the roles of emotional support, family, and social integration
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Gorman, Ecklund, and Heard 2010TRANSCRIPT
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NATIVITY DIFFERENCES INPHYSICAL HEALTH: THEROLES OF EMOTIONALSUPPORT, FAMILY, AND SOCIALINTEGRATIONBridget K. Gorman a , Elaine Howard Ecklund a &Holly E. Heard aa Department of Sociology, Rice University, Houston,Texas, USAVersion of record first published: 27 Sep 2010.
To cite this article: Bridget K. Gorman , Elaine Howard Ecklund & Holly E. Heard(2010): NATIVITY DIFFERENCES IN PHYSICAL HEALTH: THE ROLES OF EMOTIONALSUPPORT, FAMILY, AND SOCIAL INTEGRATION, Sociological Spectrum: Mid-SouthSociological Association, 30:6, 671-694
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NATIVITY DIFFERENCES IN PHYSICAL HEALTH:THE ROLES OF EMOTIONAL SUPPORT, FAMILY, ANDSOCIAL INTEGRATION
Bridget K. GormanElaine Howard Ecklund
Holly E. Heard
Department of Sociology, Rice University, Houston, Texas, USA
U.S. immigrants are a physically healthy population, but we do notunderstand the explanatory factors responsible for their physical healthstatus, particularly those related to social network support. Using datafrom the 2001 wave of the National Health Interview Survey, we examinemultiple measures of immigrant adaptation, investigating their influ-ence on measures of physical health. In particular, we examine how wellindicators of social support and integration explain the immigranthealth advantage. Results show clear evidence of an immigrant paradoxin physical health, but that measures of support and integration explainalmost none of the immigration effect on physical health.
Immigrants come to the United States, often overcoming harshconditions and obstacles, expecting the land of opportunity (Ecklund2006; Wuthnow 2006). Part of opportunity involves increased advan-tages for better health. And new migrants are generally healthy—asituation that scholars think is paradoxical because the socioeco-nomic status of immigrants tends to be lower than the native-bornpopulation. Scholars who examine health among immigrants havealso shown, however, that while they are initially healthier than thenative-born population, with time in the United States their healthstatus appears to decline (Abraido-Lanza et al. 2005; Acevedo-Garciaet al. 2005; Antecol and Bedard 2006; Cho et al. 2004; Finch et al.
Address correspondence to Bridget K. Gorman, Rice University, Department of Sociology
MS 28, 6100 Main St., Houston, TX 77005, USA. E-mail: [email protected]
Sociological Spectrum, 30: 671–694, 2010
Copyright # Taylor & Francis Group, LLC
ISSN: 0273-2173 print=1521-0707 online
DOI: 10.1080/02732173.2010.510059
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2004;Franzini andFernandez-Esquer 2004;Landale et al. 1999;Lopez-Gonzalez et al. 2005). Such an immigrant health paradox has beenobserved for many years and across a range of ethnic groups, yetfew studies investigate the more precise reasons underlying thisphenomenon. Here, using data from the 2001 wave of the NationalHealth Interview Survey (NHIS), we examine the role of social net-work support for predicting health status among adults. While mul-tiple studies have investigated the importance of various aspects ofsocial network support for health in general (see review by Berkmanand Glass 2000), the contribution of social networks to health differ-ences between immigrant and native-born populations is not wellunderstood. In this article, we examine the mediating influence ofsocial network support as an explanatory pathway linking physicalhealth outcomes to multiple measures of immigrant status.
Specifically, we investigate the following questions. First, does theimmigrant health paradox hold across different measures of physicalhealth and immigrant status? We examine two objective measures(hypertension, heart disease) and one subjective measure of physicalhealth (self-rated health), and measure immigrant status in terms ofduration of U.S. residence, citizenship status, and English languageusage during the interview. Second, if immigrants are physicallyhealthier than the native born, does social support explain this differ-ence? We examine emotional support specifically as well as measuresof social integration, including marital status, family size, frequencyof contact with family and friends, and attendance at worship servicesand other group events.
THE HEALTHY IMMIGRANT EFFECT
During the latter half of the twentieth century the number ofimmigrants entering the United States increased substantially. Over-all, 37 million foreign-born persons reside in the United States, repre-senting 12 percent of the total U.S. population (Martin and Midgeley2006). As the size of the foreign-born population continues to grow,so does research examining immigrant health and well-being. Severalstudies document that while the health profile of the foreign-bornpopulation is as good (and sometimes better) than the native-bornU.S. population, this advantage declines with duration in the UnitedStates (Antecol and Bedard 2006; Cho and Hummer 2001; Singh andSiahpush 2002). That new migrants should have such good health issurprising, given the relatively limited socioeconomic resources ofmany groups of immigrants upon initial migration (Waters 1999).
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Indeed, this pattern runs counter to a great deal of research docu-menting poor health outcomes among lower socioeconomic groupsin the United States (House and Williams 2000), and past studies fre-quently find that adjusting for socioeconomic status does not explainthe relationship between immigrant characteristics and measures ofphysical health (e.g., Angel et al. 2001a; Cho et al. 2004).
