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Immigrant Health
Steven P. Wallace, Ph.D.
UCLA School of Public Health & UCLA Center for
Health Policy Research
http://swallace.bol.ucla.edu
Outline
Who are immigrants?
What is their health status & risks?
What determinants of health vary for
them?
What are community health strategies?
What are their health systems issues?
1. Demographics of immigration
Country of origin of immigrants, all
ages, 2006
30.0
29.5
26.2
United States
20.0
Percent
15.0 15.8
10.0 7.5
5.9
0.0
Mexico Central America Rest of Latin Asia Europe/Canada Rest of world
America
43.7
40.0 32.8
California
30.0
Percent
20.0
8.7 8.7
10.0 3.2 2.8
0.0
Mexico Central America Rest of Latin Asia Europe/Canada Rest of world
America
Source: U.S. Census Bureau, 2006 Current Population Survey
Changing immigrant sources
1890 – 14.6% born
abroad, mostly W & N
Europe
1930 – 11.5% born
abroad, most
common Italy,
Poland, Russia…
Ellis Island, 1902
Immigration Reform
1965 Added Western
hemisphere quota
1965 Added family
reunification
1980 Refugee act
1986 IRCA – amnesty
for undocumented,
employer sanctions
San Ysidro border crossing
Country of origin of immigrants, all
ages, 2006
30.0
29.5
26.2
United States
20.0
Percent
15.0 15.8
10.0 7.5
5.9
0.0
Mexico Central America Rest of Latin Asia Europe/Canada Rest of world
America
43.7
40.0 32.8
California
30.0
Percent
20.0
8.7 8.7
10.0 3.2 2.8
0.0
Mexico Central America Rest of Latin Asia Europe/Canada Rest of world
America
Source: U.S. Census Bureau, 2006 Current Population Survey
Population of all Mexican Americans &
only Mexican immigrants in the U.S.
millions of persons
28.0 28.3
25.4 26.4 26.9
22.8
21.1 22.0
17.6 18.5 18.7 19.4 20.4
7.0 6.9 7.3 7.4 7.4 8.1 8.5 9.9 10.2 10.7 11.0 11.2
6.5
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
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
Population Proportion of total
12 35.0%
10.8 30.0%
30.0%
10
25.0%
Million persons
8
Percentage
6.1 20.0% 17.0%
6
4.7 13.0%
15.0%
4
10.0%
2
5.0%
0
0.0%
Mexican Mexican- Both
Mexican Mexican- Both
American
American
Source: Estimates based on U. S. Census Bureau, Current Population Survey (CPS), March 2005.
Exhibit 3: States with more than
100,000 Mexican immigrants, 2006
1. California 4.4 million
2. Texas 2.2 million
3. Arizona 713,000
4. Illinois 526,000
5. Florida 317,000
6. Georgia 316,000
7. North Carolina 273,000
8. Colorado 268,000
9. New York 209,000
10. Nevada 198,000
11. New Jersey 130,000 Source: U.S. Census Bureau,
12. Oregon 122,000 2006 Current Population
Survey
13. New Mexico 118,000
14. Washington 116,000
Age distribution of Mexican
immigrants and others, U.S. 2006
1.2 7.3 4.1
14.2
21.8 19.3
12.0
59.6 41.8
36.3 10.7
percent
11.8
21.0 53.9 9.0
22.7
19.7 23.2
6.8
Recent Long stay U.S. born U.S. born
Mexican Mexican Mexican nonLatino
immigrants immigrants Americans whites
age 0-17 18-24 25-34 35-64 65 and over
Source: U.S. Census Bureau, 2006 Current Population Survey
Contribution of Mexicans and Mexican-Americans to Population
Growth in California ages 15 to 44 and 0 to 15, 1990-2000
140 119.7
120
% Increase
100
80 60.1
60
62.8
40
20 8.7
0
Mexican Mexican- Mexican Mexican-
American American
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
of men ages 18-64, 2006
United States
Percent
93.9 91.1 84.8
82.7
Recent Mexican immigrants Long stay Mexican U.S. born Mexican U.S. born nonLatino whites
immigrants Americans
California
Percent
91.8 90.9 84.5
80.8
Recent Mexican immigrants Long stay Mexican U.S. born Mexican U.S. born nonLatino whites
immigrants Americans
Source: U.S. Census Bureau, 2006 Current Population Survey
Why immigrant health?
context
Employed in segmented labor market
– Especially manual & service occupations
– Low incomes, benefits, difficult work
Live in segregated housing
– Low income housing with more structural and
other problems
– Concentrated in low performing schools
– Experience similar shortages of public space
& other public services
Mexican immigrants = 20% of the male CA
labor force, but account for many workers in:
Cement and Concrete workers (n=13,000) 100.0
Packaging machine operators (n=13,000) 89.8 %
Agriculture Workers (n=105,000) 84.7
Dishwashers (n=25,000) 81.2
Metal/Plastic workers (n=11,000) 75.0
Roofers (n=27,000) 74.5
Gardeners (n=125,000) 66.8
Cooks (n=108,000) 63.6
Sewing Machine Operators (n=18,000) 62.7
Drywall/Ceiling Tile Installers (n=34,000) 60.1
Construction Laborer (n=142,000) 58.4
0 10 20 30 40 50 60 70 80 90 100
Mexican immigrants as (number) percent of all workers in occupation
Source: U.S. Census Bureau, 2006 Current Population Survey.
