immigrant health steven p. wallace, ph.d. ucla school of public health & ucla center for health...

Immigrant HealthImmigrant Health

Steven P. Wallace, Ph.D.Steven P. Wallace, Ph.D.UCLA School of Public Health & UCLA Center for UCLA School of Public Health & UCLA Center for

Health Policy Research Health Policy Research

http://swallace.bol.ucla.eduhttp://swallace.bol.ucla.edu

OutlineOutline

Who are immigrants?Who are immigrants?What is their health status & risks?What is their health status & risks?What determinants of health vary for What determinants of health vary for

them?them?What are community health strategies?What are community health strategies?What are their health systems issues?What are their health systems issues?

1. Demographics of immigration1. Demographics of immigration

Country of origin of immigrants, all Country of origin of immigrants, all ages, 2006ages, 2006

29.5

7.5

15.0

26.2

15.8

5.9

0.0

10.0

20.0

30.0

Mexico Central America Rest of LatinAmerica

Asia Europe/Canada Rest of world

Pe

rce

nt

43.7

8.73.2

32.8

8.72.8

0.0

10.0

20.0

30.0

40.0



Pe

rce

nt

United States

California

Source: U.S. Census Bureau, 2006 Current Population Survey

Changing immigrant sourcesChanging immigrant sources

1890 – 14.6% born 1890 – 14.6% born abroad, mostly W & N abroad, mostly W & N EuropeEurope

1930 – 11.5% born 1930 – 11.5% born abroad, most abroad, most common Italy, common Italy, Poland, Russia…Poland, Russia…

Ellis Island, 1902Ellis Island, 1902

Immigration ReformImmigration Reform

1965 Added Western 1965 Added Western hemisphere quotahemisphere quota

1965 Added family 1965 Added family reunificationreunification

1980 Refugee act 1980 Refugee act

1986 IRCA – amnesty 1986 IRCA – amnesty for undocumented, for undocumented, employer sanctionsemployer sanctions

San Ysidro border crossingSan Ysidro border crossing

Country of origin of immigrants, all Country of origin of immigrants, all ages, 2006ages, 2006

29.5

7.5

15.0

26.2

15.8

5.9

0.0

10.0

20.0

30.0



Pe

rce

nt

43.7

8.73.2

32.8

8.72.8

0.0

10.0

20.0

30.0

40.0



Pe

rce

nt

United States

California


Population of all Mexican Americans & Population of all Mexican Americans & only Mexican immigrants in the U.S.only Mexican immigrants in the U.S.

6.5 7.0 6.9 7.3 7.4 7.4 8.5 9.9 10.2 10.7 11.0 11.2

17.6 18.5 18.7 19.4 20.4 21.1 22.0 22.825.4 26.4 26.9 28.0 28.3

8.1

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

mill

ions

of p

erso

ns

Mexican immigrants only Mexican Americans, all

Source: U.S. Census Bureau, Current Population Survey 1994-2006

Mexican-born and Mexican-American Population and Percentage of Total Population in California, 2005

4.7

6.1

10.8

0

2

4

6

8

10

12

Mexican Mexican-American

Both

Mill

ion

pers

ons

13.0%

17.0%

30.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%


Both

Pe

rce

nta

ge

Proportion of totalPopulation

Source: Estimates based on U. S. Census Bureau, Current Population Survey (CPS), March 2005.

Exhibit 3: States with more than Exhibit 3: States with more than 100,000 Mexican immigrants, 2006100,000 Mexican immigrants, 2006

1.1. CaliforniaCalifornia 4.4 million4.4 million2.2. TexasTexas 2.2 million2.2 million3.3. ArizonaArizona 713,000 713,0004.4. IllinoisIllinois 526,000 526,0005.5. FloridaFlorida 317,000 317,0006.6. GeorgiaGeorgia 316,000 316,0007.7. North CarolinaNorth Carolina 273,000 273,0008.8. ColoradoColorado 268,000 268,0009.9. New YorkNew York 209,000 209,00010.10. NevadaNevada 198,000 198,00011.11. New JerseyNew Jersey 130,000 130,00012.12. OregonOregon 122,000 122,00013.13. New MexicoNew Mexico 118,000 118,00014.14. WashingtonWashington 116,000 116,000


Age distribution of Mexican Age distribution of Mexican immigrants and others, U.S. 2006immigrants and others, U.S. 2006

19.7

53.9

23.2

21.0

10.7

9.0

36.3

22.7

12.0

11.8

21.8

59.6

19.3

41.8

6.8

4.114.2

1.2 7.3

RecentMexican

immigrants

Long stayMexican

immigrants

U.S. bornMexican

Americans

U.S. bornnonLatino

whites

perc

ent

age 0-17 18-24 25-34 35-64 65 and over


Contribution of Mexicans and Mexican-Americans to Population Growth in California ages 15 to 44 and 0 to 15, 1990-2000

119.7

60.1

8.7

62.8

020406080

100120140



% I

nc

rea

se

Increase in group ages 15-44 Increase in group ages 0-15

Source: Estimates based on U. S. Census Bureau, 15-percent sample 1970, 5-percent sample 1980, 5-percent sample 1990 and 5-percent sample 2000.