To account for this pattern, two complementary explanations areoften applied. First, immigrants are healthier than their counterpartswho did not migrate—appearing to represent a selective snapshot ofresidents from their country-of-origin (Jasso et al. 2004; Landale et al.2000). Second, immigrants living in the United States benefit fromcultural ties and norms that emphasize healthier behaviors and strongfamily support networks (see discussion by Jasso et al. 2004; Vegaand Amaro 1994). Studies also indicate, however, that immigranthealth deteriorates with increasing time spent in the United States,even when socioeconomic status rises (Jasso et al. 2002). Existingresearch suggests two conclusions: first, selection cannot completelyaccount for the healthy immigrant effect, and researchers should alsoconsider the role of acculturation (often measured by duration ofresidence in the United States, language use, and citizenship). Second,over time changes in other health-related factors (e.g., declining socialsupport) may override the health gains associated with increasedeconomic well-being.1
Most often, declines in immigrant health with time spent in theUnited States are explained by increases in unhealthy behaviors.Specifically, with increasing acculturation immigrants tend to reportmore smoking (Abraido-Lanza et al. 2005; Acevedo-Garcia et al.2005; Balcazar et al. 1996), higher alcohol intake (Abraido-Lanzaet al. 2005; Balcazar et al. 1996; Elder et al. 2005), poorer diet(Jonnalagadda and Diwan 2005) and a higher body mass index(Abraido-Lanza et al. 2005; Antecol and Bedard 2006). Frequencyof exercise, however, appears to increase with acculturation (Abraido-Lanza et al. 2005; Evenson et al. 2004; Jonnalagadda and Diwan2005).
Less understood is the role of social network support as anexplanatory mechanism linking immigrant status to health outcomes.This is surprising, since theoretical works exploring the strong andpositive connection between social networks and health date backto the late nineteenth century and the works of Emile Durkheim,especially Suicide, which established the foundational connections
1While most research supports a decline in health with time spent in the United States,
other work suggests that health may actually improve during the short term (Jasso et al. 2004).
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between social integration and health (Durkheim 1897, 1951).Berkman and Glass (2000), in their excellent review of the existingliterature, conclude that social networks influence individual healththrough four pathways. First, health is influenced by the provisionof social support, including emotional, instrumental, appraisal, andinformational support. Second, social networks influence healththrough social influence, whereby shared norms regarding healthbehaviors (e.g., the acceptability of smoking) shape health outcomes.Third, networks have an impact on health by promoting socialengagement and attachment, through contact with friends, family,and participation in social functions. Fourth, networks can provideaccess to material resources that have a direct influence on health(e.g., membership in religious organizations that assist in accessinghealth care). These pathways are not mutually exclusive, often oper-ating simultaneously.
In this study, we examine the relevance of two of these pathways:the provision of social support (specifically, emotional support), andsocial engagement and attachment, which we refer to as social inte-gration and test with measures of marital status and household struc-ture, recent contact with friends and family, and attendance at churchand other group events. Our focus on these specific pathways is basedon the considerable evidence that social support is related to numer-ous health outcomes, as well as mortality (Glass et al. 1999). Forexample, emotional and instrumental support were negatively relatedto somatic symptoms in a mostly immigrant sample of Chinese Amer-icans in Los Angeles County (Mak and Zane 2004). Numerousaspects of social integration also are related to health. Single parentscan experience stress and role overload (Weiss 1979) that negativelyimpact health, while marriage benefits the health of both men andwomen by providing economic resources and encouraging risk-aversebehavior and health monitoring (Waite 1995). Finally, indices ofsocial integration that include social contacts and group membershipare significant predictors of mortality and risky health behaviors(Berkman and Breslow 1983, Berkman and Syme 1979).
Immigration researchers often argue that the migration experiencerelies on and encourages strong social network support (Sanders et al.2002; Vega et al. 1991). Because of the family reunification process ofU.S. immigration policy (Martin and Midgeley 2006), immigrantsoften settle in areas of the country where they know people and findother co-ethnic residents (Arnold 1989). This process of chainmigration (Arnold 1989; Nee and Sanders 2001) may mean that—at least initially—immigrants come to the United States with strongsocial network ties. These network ties may be particularly important
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for a population faced with adjustment to a new culture and with sig-nificant need for assistance. Indeed, immigrants are more likely thanthe native born to both utilize and provide instrumental supportssuch as economic exchanges and coresidence with extended kin(Glick 1999, 2000). Social ties can also benefit health by reducingthe stress associated with moving to a new country and culture, ormore directly through, for example, providing guidance about howto navigate the U.S. medical system. With increasing acculturationand duration in the United States, social ties might weaken as immi-grants become part of the broader community (Alba and Nee 2003;Nee et al. 1994), with the unintended consequence that their healthdeclines as well.
Yet, other research argues that the experience of social networkbonding for immigrants is not always a positive one. Rogler (1994)notes that immigration engenders an upheaval in social relationships,as immigrants must break primary ties to family and friends in thehome country and seek out or strengthen sources of support in thereceiving country. This process of loss and readjustment in socialrelationships may contribute to acculturative stress and poorerhealth. A study of South Asian immigrant women reveals that lossof extended family and social activities are stress factors that contrib-ute to their mental health concerns (Ahmad et al. 2004). Uponarrival, immigrants become tightly enmeshed in the family network,which Rumbaut (1997, p. 8) notes can be ‘‘at once a rich resourceand a potential vulnerability.’’ The isolation and dependency newimmigrants experience can amplify family conflicts, especially duringthe stressful resettlement process. Even non-kin networks can besources of stress. Usita (2005) found that immigrant Japanese womencited coethnic immigrant women as an important source of interper-sonal problems in their lives, but were unwilling to end those relation-ships because they were also a source of ethnic identity. Finally,membership in social networks can involve both giving and receivingsocial support and engagement (see Cherlin 2005; Kahn andAntonucci 1980); if immigrants are more embedded in social net-works, they may be obligated to provide resources to kin, to theneglect of their own health.