“Carwasheros”
Difficult work
Largely
undocumented
Often paid less than
minimum wage
No benefits,
insurance
Living wage could
easily be passed on
in price
Photo: LA Times March 27, 2008
Why immigrant health?
Individual factors
Knowledge – prior experience with health
and healing systems
Culture – beliefs and values related to
health and healing
Beliefs, rumors – about immigration status
and risks
2. Immigrant health status & Risks
Life expectancy @ birth
NLwhite women 80.3
79.9
NLwhite men 75.6
74.8
black women 81.0
74.6
black men 75.6
67.5
API women 85.0
86
API men 80.7
78.9
Latino women 84.1
82
Latino men 79.0
75.2
U.S. born Immigrant
Source: Singh & Hiatt, International Journal of Epidemiology, 2006
Relative Rates, Immigrant v. Native
(adjusted for age, sex, income, region, etc)
1.12
Native rate=1
0.86 0.89
0.79 0.83
0.73 0.64
0.61 0.61 0.68 0.59 0.59
0.59
0.48 0.48
0.38
diabetes heart disease hypertension asthma
Latino African Americans Asian nonHispanic whites
Source: Singh & Hiatt, International Journal of Epidemiology, 2006
Immigrant Birth Outcomes Better
11.9%
10.5%
US born mother Immigrant mother
7.9%
7.14*
6.4%
5.12*
Preterm birth Low birthweight Infant deaths*
* Per 1000 live births
Source – CDC, MMWR, December 6, 2002 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5148a3.htm
Immigrant paradox:
High risk factors
Low income
Low education
Poor working
conditions
Overcrowded housing
Immigrant paradox:
BUT good outcomes
Mortality
Chronic conditions
like heart disease
(except diabetes)
Birth outcomes
3. Determinants of Health
Mexican Immigrants have lowest levels of education
100% 5.4 5.2
12.8
90% 7.8 10.1 19.1
30.0 35.6
80%
70% 33.7 29.2
32.4 27.2
60%
27.1 18.6
50%
40%
44.0
30% 45.9 31.4
53.1 52.2 38.5
20%
10% 14.0 14.4
4.4 7.8
0%
Recent Mexican Longer-stayed Mexican U.S.-Born U.S.-Born Non- Immigrants from
immigrants Mexican American Whites Whites a country other
immigrants than Mexico
Less than 10 grade 10 - 12 grade Technical Professional
Source: SSA, Inmigrantes Mexicanos y Centroamericanos en Estados Unidos, 2006
Adults 25 years and older, U.S., http://www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=196
Mexican immigrants have high levels of poverty
28.4
United States
30.0
19.6 19.6
Porcentage
20.0
14.8
12.1
10.0 8.1
0.0
Recent Mexican Longer-stayed Mexican- U.S.-Born U.S.-born Non- Immigrants from
Immigrants Mexican Americans Whites whites a country other
immigrants than Mexico
California
30.0
24.9
Porcentage
20.0 18.5
13.8
11.5
9.6
10.0 7.7
0.0
Recent Mexican Longer-stayed Mexican- U.S.-Born U.S.-born Non- Immigrants from
Immigrants Mexican Americans Whites whites a country other
immigrants than Mexico
Source: SSA, Inmigrantes Mexicanos y Centroamericanos en Estados Unidos, 2006
Adults 18 years and over living in poverty, U.S. And CA, 2005
http://www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=196
Immigrant paradox: Why?
Selection effects = health/social capital
– Health? (Rural Mexican women, Rubalcava, AJPH,
2008)
– Education (found in all countries, exc. Puerto
Rico; Feliciano,Demography, 2005)
– Social Networks?
– Other human capital?
Immigrant paradox: Why?
Selection effects
Return migration (salmon effect)
– 1/3 of Mexican immigrants return w/i 10 years
– Mortality is lower for Mexicans (who can
return) than Cubans (who can not)
– Can this explain birth outcomes??
Immigrant paradox: Why?