Exhibit 8: Labor force participation Exhibit 8: Labor force participation of men ages 18-64, 2006of men ages 18-64, 2006

93.9 91.1 82.7 84.8

Recent Mexican immigrants Long stay Mexicanimmigrants

U.S. born MexicanAmericans

U.S. born nonLatino whites

Pe

rce

nt

91.8 90.9 80.8 84.5

Recent Mexican immigrants Long stay Mexicanimmigrants

U.S. born MexicanAmericans

U.S. born nonLatino whites

Pe

rce

nt

United States

California


Why Why immigrantimmigrant health? health?contextcontext

Employed in segmented labor marketEmployed in segmented labor market– Especially manual & service occupationsEspecially manual & service occupations– Low incomes, benefits, difficult workLow incomes, benefits, difficult work

Live in segregated housingLive in segregated housing– Low income housing with more structural and Low income housing with more structural and

other problemsother problems– Concentrated in low performing schoolsConcentrated in low performing schools– Experience similar shortages of public space Experience similar shortages of public space

& other public services& other public services

Mexican immigrants = 20% of the male CA Mexican immigrants = 20% of the male CA labor force, but account for many workers in:labor force, but account for many workers in:

Source: U.S. Census Bureau, 2006 Current Population Survey.

58.4

60.1

62.7

63.6

66.8

74.5

75.0

81.2

84.7

89.8

100.0

0 10 20 30 40 50 60 70 80 90 100

Construction Laborer

Drywall/ Ceiling Tile Installers

Sewing Machine Operators

Cooks

Gardeners

Roofers

Metal/ Plastic workers

Dishwashers

Agriculture Workers

Packaging machine operators

Cement and Concrete workers

Mexican immigrants as (number) percent of all workers in occupation

(n=13,000)(n=13,000)

(n=105,000)

(n=25,000)

(n=11,000)

(n=27,000)

(n=125,000)

(n=108,000)(n=18,000)

(n=34,000)

(n=142,000)

%

““Carwasheros”Carwasheros”

Difficult workDifficult workLargely Largely undocumentedundocumentedOften paid less than Often paid less than minimum wageminimum wageNo benefits, No benefits, insuranceinsuranceLiving wage could Living wage could easily be passed on easily be passed on in pricein price

Photo: LA Times March 27, 2008Photo: LA Times March 27, 2008

Why Why immigrantimmigrant health? health?Individual factorsIndividual factors

Knowledge – prior experience with health Knowledge – prior experience with health and healing systemsand healing systems

Culture – beliefs and values related to Culture – beliefs and values related to health and healinghealth and healing

Beliefs, rumors – about immigration status Beliefs, rumors – about immigration status and risksand risks

2. Immigrant health status & Risks2. Immigrant health status & Risks

Life expectancy @ birthLife expectancy @ birth

75.2

82

78.9

86

67.5

74.6

74.8

79.9

79.0

84.1

80.7

85.0

75.6

81.0

75.6

80.3

Latino men

Latino women

API men

API women

black men

black women

NLwhite men

NLwhite women

U.S. born Immigrant

Source: Singh & Hiatt, International Journal of Epidemiology, 2006

Relative Rates, Immigrant v. NativeRelative Rates, Immigrant v. Native (adjusted for age, sex, income, region, etc)(adjusted for age, sex, income, region, etc)

0.61

0.38

1.12

0.83

0.61

0.860.79

0.89

0.590.680.59

0.730.59

0.48

0.64

0.48

diabetes heart disease hypertension asthma

Latino African Americans Asian nonHispanic whites

Source: Singh & Hiatt, International Journal of Epidemiology, 2006

Native rate=1Native rate=1

11.9%

7.9%

10.5%

7.14*

5.12*6.4%

Preterm birth Low birthweight Infant deaths*

US born mother Immigrant mother

Source – CDC, MMWR, December 6, 2002 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5148a3.htm

Immigrant Birth Outcomes BetterImmigrant Birth Outcomes Better

* Per 1000 live births* Per 1000 live births

Immigrant paradox:Immigrant paradox:High risk factorsHigh risk factors

Low incomeLow income

Low educationLow education

Poor working Poor working conditionsconditions

Overcrowded housingOvercrowded housing

Immigrant paradox:Immigrant paradox:BUT good outcomesBUT good outcomes

Mortality Mortality

Chronic conditions Chronic conditions like heart disease like heart disease (except diabetes)(except diabetes)