Immigrant Physical Health
Examining physical morbidity and mortality is a key facet of studiesof immigrant physical health. Using data from the National Longi-tudinal Mortality Study and the National Health Interview Study,Singh and Siahpush (2002) conclude that risks for all-cause mortality,
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as well as cause-specific mortality (e.g., death due to cardiovasculardisease), are significantly lower among the foreign born. Studies ofmorbidity also find lower rates of physical health problems, includinghypertension and heart disease, among the foreign born (Wilkinsonet al. 1996), although rates increase with acculturation (Singh andSiahpush 2002, Steffen et al. 2006).
Yet, while the immigrant paradox is clear for most measures ofphysical health, the picture is less clear for self-rated health. This isperhaps not surprising since adults often base these subjective healthassessments on a variety of factors from several different domains oflife, including social and emotional well-being (Idler and Benyamini1997). Some studies find that immigrant adults report better self-rated health than the native born (Cho et al. 2004; Finch and Vega2003) and that self-rated health declines with time spent in the UnitedStates (Finch et al. 2004), while others report better self-rated amongthe native born (Angel et al. 2001a, 2001b; Franzini and Fernandez-Esquer 2004; Wilkinson et al. 2006). Studies that consider languageuse, however, tend to report poorer self-rated health among adultswho are not proficient in English, which may reflect differences inhow non-English speakers interpret and assess queries about theirhealth status (see discussion by Franzini and Fernandez-Esquer2004). Regardless of which group experiences an elevated poor healthrisk, effects appear very sensitive to adjustment for socioeconomic anddemographic differences between foreign- and native-born groups(e.g., Angel et al. 2001b; Cho et al. 2004; Finch and Vega 2003).
We found no studies that explore the explanatory role of socialsupport and integration in the relationship between immigrationand hypertension or heart disease, and findings for self-rated healthare fragmented at best. Several studies show a direct, protective effectfor multiple measures of support and=or integration in multivariatemodels examining the relationship between immigrant status andself-rated health, although direct assessments of how much thesemeasures explain the effects of immigrant status are not included(Angel et al. 2001b; Cho et al. 2004; Finch and Vega 2003; Franziniand Fernandez-Esquer 2004). However, two studies by Finch andcolleagues (2001, 2004) do test for mediating effects, finding no evi-dence that social support or integration explain the effects of nativityor English acculturation on self-rated health for Mexican adults. Fur-thermore, Angel and colleagues (2001a) find that church attendanceand satisfaction with home and family life have no influence onself-rated health among foreign-born Hispanics, although they allhave a protective influence for the native born; these might helpexplain the higher self-rated health scores among the native born.
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And, Finch and Vega (2003) find that instrumental and religious sup-port buffer the negative effects of acculturative stress (measured asperceived discrimination due to Mexican-origin status) on self-ratedhealth, but did not test for buffering effects between social support=integration and indicators of acculturation.
DATA AND MEASURES
Study Sample
Analyses are based on data from the 2001 wave of the NHIS, anannual survey conducted by the National Center for Health Statisticsand the Centers for Disease Control and Prevention, administered bythe U.S. Census Bureau. NHIS uses a multistage, stratified, clustersample design, with oversamples of blacks and Hispanics. Data werecollected with each member of the household via face-to-face inter-views about health and other attributes. When weighted, data arenationally representative of the non-institutionalized civilian popu-lation in the United States.
For each family in the NHIS, one sample adult (aged 18 andabove) was randomly selected and included in the sample adult core.These respondents were asked a detailed set of questions regardinghealth status, health care services, and behavior. In the 2001 wave(N¼ 33,326), the survey asked additional questions regarding socialsupport and integration. The sample for this study includes adultswith non-missing information on the physical health outcome mea-sures (N¼ 31,732).2 Missing values on independent measures wereimputed using the impute command in STATA (see StataCorp 2003for more information).3
Physical Health Measures
We examine three physical health outcomes in this article. Respon-dents were asked whether they had ever been told by a doctor or
2Because of our interest in family structure as a mediator between immigration status and
health outcomes, we also removed 289 adults from our sample who reported that they lived
with other adults and children (but no parents), due to the small number of persons living in
this family structure type.3For imputed measures, the majority had a very low rate of missing values (0.1–3.6 percent).
Nonresponse was much higher for the family income-to-poverty ratio (22.1 percent of cases),
so logistic regression models include a dummy variable that flags missing cases on income (not
shown).
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other health professional they had hypertension (or high blood press-ure), and whether they were ever told they had heart disease (coro-nary heart disease, angina pectoris, or any other heart condition ordisease). Responses for hypertension and heart disease were coded1¼ yes, 0¼ no. In addition, we examined self-rated health. Respon-dents were asked to rate their health in general on a five-point scale(poor, fair, good, very good, and excellent). We recoded thismeasure into two categories that contrast poor health (1¼ poor orfair self-rated health) with good health (0¼ good, very good, orexcellent health) because this measure was highly skewed towardsgood health, and to focus our attention on adults who do notreport good health—the most problematic outcome from a healthstandpoint.
