Health and migration: Latin Americans in the United States

Fernando Riosmena and Warren C. Jochem

Latin American immigrants to the United States come from a variety of places and, thus, disease environments. As such, their health profiles differ considerably from those of individuals born in the United States (including those of people of Hispanic descent), though not necessarily in the way one might expect. Although foreign-born Latinos come from places with arguably less favorable health profiles relative to that of the United States, they exhibit better physical health than US-born non-Hispanic whites in many (but not all) measures, especially mortality (Cunningham et al. 2008). This finding is known as the Hispanic Health Paradox (HHP) because Latino immigrants tend to have lower average socioeconomic status, and social class generally has a strong and positive relationship with health (Adler & Ostrove 1999). Despite this (initial) advantage, the health of Hispanic immigrants also seems to worsen with their adaptation to the prevalent values, customs, and behaviors of the host society, a process known as negative acculturation (Lara et al. 2005). In this essay, we describe the general mechanisms that could explain differences in the health profile of Latin American immigrants, and on those that could explain their health trajectories after arrival in the United States. As both factors in sending and destination areas explain these patterns, we argue that knowing where migrants come from and the reasons why they migrated are vital to understanding both of these phenomena and, thus, the health care needs of the immigrant population.

The Hispanic paradox or the immigrant health advantage

Data problems There are four broad categories of possible mechanisms explaining the HHP. The first relates to data errors. If immigrant health measures are disproportionately biased, their good health could be exaggerated. While there is indeed some evidence that data problems lead us to sometimes overestimate the health of immigrants, the HHP cannot be solely explained by these errors. For instance, estimates of the immigrant advantage based on self-reported health measures, such as have you ever been diagnosed with [diabetes, cancer, etc.], may be exaggerated the more these measures depend on previous screening. This is because screening is in turn contingent on access to health insurance and health care, to which foreign-born Hispanics in the United States have lower levels of access (Angel et al. 2002). Although the HHP is first and foremost observed in mortality, and death rates are not affected by self-reporting biases, mortality estimates based on vital statistics and population enumeration are (slightly) downward-biased for Latino immigrants in particular due to the misclassification of ethnicity in death certificates (Arias et al. 2010). Some of these problems are remedied by the use of population-based surveys linked to the national death index, though mortality estimates using these are also slightly downwardly biased due to poor matching (Patel et al. 2004). Despite these problems, note that the Latino immigrant advantage in mortality is not the sole result of these artifacts (Markides & Eschbach 2005). Return migration selection The immigrant advantage could also be partially explained by negative health selection in

The Encyclopedia of Global Human Migration, Edited by Immanuel Ness. 2013 Blackwell Publishing Ltd. Published 2013 by Blackwell Publishing Ltd. DOI: 10.1002/9781444351071.wbeghm267

health and migration: latin americans in the united states

fully explain the immigrant health advantage by itself either.

return migration, better known as the salmon bias hypothesis. As most studies looking at the health of migrants use US-based data only, they only observe those members of an immigrant cohort who still remain in the United States. If those less healthy are more likely to leave the United States, whether solely due to their poor health or due to other reasons associated with poor health, the observed health of remaining migrants will appear to be better than it would otherwise have been if returnees had not left or were included in these calculations. Studies that have been able to directly compare the health of both immigrants in the United States and return migrants back in the country of origin have found some salmon bias. However, as in the case of data errors, this statistical artifact cannot explain the entire immigrant health advantage as the amount of bias is modest (Turra & Elo 2008) or as the immigrant health advantage is still observed in populations with negligible return migration (Abrado-Lanza et al. 1999). Emigration selection Other explanations for the HHP must thus lie elsewhere. The fact that immigrants have better health outcomes than non-Hispanic whites could reflect the fact that their health is better than those of (nonmigrants) left behind. If so, the HHP is the product of (positive) emigration selection, a set of processes whereby health itself or unmeasured characteristics correlated with health are associated with emigration to the United States. This is likely, given that migration tends to be a hard and selective endeavor (Orrenius & Zavodny 2005). Notwithstanding the plausibility of this argument, most studies dealing with this topic fail to test emigration selection directly by comparing the health conditions of migrants (or, better, migrants-to-be) with those of their nonmigrant counterparts. The handful of studies that manage to directly compare the experience of immigrants in the United States with nonmigrants in sending countries have found some but generally weak evidence consistent with positive emigration selection (e.g., Rubalcava et al. 2008). Thus, selection may not

Sociocultural protection versus negative acculturation in migrant health trajectories