Birth outcomesBirth outcomes

3.3. Determinants of HealthDeterminants of Health

Mexican Immigrants have lowest levels of educationMexican Immigrants have lowest levels of education

53.1 52.2

14.04.4 7.8

14.4

33.7 32.4

44.0

38.545.9 31.4

27.1

27.2

18.6

5.4 5.212.8

30.019.1

35.6

29.2

10.17.8

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Recent Mexicanimmigrants

Longer-stayedMexican

immigrants

MexicanAmerican

U.S.-BornWhites

U.S.-Born Non-Whites

Immigrants froma country other

than Mexico

Less than 10 grade 10 - 12 grade Technical Professional

Source: SSA, Inmigrantes Mexicanos y Centroamericanos en Estados Unidos, 2006Adults 25 years and older, U.S., http://www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=196

28.4

19.6

14.8

8.1

19.6

12.1

0.0

10.0

20.0

30.0

Recent MexicanImmigrants


immigrants

Mexican-Americans

U.S.-BornWhites

U.S.-born Non-whites


than Mexico

Por

cent

age

Mexican immigrants have high levels of povertyMexican immigrants have high levels of poverty

24.9

18.5

11.57.7

13.89.6

0.0

10.0

20.0

30.0



immigrants

Mexican-Americans

U.S.-BornWhites

U.S.-born Non-whites


than Mexico

Por

cent

age

United States

California

Source: SSA, Inmigrantes Mexicanos y Centroamericanos en Estados Unidos, 2006Adults 18 years and over living in poverty, U.S. And CA, 2005http://www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=196

Immigrant paradox: Why?Immigrant paradox: Why?

Selection effects = health/social capitalSelection effects = health/social capital– Health? (Rural Mexican women, Health? (Rural Mexican women, Rubalcava, AJPH,

2008)– Education (found in all countries, exc. Puerto Education (found in all countries, exc. Puerto

Rico; Rico; Feliciano,Demography, 2005))– Social Networks?Social Networks?– Other human capital?Other human capital?


Selection effectsSelection effects

Return migration (salmon effect)Return migration (salmon effect)– 1/3 of Mexican immigrants return w/i 10 years1/3 of Mexican immigrants return w/i 10 years– Mortality is lower for Mexicans (who can Mortality is lower for Mexicans (who can

return) than Cubans (who can not)return) than Cubans (who can not)– Can this explain birth outcomes??Can this explain birth outcomes??


Selection effectsSelection effectsReturn migration (salmon effect)Return migration (salmon effect)Health behaviors (culture)Health behaviors (culture)– Lower rates of smoking, healthier dietsLower rates of smoking, healthier diets– Stronger social networksStronger social networks

Direct effects – helping out, share info, etcDirect effects – helping out, share info, etcIndirect effects – buffer stressIndirect effects – buffer stress

– Erodes w/acculturationErodes w/acculturationAcculturative stressAcculturative stressChanging behaviorsChanging behaviors


Selection effectsSelection effects

Return migration (salmon effect)Return migration (salmon effect)

Health behaviors (culture)Health behaviors (culture)

Community effects (context)Community effects (context)– Immigrants communities have an independent Immigrants communities have an independent

protective effectprotective effect– Assimilation reduces (vs. acculturation)Assimilation reduces (vs. acculturation)

n.s.=married, educ, income, immigrant, English interview, neighborhood poorn.s.=married, educ, income, immigrant, English interview, neighborhood poor

4. Community health strategies4. Community health strategies

Sustain healthy Sustain healthy behaviorsbehaviors

Improve medical Improve medical infrastructureinfrastructure

Improve social & Improve social & environmental context environmental context of healthof health

Photo: Photo: http://www.flickr.com/photos/roscoland/962051804/

Healthy BehaviorsHealthy Behaviors

Promote good nutrition: in schools, stores, Promote good nutrition: in schools, stores, food stampsfood stamps

Facilitate physical activities: via sports, Facilitate physical activities: via sports, parks school yardsparks school yards

Disseminate information via promotorasDisseminate information via promotoras

Sustain social networks via public spaceSustain social networks via public space

Improve medical infrastructureImprove medical infrastructure

Sustain/expand community clinics, school Sustain/expand community clinics, school based clinicsbased clinics

Increase bilingual, bicultural workforceIncrease bilingual, bicultural workforce

Better connect workers to workers Better connect workers to workers compensation systemcompensation system

Expand preventive & elder care, Expand preventive & elder care, screenings & treatmentscreenings & treatment

Improve context for healthImprove context for health

Improve housing, building enforcementImprove housing, building enforcement

Improve workplace health & safety, Improve workplace health & safety, CalOSHA, living wage and other CalOSHA, living wage and other enforcementenforcement