Independent Measures
Our predictor measures are clustered into five categories: immi-gration characteristics, social support and integration, health beha-viors, mental health, and demographic and socioeconomic statuscontrols. Because immigration characteristics are our predictors ofinterest, we included three measures to tap the immigration statusof respondents. First, we included a categorical measure of durationof residence in the United States: U.S. born (reference), born outsidethe United States and living in the United States for fewer than 5years, born outside the United States and living in the UnitedStates for 5–14 years, and born outside the United States and livingin the United States for 15 or more years. We also included measuresof citizenship status (1¼U.S. citizen, 0¼ not a U.S. citizen) andwhether the NHIS interview was completed in English (1¼ non-English interview, 0¼English interview).4
We also include six measures of social support and integration.Family structure is an eight-category measure encompassing unionstatus, residence with extended kin, and presence of children: livingalone (reference); living with roommates; married or cohabiting with-out children; other adult-only families; single parent; married orcohabiting with children; stepfamily with children; and parent(s),children, and adult relatives. We tap social support with a measureof emotional support. Specifically, respondents were asked, ‘‘How
4It is important to include language because differences in health measures such as
self-reported health may be an artifact of low proficiency in English language (Bzostek et al.
2007).
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often do you get the social and emotional support you need?’’Responses were measured on a five-point scale, where 1¼ never,2¼ rarely, 3¼ sometimes, 4¼ usually, and 5¼ always. Since themeasure was skewed towards higher levels of support, we collapsed itinto three categories: never or rarely gets needed support (reference),sometimes gets needed support, and usually or always gets neededsupport.
The NHIS also included a series of yes=no questions tapping socialintegration during the past two weeks. First, respondents were askedwhether they (1) talked to friends or neighbors on the telephone, and(2) talked on the telephone with any relatives who lived outside theirhome. We combined these two questions into a three-category indi-cator of whether respondents talked to either friends or family butnot both, talked to both friends and family, or talked to neither (ref-erence). Similarly, we combined two questions on whether respon-dents got together socially with friends and neighbors, or got togetherwith relatives living outside their home, to create a categorical mea-sure indicating whether respondents got together with either friendsor family but not both, got together with both friends and family,or neither (reference). Last, we include dichotomous measures ofwhether respondents attended a church, temple, or another place ofworship for services or other activities (1¼ yes, 0¼ no), and whetherthey went to a show or movie, sports event, club meeting, class orother group event (1¼ yes, 0¼ no).
Health behaviors were captured with four measures. First, weincluded smoking status as a dummy measure, where 1¼ currentsmoker and 0¼ not a current smoker. Second, we compared thosewho reported binge drinking (consuming more than five drinks peroccasion) with adults who reported all lower levels of alcoholconsumption. Third, based on body mass index, we created a dichot-omous measure where 1¼ obese weight, and 0¼ all lower weight.Fourth, we created a measure of physical exercise based on theaverage response to four questions regarding the frequency of physi-cal activity each week: (1) vigorous activities for at least ten minutesthat cause heavy sweating or large increases in breathing or heartrate; (2) light or moderate activities for at least ten minutes thatcause only light sweating or a slight to moderate increase inbreathing or heart rate; (3) physical activities specifically designedto strengthen muscles such as lifting weights or doing calisthenics;and (4) physical activities designed to stretch muscles, such as yoga(Cronbach’s alpha ¼.74). Because most adults reported low levelsof exercise, we dichotomized this measure so that 1¼ no exerciseand 0¼ all higher levels of exercise.
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We also control for measures of mental health, since studiesdemonstrate that mental health influences physical health status(e.g., Rugulies 2002). Our mental health measures include an indi-cator of short-term depressive mood constructed from the averageresponse to six questions (1¼ none of the time to 5¼ all of the time).Specifically, the questions asked how often, during the last 30 days,the respondent felt sad, hopeless, restless, nervous, worthless, andthat everything was an effort (Cronbach’s alpha¼ .86). This indexwas constructed from questions drawn from Item Response Theorymodels, and was validated with a two-stage clinical reappraisal sur-vey (Kessler 2002). Because this measure was highly skewed towardsadults who reported no symptoms, we created a dichotomous mea-sure of depressive mood where 1¼ some, most, or all of the time,and 0¼ none or a little of the time. Our second measure of mentalhealth was based on a question that asked how satisfied respondentswere with their life, where 1¼ very dissatisfied, 2¼ dissatisfied,3¼ satisfied, and 4¼ very satisfied. Because this measure was alsoskewed, we recoded this as a ‘‘dissatisfaction with life’’ measurewhere 1¼ very dissatisfied or dissatisfied, and 0¼ very satisfied orsatisfied. Last is a measure of unhappiness, based on a question thatasked how often respondents felt happy in the past 30 days (1¼ noneof the time, 2¼ a little of the time, 3¼ some of the time, 4¼mostof the time, and 5¼ all of the time). We recoded this measure tocontrast those who are rarely happy (1¼none of the time or a littleof the time) with those who report more frequent happiness(0¼ some, most, or all of the time). These are not meant to be clinicalmeasures of mental illness, but indicators of respondents who report‘‘worse than average’’ mental health.
Last, we include seven demographic and socioeconomic controls.This includes three demographic characteristics: gender (1¼ female,0¼male), age at interview (range: 18 years to 85þ years), as wellas a categorical measure of racial=ethnic group membership (non-Hispanic white (reference), non-Hispanic black, Mexican, PuertoRican, Cuban, other Hispanic, non-Hispanic Asian, and all othergroups). In addition, we include a continuous measure of the highestgrade of school completed (range: 0¼ never attended school to 21¼doctoral degree). We also added a measure of the family’s income-to-poverty ratio, representing each respondent’s family income as aproportion of the income level that defined the federal poverty line.Finally, we included a categorical measure of respondent’s employ-ment status (currently working (reference), unemployed, retired, andnever worked), as well as a dichotomous measure of health insurance,where 1¼ no medical insurance, and 0¼ has medical insurance.
