years of arrival and men close a third of the gap within fifteen years.

Self-rated health within the Canadian immigrant population: risk and the healthy immigrant effect

Set within the determinants of health framework and drawing upon Statistics Canada's longitudinal National Population Health Survey, this paper explores the self-assessed health of Canada's immigrant population. Using both descriptive and multivariate techniques, including logistic regression and survival analysis, the intent is to identify differences in self-assessed health between the immigrant and native-born populations, the factors that contribute to immigrant self-assessed health, and the factors associated with declining self-assessed health status. In each case, the key questions are whether differences in health status exist between the native- and foreign-born. Results indicate mixed support for the Healthy Immigrant Effect, with the native- and foreign-born neither more nor less likely to rank their health as fair or poor. However, results from the proportional hazards model indicated that the native-born were at lower risk to transition to poor health.

Recent Research on Immigrant Health from Statistics Canada’s Population Surveys

This paper reviews recent research using Statistics Canada data to compare immigrant health with that of the Canadian-born. A number of Statistics Canada studies have been used for such comparisons, including the National Population Health Survey and the Canadian Community Health Survey. Across the range of indicators studied, compared to the Canadian-born, immigrants are generally in as good or better health, have similar or better health behaviours, and similar or less frequent health service use (the "healthy immigrant effect"). These indications appear to be strongest among recent and non-European immigrants. These studies have established baseline patterns and identified that important distinctions exist among immigrant subgroups. Future research on more detailed subgroups that uses longitudinal data and cross-culturally validated instruments is needed.

New Approaches to Immigrant Health Assessment

While immigrant subgroups may present vulnerabilities in terms of health status, health service use, and social determinants, comprehensive information on their health is lacking. To examine mortality (1980-1998) and health service utilization (1985-2002) patterns in Canadian immigrants, a record linkage pan-Canadian research initiative using immigration and health databases has been undertaken. Preliminary results indicate that overall mortality is low among Canadian immigrants as compared to the general population for most leading causes (thus supporting the notion of "healthy immigrant effect"), with cause-specific exceptions. Moreover, results from British Columbia show that overall physician visits are low for immigrants, but not for all subgroups. Results from Ontario demonstrate a sharp increase in physician claims approximately three months following landing. Future analyses will address the short- and long-term health outcomes of immigrant subgroups, including less common diseases. Results are pertinent to practitioners working with immigrants and can inform immigrant health policy.