Selection effects
Return migration (salmon effect)
Health behaviors (culture)
– Lower rates of smoking, healthier diets
– Stronger social networks
Direct effects – helping out, share info, etc
Indirect effects – buffer stress
– Erodes w/acculturation
Acculturative stress
Changing behaviors
Immigrant paradox: Why?
Selection effects
Return migration (salmon effect)
Health behaviors (culture)
Community effects (context)
– Immigrants communities have an independent
protective effect
– Assimilation reduces (vs. acculturation)
n.s.=married, educ, income, immigrant, English interview, neighborhood poor
4. Community health strategies
Sustain healthy
behaviors
Improve medical
infrastructure
Improve social &
environmental context
of health
Photo: http://www.flickr.com/photos/roscoland/962051804/
Healthy Behaviors
Promote good nutrition: in schools, stores,
food stamps
Facilitate physical activities: via sports,
parks school yards
Disseminate information via promotoras
Sustain social networks via public space
Improve medical infrastructure
Sustain/expand community clinics, school
based clinics
Increase bilingual, bicultural workforce
Better connect workers to workers
compensation system
Expand preventive & elder care,
screenings & treatment
Improve context for health
Improve housing, building enforcement
Improve workplace health & safety,
CalOSHA, living wage and other
enforcement
Improve air quality in immigrant
communities
Summary, immigrant paradox
Better health outcomes despite many risk
factors
Some health advantage due to selection,
other to health behaviors, other to social &
community conditions
To maintain health capital, community
health strategies are important
5. Medical Care Issues
Mexican immigrants have the lowest levels
of health insurance of all in CA in poverty
100%
30.9 33.8
80% 43.0
45.3
57.3
60% 77.3
21.2
35.0
17.6 24.3
40%
14.2
20% 45.0
9.3 37.0 34.1 32.7
28.5
13.4
0%
Recent Mexican Longer-stayed Mexican American U.S.-Born Whites U.S.-Born Non- Immigrants from a
immigrants Mexican Whites country other than
immigrants Mexico
Public Private or both No health insurance
Source: SSA, Inmigrantes Mexicanos y Centroamericanos en Estados Unidos, 2006
Adults 18 years and older who live in poverty, U.S., http://www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=196
Mexican immigrants lack connection to
health care facilities
20.9% 14.7% 9.2%
42.4%
14.5% 46.2% 66.3% 79.4%
39.6% 31.1%
14.7% 9.0%
Recent Mexican Longer-stay Mexican American U.S.-Born Whites
Immigrants Mexican
immigrants
Doctor's office or health center Clinic None
Source: California Health Interview Survey, 2003
Adults 18 or older, California
Mexican immigrants have the highest levels of
no medical visits in the past two years
37.4%
22.0%
16.0%
7.3%
Recent Mexican Longer-stay Mexican U.S.-Born Whites
immigrants Mexican Americans
Immigrants
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
emergency room visits
16.7%
15.5%
11.9%
7.1%
Recent Mexican Longer-stayed Mexican- U.S.-Born Whites
Immigrants Mexican Americans
immigrants
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
dental services in Mexico
12.9% Low income Other
10.6% 10.5%
8.1%
5.3%
0.9% 0.7% 0.2%
Recent Mexican Longer-stayed Mexican- U.S.-Born Whites
Immigrants Mexican Americans
immigrants
Source - 2001 California Health Interview Survey
Adults 18 years or over, California
Adults age 18 and over with no
doctor visit past year
38.2%
26.0%
19.9%
14.3%
Recent Long-stay Mexican- U.S. Born
Mexican migrants Americans whites
migrants (10+ years)
Source: California Health Interview Survey, 2003
Adults age 18 and over with no
dental visit in past year
62.4%
46.1%
34.3%
26.8%
Recent Long-stay Mexican- U.S. Born
Mexican migrants Americans whites
migrants (10+ years)
Source: California Health Interview Survey, 2003
Adults age 65 and over with no
influenza immunization past year
28.8%
25.5% 25.0%
All Mexican Mexican- U.S. Born whites
migrants Americans
Source: California Health Interview Survey, 2003
Adults age 50 and over who have
never had a colorectal exam
67.1%
54.3%
42.2%
All Mexican Mexican- U.S. Born whites
migrants Americans
Source: California Health Interview Survey, 2003
Women age 18-64 with no pap
smear past three years
16.2%
13.1% 12.0% 11.2%
Recent Long-stay Mexican- U.S. Born
migrants migrants Americans whites
(<10 years) (10+ years)
Source: California Health Interview Survey, 2003
Summary, health care
Mexican and Central American immigrants
are an important part of California’s
population
They face substantial access to care
barriers
It is possible to provide adequate access
to care to these populations
Conclusion
Immigrants are “here
to stay”
They face a number
of special health,
health behavior, and
access to health care
issues
It is critical to address
those issues to
maintain a health
California
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