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Analysis
We utilized the STATA software package for analysis (StataCorp2003). Taylor-series-approximate methods with SVY commands weredone to adjust for the complex sample design of the NHIS. Ratherthan assuming that observations are independent, STATA correctsfor the intracluster correlation that occurs due to sample design, pro-ducing more accurate standard errors and reducing the chance offalse-positive significance tests. Because blacks and Hispanics wereoversampled, we use weights in all analyses.
Table 1 presents weighted means and percentages for each inde-pendent predictor. These were calculated for the full sample and bynativity status to give the reader a general sense of how sample immi-grants (n¼ 4,821) differ from the native born (n¼ 26,911). More thanhalf (52.2 percent) of the immigrants in the population have lived inthe United States for 15 years or more, while 19.6 percent have livedin the United States for fewer than five years. Just under half are U.S.citizens, and almost one-third completed the NHIS interview in alanguage other than English.
In terms of family structure—when compared to nonimmigrants—fewer immigrants live alone, are married or cohabiting withoutchildren, are single parents, or live in a stepfamily, but a higher per-centage are living in other adult-only families (e.g., with a spouse andtheir parents in the home), married or cohabiting with children, orliving with children and other adult relatives (with or without aspouse). Immigrants generally have less social support support, andscore lower on measures of integration when compared to the nativeborn. Immigrants less frequently report getting needed social andemotional support and talk on the phone and get together withfriends and family less often than nonimmigrants. Fewer reportedattending a group event in the two weeks prior to the interview.Immigrants, however, are more socially integrated into religiousorganizations, with 55.0 percent of immigrants reporting attendanceat a place of worship during the past two weeks compared to 50.1percent of the U.S. born.
In terms of health behaviors, immigrants report less smoking andbinge drinking, and fewer are obese. However, immigrants do not doas well as the native born in terms of exercise, with 44.2 percentreporting no weekly exercise (in contrast to 31.9 percent of the nativeborn). Looking at demographic and socioeconomic characteristics,immigrants are younger than the native born (42.4 years old com-pared to 45.1 years old), but do not differ in terms of the proportionwho are female. One-quarter of immigrants are Mexican, and more
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Table 1. Weighted sample characteristics
Full sample
(N¼ 31,732)
U.S. born
(n¼ 26,911)
Foreign born
(n¼ 4,821)
Immigration Characteristics
Duration of residence, %
U.S. born (ref) 87.4 100.0 —
< 5 years 2.5 — 19.6
5–14 years 3.5 — 28.2
15þ years 6.6 — 52.2
U.S. citizen, % 92.8 99.2 48.3���
Non-English interview, % 5.1 1.3 32.0���
Social Support and Integration
Family structure, %
Living alone 16.6 17.3 11.8���
Living with roommates 2.2 2.2 1.9
Married or cohabiting, no children 27.3 28.6 18.2���
Other adult-only families 14.9 14.6 16.9��
Single parent 3.5 3.6 3.0��
Married or cohabiting, with children 20.9 20.2 25.5���
Stepfamily with children 3.3 3.4 2.3���
Parent(s), children, and adult relatives 11.3 10.0 20.4���
How often get needed social=emotional
support, %
Never or rarely 5.4 5.0 7.7���
Sometimes 12.1 11.8 14.5���
Usually or always 82.5 83.2 77.8���
Phoned friends or family last 2 weeks, %
Neither 5.5 3.7 5.2���
Either family or friends 22.4 12.5 16.0���
Both family and friends 72.1 83.8 78.9���
Got together with friends or family last 2
weeks, %
Neither 3.9 5.1 7.8���
Either family or friends 12.9 22.0 25.3���
Both family and friends 83.2 72.9 66.8���
Went to place of worship last 2 weeks 50.7 50.1 55.0���
Went to a group event last 2 weeks, % 58.5 59.4 52.6���
Health Behaviors
Current smoker 22.7 23.8 15.6���
Binge drinker 6.8 6.9 5.8�
No exercise 33.5 31.9 44.2���
Obese 21.6 22.6 15.1���
Demographic and Socioeconomic Characteristics
Age, mean 44.8 (17.2) 45.1 (17.2) 42.4 (17.5)���
Female, % 52.1 52.2 51.7
Race=Ethnicity, %
White (ref) 74.1 81.2 24.4���
Black 11.0 11.4 8.0���
(Continued )
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than 24 percent are non-Hispanic white (though this is much lowerthan among the native born, where the population is 81.3 percentnon-Hispanic white). While non-Hispanic blacks make up a signifi-cantly greater proportion of the native-born population (11.4 percentamong U.S.-born adults vs. 8.0 percent among foreign-born adults),all other ethnic groups (i.e., Puerto Ricans, Cubans, other Hispanics,Asians, and other groups) are significantly more prevalent among theimmigrant population. As expected, immigrants report lower educa-tional attainment, more poverty, and less medical insurance. Immi-grants and the native born, however, report equivalent rates ofemployment and unemployment, although significantly fewer immi-grants are retired, and significantly more report that they have neverworked.