Sociocultural protection Most of these studies looking at the HHP use outcomes measured some time after migration takes place. Therefore factors in the host country could also contribute to their health trajectory and observed advantage and thus constitute a fourth mechanism to explain the HHP (and, as we explain below, this may be intimately related to the negative acculturation in health phenomenon). Sociocultural protective factors could be contributing to migrants ability to cope better with their health status by allowing them to shelter in and receive social support from their communities and networks, which allows them to better cope with stress and to maintain health-protective behaviors. This is a likely issue given the strong role of networks in the migration process at large (Massey & Espinosa 1997). Consistent with this idea of sociocultural protection, Hispanics living in neighborhoods with large concentrations of co-ethnics are healthier than those outside such neighborhoods in spite of the lower socioeconomic conditions in the former places (e.g., Eschbach et al. 2005). While these studies provide insights regarding the acculturation process in general, they have not strictly provided evidence of sociocultural protection among immigrants, as they have not distinguished if the barrio effect was beneficial in the same way for both the US- and the foreign-born. The evidence from studies which have made this distinction or which have looked exclusively at foreign-born Latinos is mixed, some finding no barrio advantage for immigrants (e.g., Lee & Ferraro 2007), but some finding it (e.g., Osypuk et al. 2009). Negative acculturation These protective processes may weaken over time, as suggested by the fact that immigrant

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health is negatively associated with measures of exposure to US society, such as duration of stay and acculturation scales (Lara et al. 2005). As such, scholars have argued that immigrant incorporation into the cultural mainstream includes the adoption of unhealthier lifestyles that are generally more pervasive in the United States than in migrants countries of origin. Such lifestyle changes include lower consumption of fruit and vegetables, fiber, and other unfavorable dietary practices (Akresh 2007). Most likely as a result of these changes, acculturation measures are associated with higher obesity levels (Akresh 2007). Smoking prevalence and alcohol use (Abrado-Lanza et al. 2005), disability rates (Singh & Siahpush 2002), and chronic disease prevalence (Gorman & Read 2006) are also higher with increased acculturation. Longer durations of stay (or an earlier age at immigration) are also associated with a higher risk of mortality (Coln-Lpez et al. 2009). As such, some of these studies support the idea of protection, or may at least suggest that spatial mobility away from migrant or ethnic enclaves (e.g. South et al. 2005) and negative health acculturation processes are related. Also note that part of the immigrant advantage on health could be artificially driven by differential access to health care. As health care access tends to increase with US experience, the negative correlation between self-reported health measures and duration in the United States could thus be exaggerated by the lower access to screening among less experienced migrants (Jurkowski & Johnson 2005). But again, as negative acculturation is observed in outcomes such as mortality, the problem with self-reported measures is not the whole story. homeland. In addition, migrants also tend to be quite healthy, healthier than nonmigrants remaining behind in sending areas, and healthier than the general US population. Note, however, that the mortality advantage sometimes does not hold for many health outcomes (Cunningham et al. 2008), which may imply that migrants have a longer but unhealthier life and a less active old age (Eschbach et al. 2007). This trajectory may be the product of a paradoxical process of adaptation to US society: immigrants generally come to the United States to improve their standards of living and those of their offspring, and assimilating into the mainstream should be accompanied by favorable structural changes. However, something seems to happen during this process that is detrimental to peoples health. We cannot help but posit that this is due to the accumulation of stress related to disadvantage (see Crimmins et al. 2007), which may erode some of the potential protection effects mentioned above. Note that, while space considerations only allow us to depict general patterns, there is considerable variation across national groups of Hispanic origin in both the immigrant health advantage (Hummer et al. 2000) and negative acculturation processes (Cho et al. 2004). Given that Latino immigrants come from a great variety of places and due to diverse reasons, scholars, policymakers, and health practitioners should avoid overgeneralizing prescriptions to improve or treat migrant health: we need to know more about the health status and trajectories of specific groups and what explains variation (and not only central tendency measures) in health profiles and trajectories. Finally, because of variation across national groups and due to the fact that both health selection in emigration and return migration seem to matter, it is important to keep the places people come from in perspective. SEE ALSO: Ethnic selection in immigration to Latin America; Health and migration: an overview; Mental health and migration; Public health and development; Public health and migration

Conclusions
We have briefly shown the complexity of mechanisms affecting Latino migrant health. On the one hand, the Latino immigrant health advantage is indeed partially the result of some data problems and due to the return migration of people with slightly worse health to their