Improve air quality in immigrant Improve air quality in immigrant communitiescommunities

Summary, immigrant paradoxSummary, immigrant paradox

Better health outcomes despite many risk Better health outcomes despite many risk factorsfactors

Some health advantage due to selection, Some health advantage due to selection, other to health behaviors, other to social & other to health behaviors, other to social & community conditionscommunity conditions

To To maintain health capitalmaintain health capital, community , community health strategies are importanthealth strategies are important

5. Medical Care Issues5. Medical Care Issues

13.4

28.537.0 34.1

45.032.79.3

14.2

17.635.0

21.2

24.3

30.9 33.843.0

77.3

57.345.3

0%

20%

40%

60%

80%

100%



immigrants

Mexican American U.S.-Born Whites U.S.-Born Non-Whites

Immigrants from acountry other than

Mexico

Public Private or both No health insurance

Source: SSA, Inmigrantes Mexicanos y Centroamericanos en Estados Unidos, 2006Adults 18 years and older who live in poverty, U.S., http://

www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=196

Mexican immigrants have the lowest levels Mexican immigrants have the lowest levels of health insurance of all in CA in povertyof health insurance of all in CA in poverty

Mexican immigrants lack connection to Mexican immigrants lack connection to health care facilitieshealth care facilities

39.6% 31.1%14.7% 9.0%

46.2% 66.3%

42.4%20.9% 14.7% 9.2%

79.4%14.5%


Longer-stayMexican

immigrants

Mexican American U.S.-Born Whites

Doctor's office or health center Clinic None

Source: California Health Interview Survey, 2003Adults 18 or older, California

Mexican immigrants have the highest levels of Mexican immigrants have the highest levels of no medical visits in the past two years no medical visits in the past two years

22.0%16.0%

7.3%

37.4%


Longer-stayMexican

Immigrants

MexicanAmericans

U.S.-Born Whites

Source- CONAPO, Migración México-Estados Unidos, Temas de salud. 2005.Adults 18 years or older, U.S. http://www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=154

Mexican immigrants have the lowest levels of Mexican immigrants have the lowest levels of emergency room visits emergency room visits

7.1%

11.9%

16.7% 15.5%



immigrants

Mexican-Americans

U.S.-Born Whites

Fuente- CONAPO, Migración México-Estados Unidos, Temas de salud. 2005.Adults 18 and over U.S.http://www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=154

Mexican immigrants have the highest use of health or Mexican immigrants have the highest use of health or dental services dental services in Mexicoin Mexico

8.1%

12.9%

5.3%

0.7%

10.6%

0.2%0.9%

10.5%



immigrants

Mexican-Americans

U.S.-Born Whites

Low income Other

Source - 2001 California Health Interview SurveyAdults 18 years or over, California

Adults age 18 and over with no Adults age 18 and over with no doctordoctor visit past year visit past year

38.2%

26.0%19.9%

14.3%

RecentMexicanmigrants

Long-staymigrants

(10+ years)

Mexican-Americans

U.S. Bornwhites

Source: California Health Interview Survey, 2003

Adults age 18 and over with no Adults age 18 and over with no dentaldental visit in past year visit in past year

62.4%46.1%

34.3%26.8%

RecentMexicanmigrants

Long-staymigrants

(10+ years)

Mexican-Americans

U.S. Bornwhites


Adults age 65 and over with no Adults age 65 and over with no influenza immunization past yearinfluenza immunization past year

25.5%28.8%

25.0%

All Mexicanmigrants

Mexican-Americans

U.S. Born whites


Adults age 50 and over who have Adults age 50 and over who have never had a colorectal examnever had a colorectal exam

67.1%

54.3%42.2%

All Mexicanmigrants

Mexican-Americans

U.S. Born whites


Women age 18-64 with no pap Women age 18-64 with no pap smear past three yearssmear past three years

13.1% 12.0%16.2%

11.2%

Recentmigrants

(<10 years)

Long-staymigrants

(10+ years)

Mexican-Americans

U.S. Bornwhites


Summary, health careSummary, health care

Mexican and Central American immigrants Mexican and Central American immigrants are an important part of California’s are an important part of California’s populationpopulation

They face substantial access to care They face substantial access to care barriersbarriers

It is possible to provide adequate access It is possible to provide adequate access to care to these populationsto care to these populations

ConclusionConclusion

Immigrants are “here Immigrants are “here to stay”to stay”They face a number They face a number of special health, of special health, health behavior, and health behavior, and access to health care access to health care issuesissuesIt is critical to address It is critical to address those issues to those issues to maintain a health maintain a health CaliforniaCalifornia

immigrant health steven p. wallace, ph.d. ucla school of public health & ucla center for health...

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