RESULTS
Physical Health Status by Immigration Characteristics
Table 2 presents bivariate relationships between indicators of immi-gration status and health measures. We see evidence of the predictedimmigrant paradox across multiple measures of physical healthstatus. Immigrants generally have better physical health than thenative born, although this health advantage diminishes over time.
Table 1. Continued
Full sample
(N¼ 31,732)
U.S. born
(n¼ 26,911)
Foreign born
(n¼ 4,821)
Mexican 6.5 3.8 25.2���
Puerto Rican 1.1 0.7 3.8���
Cuban 0.6 0.2 3.9���
Other Hispanic 2.4 0.9 13.4���
Asian 1.3 0.3 8.0���
Other 2.9 1.4 13.2���
Education, mean 14.4 (3.4) 14.5 (3.0) 13.1 (5.3)���
Family income below the poverty line, % 8.7 7.6 16.2���
Employment status, %
Working 67.2 67.3 66.7
Retired 14.2 14.9 9.0���
Unemployed 14.5 14.6 13.7
Never worked 4.1 3.1 10.5���
No medical insurance, % 14.5 12.4 29.4���
Note. Standard deviations in parentheses.�p� .05; ��p� .01; ���p� .001 (two-tailed t-test; reference: U.S. born).
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Immigrants living in the United States for fewer than five years reportthe lowest levels of poor health, hypertension, and heart disease, andthe incidence of these health problems increases with duration in theUnited States. Other indicators of acculturation also suggest thatimmigrants have better physical health. U.S. citizens report morephysical health problems (e.g., 24.2 percent of citizens have beendiagnosed with hypertension, compared to 12.1 percent of nonciti-zens), while those who were interviewed in a language other thanEnglish are less likely to report hypertension and heart disease—although more non-English speakers report poor-to-fair self-ratedhealth. Overall, these results confirm prior research suggesting animmigrant paradox in physical health.
Logistic Regression Models
Next, we examine the relationship between immigrant characteristicsand health status using a multivariate framework. Our goals are two-fold: (1) to document the extent of an immigrant health advantage,
Table 2. Weighted percentage scores on physical health measures, by
immigrant characteristics (N¼ 31,732)
Poor=Fair SRH Hypertension Heart disease
Duration of residence
U.S. born (ref) 11.3 24.0 11.2
< 5 years 5.9��� 7.2��� 3.4���
5–14 years 7.7��� 12.3��� 3.5���
15þ years 14.3��� 26.4 8.6���
U.S. citizen
Yes (ref) 11.5 24.2 11.1
No 7.6��� 12.1��� 3.9���
Non-English interview
Yes (ref) 13.6 18.4 5.4
No 11.1��� 23.6��� 10.9���
Race=Ethnicity
White (ref) 10.3 23.5 11.8
Black 17.2��� 29.6��� 9.1���
Mexican 5.8��� 20.6 6.1���
Puerto Rican 20.3��� 27.2 10.6
Cuban 11.2 16.1��� 4.4���
Other Hispanic 17.4��� 27.0 7.6��
Asian 10.6 15.3��� 5.1���
Other 9.6 15.9��� 5.4���
Note. SRH¼ self-rated health.�p� .05; ��p� .01; ���p� .001 (two-tailed t-test, relative to noted reference group).
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across measures of migrant status, after accounting for demographicand socioeconomic status characteristics, and (2) to assess the relativecontributions of social support and social integration in explainingthe relationship between immigrant status and adult physical health.Table 3 presents logistic regression models using the set of immi-gration characteristics to predict our measures of physical healthstatus. To assess the relevance of potential explanatory mechanismslinking immigration status to adult health, we sequentially add con-trols for demographics and socioeconomic status (Model 1), socialsupport and social integration (Model 2), and health behaviors andmental health status (Model 3) to our models.
Looking at Model 1 for each outcome, we see that the immigrantparadox is partially explained by demographic and socioeconomiccharacteristics (and by simultaneously considering all measures ofimmigrant status). Duration of residence is no longer a significantpredictor of poor self-rated health (compared to Table 2), and mostof the effect is explained away in the hypertension and heart diseasemodels. In addition, being a U.S. citizen is no longer a significant pre-dictor of heart disease (although it is still associated with poorself-rated health and hypertension), and language of interview hasno significant effect for any physical health measure. Overall, demo-graphic and socioeconomic background characteristics have strong,direct effects on physical health. While there is some variability acrosseach measure of physical health, in general respondents who areolder, are Black, Puerto Rican, ‘‘Other’’ Hispanic, or Asian, are poor,and are not working tend to report poorer physical health, whilefemales and the well-educated report better health. An exception isheart disease; respondents who identify as Black, Mexican, or Otherrace=ethnicity are less likely to receive such a diagnosis. Interestingly,those without medical insurance are actually less likely to be diag-nosed with hypertension or heart disease; this is probably explainedby the irregularity of access to medical care among the uninsured.
Recall from Table 1 that the foreign born actually reported lowerlevels of social support and integration (with the exception of churchattendance and some aspects of family structure). It is not surprisingthat these measures cannot explain the association between immi-grant characteristics and better physical health in Model 2. Indeed,immigrant effects are largely unchanged from Model 1. Living in afamily household, however, is not always positively related to physi-cal health; in fact, residing with others is associated with betterself-rated health only if one is married or cohabiting with children.And we find significantly poorer self-rated health for those living insingle parent families and other-adult family types, higher rates of
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Table
3.