health and migration: latin americans in the united states

older US- and foreign-born Mexican Americans. In J. L. Angel & K. E. Whitfield (eds.), The Health of Aging Hispanics: The Mexican-Origin Population. New York: Springer. Eschbach, K., Mahnken, J. D., & Goodwin, J. S. (2005) Neighborhood composition and incidence of cancer among Hispanics in the United States. Cancer 103(5), 10361044. Frenk, J., Bobadilla, J. L., & Lozano, R. (1996) The epidemiological transition in Latin America. In I. Timaeus, J. Chackiel, & L. T. Ruzicka (eds.), Adult Mortality in Latin America. Oxford: Oxford University Press. Gorman, B. K. & Read, J. N. G. (2006) Gender disparities in adult health: An examination of three measures of morbidity. Journal of Health and Social Behavior 47(2), 95-110. Hummer, R. A., Rogers, R. G., Amir, S. H., et al. (2000) Adult mortality differentials among Hispanic subgroups and non-Hispanic whites. Social Science Quarterly 81(1), 459476. Jurkowski, J. M. & Johnson, T. P. (2005) Acculturation and cardiovascular disease screening practices among Mexican Americans living in Chicago. Ethnicity & Disease 15(3), 411417. Lara, M., Gamboa, C., Kahramanian, M. I., et al. (2005) Acculturation and Latino health in the United States: A review of the literature and its sociopolitical context. Annual Review of Public Health 26, 367397. Lee, M.-A. & Ferraro, K. F. (2007) Neighborhood residential segregation and physical health among Hispanic Americans: Good, bad, or benign? Journal of Health and Social Behavior 48(2), 131148. Markides, K. S. & Eschbach, K. (2005) Aging, migration, and mortality: Current status of research on the Hispanic paradox [special issue 2]. Journals of Gerontology Series B (60), S68S75. Markides, K. S., Salinas, J., & Wong, R. (2010) Ageing and health among Hispanics/Latinos in the Americas. In D. Dannefer & C. Phillipson (eds.), Handbook of Aging and the Life Course. London: Sage. Massey, D. S. & Espinosa, K. E. (1997) Whats driving MexicoUS migration? A theoretical, empirical, and policy analysis. American Journal of Sociology 102(4), 939999. Orrenius, P. M. & Zavodny, M. (2005) Selfselection among undocumented immigrants from Mexico. Journal of Development Economics 78(1), 215240. Osypuk, T. L., Diez Roux, A. V., Hadley, C., et al. (2009) Are immigrant enclaves healthy places to

References and further reading

Abrado-Lanza, A. F., Chao, M. T., & Flrez, K. R. (2005) Do healthy behaviors decline with greater acculturation? Implications for the Latino mortality paradox. Social Science & Medicine 61(6), 12431255. Abrado-Lanza, A. F., Dohrenwend, B. P., Ng-Mak, D. S., et al. (1999) The Latino mortality paradox: A test of the salmon bias and healthy migrant hypotheses. American Journal of Public Health 89(10), 15431548. Adler, N. E. & Ostrove, J. M. (1999) Socioeconomic status and health: What we know and what we dont. Annals of the New York Academy of Sciences 896, 315. Akresh, I. R. (2007) Dietary assimilation and health among Hispanic immigrants to the United States. Journal of Health and Social Behavior 48(4), 404417. Angel, R. J., Angel, J. L., & Markides, K. S. (2002) Stability and change in health insurance among older Mexican Americans: Longitudinal evidence from the Hispanic established populations for epidemiologic study of the elderly. American Journal of Public Health 92(8), 12641271. Arias, E., Eschbach, K., Schauman, W. S., et al. (2010) The Hispanic mortality advantage and ethnic misclassification on US death certificates. American Journal of Public Health 100(S1), S171177. Boyle, P. & Norman, P. (2010) Migration and health. In T. Brown, S. McLafferty, & G. Moon (eds.), A Companion to Health and Medical Geography. Malden, MA: Wiley-Blackwell. Cho, Y., Frisbie, W. P., Hummer, R. A., et al. (2004) Nativity, duration of residence, and the health of Hispanic adults in the United States. International Migration Review 38(1), 184211. Coln-Lpez, V., Haan, M. N., Aiello, A. E., et al. (2009) The effect of age at migration on cardiovascular mortality among elderly Mexican immigrants. Annals of Epidemiology 19(1), 814. Crimmins, E. M., Kim, J. K., Alley, D. E., et al. (2007) Hispanic paradox in biological risk profiles. American Journal of Public Health 97(7), 13051310. Cunningham, S. A., Ruben, J. D., & Narayan, K. M. V. (2008) Health of foreign-born people in the United States: A review. Health & Place 14(4), 623635. Eschbach, K., Al Snih, S., Markides, K. S., et al. (2007) Disability and active life expectancy of

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live? The Multi-ethnic Study of Atherosclerosis. Social Science & Medicine 69(1), 110120. Patel, K. V., Eschbach, K., Ray, L. A., et al. (2004) Evaluation of mortality data for older Mexican Americans: implications for the Hispanic paradox. American Journal of Epidemiology 159(7), 707715. Popkin, B. M. (2003) The nutrition transition in the developing world. Development Policy Review 21(56), 581597. Rubalcava, L. N., Teruel, G. M., Thomas, D., et al. (2008) The healthy migrant effect: New findings from the Mexican family life survey. American Journal of Public Health 98(1), 7884. Singh, G. K. & Siahpush, M. (2002) Ethnicimmigrant differentials in health behaviors, morbidity, and cause-specific mortality in the United States: An analysis of two national databases. Human Biology 74(1), 83109. South, S. J., Crowder, K., & Chavez, E. (2005) Migration and spatial assimilation among US Latinos: Classical versus segmented trajectories. Demography 42(3), 497521. Turra, C. M. & Elo, I. T. (2008) The impact of salmon bias on the Hispanic mortality advantage: New evidence from social security data. Population Research and Policy Review 27(5), 515530.