Oddsratiosfrom
logisticregression,odels:Physicalhealthmeasures
Poorto
fairSRH
Everdiagnosedwith
hypertension
Everdiagnosedwithheart
disease
Model
1
Model
2
Model
3
Model
1
Model
2
Model
3
Model
1
Model
2
Model
3
ImmigrationCharacteristics
Durationofresiden
ce(ref:U.S.born)
<5years
.97
.96
1.13
.57��
.56��
.66�
.79
.78
.86
5–14years
.94
.93
1.04
.82
.82
.93
.69
.69
.71
15þyears
.95
.91
.99
.88
.87
.95
.72��
.72��
.73��
U.S.citizen
2.06��
�2.01��
�1.89��
�1.32��
1.31��
1.28�
1.25
1.25
1.23
Non-English
interview
.87
.93
.93
1.10
1.13
1.16
.99
1.02
1.02
SocialSupportandIntegration
Familystructure
(ref:Livingalone)
Livingwithroommates
1.01
1.24
.91
.96
1.14
1.19
Marriedorcohabiting,noch
ildren
1.10
1.14�
1.08
1.07
1.16��
1.17��
Other
adult-only
families
1.23��
1.24��
1.12
1.06
1.07
1.06
Single
parent
1.28��
1.16
1.16�
1.09
1.19
1.16
Marriedorcohabiting,withch
ildren
.69��
�.80��
.93
.94
.86
.89
Stepfamilywithch
ildren
1.01
1.08
.99
.96
1.15
1.19
Parent(s),ch
ildren,andadultrelatives
1.05
1.04
1.02
.97
1.26�
1.26�
Social=em
otionalsupport
(ref:Never
or
rarely)
Sometim
es1.02
1.30��
.85
.88
.88
.94
Usuallyoralways
.56��
�.95
.78��
�.91
.78��
.93
Gottogether
withfriends=family(ref:Neither)
Either
familyorfriends
.76��
.87
1.02
1.06
1.16
1.21
Both
familyandfriends
.69��
�.84
.97
1.01
1.21
1.27�
Phoned
friendsorfamily(ref:Neither)
Either
familyorfriends
.96
.98
1.21�
1.18
.96
.97
Both
familyandfriends
.81�
.89
1.08
1.11
.91
.95
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Wen
tto
placeofworship
.86��
.91
.95
.96
.88��
.88��
Wen
tto
agroupeven
t.62��
�.71��
�.87��
�.90�
.87��
.89�
HealthBehaviors
Curren
tsm
oker
1.36��
�.93
.91
Bingedrinker
.72��
1.32��
�1.12
Noexercise
1.61��
�1.01
.91�
Obese
1.75��
�2.79��
�1.27��
�
MentalHealth
Dep
ressed
mood
2.82��
�1.46��
1.59��
�
Dissatisfiedwithlife
1.87��
�1.13
1.31�
Unhappy
1.52��
�1.09
1.07
Dem
ographic
andSocioeconomic
Status
Age
1.04��
�1.04��
�1.04��
�1.06��
�1.06��
�1.06��
�1.05��
�1.05��
�1.05��
�
Fem
ale
.81��
�.85��
�.82��
�.91��
.91��
.94
.81��
�.83��
�.84��
�
Race=Ethnicity(ref:White)
Black
1.74��
�1.72��
�1.68��
�1.92��
�1.92��
�1.79��
�.86�
.87�
.87�
Mexican
1.03
1.12
1.17
1.02
1.06
.97
.55��
�.57��
�.56��
�
Puerto
Rican
1.87��
�1.77��
�1.58��
1.64��
�1.64��
�1.48��
1.14
1.13
1.09
Cuban
1.41
1.45
1.26
.95
.95
.93
.59
.58�
.56�
Other
Hispanic
1.37��
1.35�
1.40�
.98
.98
.96
.70
.71
.71
Asian
1.17
1.04
1.16
1.54�
1.50�
1.71��
.91
.87
.89
Other
1.18
1.15
1.27
1.02
1.01
1.08
.66�
.65�
.67�
Education
.88��
�.90��
�.92��
�.96��
�.97��
�.98��
�.99
.99
.99
Familyincomebelow
thepovertyline
1.68��
�1.55��
�1.41��
�1.03
1.02
.96
1.37��
�1.36��
�1.32��
�
Employmen
tstatus(ref:working)
Retired
1.26��
�1.32��
�1.39��
�.90
.91
.95
1.37��
�1.36��
�1.35��
�
Unem
ployed
5.10��
�4.74��
�3.77��
�1.63��
�1.59��
�1.49��
�2.34��
�2.26��
�2.04��
�
Never
worked
3.00��
�3.07��
�2.54��
�1.16
1.16
1.13
1.53��
1.52��
�1.44��
Nomed
icalinsurance
1.09
.99
.94
.85��
.83��
�.83��
�.83�
.81��
.81�
PseudoR2
.19
.21
.25
.17
.17
.20
.13
.13
.13
Note.SRH¼self-ratedhealth.
� p�.05;��p�.01;��
� p�.001(two-tailed
t-test).
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hypertension for single parents, and higher rates of heart disease forcouples with no children and parents living with children and otherrelatives. In contrast, all other indicators of social support and inte-gration are negatively associated with poor self-rated health, whilefrequent social=emotional support and attendance at group eventsis associated with a lower risk of hypertension. Social=emotional sup-port, group events, and attendance at worship services all have anegative relationship to heart disease. Unexpectedly, we find thattalking to either friends or family on the phone, but not both, is posi-tively associated with hypertension. It is possible that this kind ofsocial contact indicates social obligation rather than social support,or occurs in response to specific health problems or diagnoses.
In Model 3 we add indicators of health behaviors and mentalhealth status, finding little mediating effect. After adjusting for sev-eral potential mediators, U.S. citizens still experience significantlyelevated odds of poor-to-fair self-rated health (89 percent higher)and hypertension (28 percent higher). In addition, when comparedto the native born, new immigrants (living in the United States fewerthan 5 years) remain 34 percent less likely to be diagnosed withhypertension, while long term immigrants (more than 15 years inthe United States) are 27 percent less likely to report heart disease.
While health behaviors and mental health indicators in Model 3 donot mediate the influence of immigrant status on physical health, theydo seem to explain some of the influence of family structure and othermeasures of support and integration shown in Model 2. In particular,sometimes receiving social=emotional support becomes associatedwith poorer self-rated health, and the benefits of frequent social=emotional support are eliminated across all outcomes. In addition,the poor health and hypertension associated with being a singleparent are explained by the poor mental health and health behaviorsamong single parents, especially obesity and depressive mood. Thebetter self-rated health associated with phoning friends and relativesand attending worship services is not significant in the full model.Interestingly, a positive relationship emerges between getting togetherwith both friends and family and being diagnosed with heart disease.Again, this may signal a social response to health problems. Theinfluence of health measures are generally in the expected directions;unhealthy behavior and poor mental health is associated with poorphysical health status. One exception is that binge drinking has anegative relationship to poor self-rated health. While the meaningof this relationship is unclear, it is possible that adults only engagein binge drinking when they feel that their health status is goodenough to tolerate any potential negative health effects.
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CONCLUSIONS
This study expands the immigrant health literature by examining theextent and potential underlying causes of the immigrant paradox inhealth. Specifically, we analyzed the relationship between immigrantstatus and health, exploring the relative contributions of social sup-port and integration to explaining the immigrant paradox. Consistentwith previous research (e.g., Wilkinson et al. 1996), we find clearevidence that immigrants have better physical health, includingdiagnoses of hypertension and heart disease. These effects hold evenafter accounting for demographic and socioeconomic factors such asrace and ethnicity, income-to-poverty ratio, and insurance status.Despite mixed evidence of immigrant effects on self-rated health(see Angel et al. 2001a; Cho et al. 2004), we show that immigrantsreport better health than U.S. citizens, and this is not explained byimmigrants’ relative disadvantage in terms of demographic and socio-economic risk factors.
That said, there is little evidence in our analyses that social supportand integration explain the immigrant health paradox related tophysical health. Our results support the conclusions of Finch andcolleagues (2004), suggesting that analyses that separate the effectsof acculturation from effects of social support are unlikely to findsupport for the proposition that social support explains the healthyimmigrant effect. Our analyses show that researchers cannot claimunequivocally that immigrants receive more social support than thenative born (aside from having somewhat higher rates of attendanceat worship services and greater representation in selected familytypes). Our findings that immigrants are more likely than non-immigrants to live in families with children and non-nuclear relatives,but are less likely to receive frequent emotional support or to havecontact with both family and friends, are supported by studies of sin-gle immigrant ethnic groups (Franzini and Fernandez-Esquer 2004).While chain migration may allow immigrants to enter the UnitedStates with an existing set of social ties that facilitate their adaptation(Arnold 1989), it is not clear that these social ties provide the kindof social support that is beneficial to health. We show surprisinglythat moderate-to-high levels of emotional support and contact canactually be related to negative physical health outcomes. This mayindicate a social response to health problems, or may be a sign ofsocial obligation to others (see Kahn and Antonucci 1980). Our find-ings reveal that neither social support and integration nor healthbehaviors can explain why immigrants have better physical health,suggesting that future research should reconsider the question of
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what makes immigrant health distinctive. Our study principally high-lights the benefits of examining physical health with multiple mea-sures. In so doing we advance the small amount of research thatemploys diverse measures of acculturation (Franzini and Fernandez-Esquer 2004), as well as provide evidence that social networks canhave an impact on health through multiple pathways, including socialsupport and social integration (Berkman and Glass 2000).
These data have several limitations that the reader should keep inmind. First, the National Health Interview Survey does not containindicators of stress, even though other researchers have noted theimportance of stress for health among immigrants (Finch et al.2004). Second, while we use measures of acculturation that arecommon in the immigration literature (see Franzini and Fernandez-Esquer 2004), we are unable to measure factors such as culturally-specific media consumption, residence within ethnic communities,ethnic and national identity, or cultural values for which indicatorssuch as language use, citizenship, and duration of residence serveas proxies. Future research should consider attitudinal and value-based measures of acculturation as well.
In spite of these limitations, our results have specific policy impli-cations, pointing to the need for implementing fewer stereotypesabout immigrants’ social support networks—in short, we shouldnot assume that all immigrants come from big, happy families thatprovide healthy social support. Rather, based on these findings, pro-ponents of social support systems for immigrants might include pro-vision of public transportation passes or immigrant communitycenters to act as social support boosters. Ultimately, this study tellsa cautionary but rich tale about immigration and health outcomes.Our results challenge the conventional wisdom that immigrants’superior social network support is an important reason for theirhealth advantage. Immigrants face more risk factors for poor healthcompared those born in the United States, but it remains anunanswered question why these risk factors do not always translateinto negative health outcomes for those who choose to migrate to thiscountry.
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