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Published in final edited form as: Soc Sci Med. 2012 Sep 16;75(12):2055–2059. doi: 10.1016/j.socscimed.2012.09.008

Special Issue introduction: Place, migration and health

Dolores Acevedo-Garcia 1,*, Joanna Almeida 2
PMCID: PMC3764998  NIHMSID: NIHMS505257  PMID: 23072818

This Special Issue of Social Science & Medicine highlights new promising directions for advancing research on the health of immigrant populations. Our hope is that this collection of papers will contribute to a more thorough and integrated examination of the roles of place (i.e., contextual influences) and migration (i.e., population movements and immigrant adaptation) on the health of immigrants, their families and on overall population health in their sending and receiving societies. The articles in this issue review the utility and limitations of conceptual frameworks and analytic strategies commonly used for understanding immigrant health and propose new ones. In addition, the articles empirically examine immigrant health in context using innovative analytic strategies, and begin to tackle issues concerning possible cross-national (i.e., sending and receiving country) influences on immigrant health.

Why a Special Issue on place, migration and health?

Why place?

Attention to place (i.e., social and physical context) in social epidemiological research has increased in the last two decades, ranging from the examination of health effects of neighborhoods to the role that national or state level income inequality play in shaping health outcomes (Kawachi & Kennedy, 2006; Macintyre, Ellaway, & Cummins, 2002; Wilkinson & Pickett, 2006). However, research on how context influences immigrant health is an emerging area of investigation that could benefit from a more refined conceptualization of context—one that is more specific to the realities of immigrants whose lives are embedded in multiple places, (e.g., the sending and receiving country) and in relatively more complex interactions than the lives of non-immigrants. First, the country or community of origin context can often be a persistent and continued influence on the lives of immigrants. For instance, immigrants maintain cross-national ties with kin and non-kin in their countries of origin via economic and social remittances (Levitt, 2000, 2001; Levitt & Lamba-Nieves, 2011; Levitt & Waters, 2002). Second, relative to non-immigrants, immigrants experience the context of the country of destination in different ways, often living in communities that reproduce to some extent the ethnic composition, language and culture of the country of origin. Nonetheless, irrespective of whether these ethnic immigrant communities are health protective, immigrants’ engagement with the receiving context is often constrained by discrimination, public policies that may deny and restrict their access to rights otherwise granted to the native born, and immigrants’ limited knowledge of how to navigate the institutions of the host country (Capps et al., 2002; Finch, Hummer, Kol, & Vega, 2001). While in social science research there is an understanding that immigrants’ well-being is the result of a two-way interaction between the characteristics of immigrants and the sending and receiving contexts, in health research this perspective is yet to be fully incorporated.

Why migration?

As noted by Willen (2012) immigration and migration denote different meanings. For the title of this Special Issue, we chose migration because it is a more inclusive term that comprises moves that are temporary and permanent, as well as moves between and within countries (e.g., rural to urban migration). Though the papers in this Special Issue all focus on between-country migration, they propose frameworks and analytic strategies that could be applied to the study of within-country migration. For example, in countries where migrants have limited political and economic rights (e.g., China, Myanmar), internal migration can be as consequential to health as international migration (Dishingkar, 2006). This may also be true in cases where internal migrants need to overcome significant socioeconomic, language and cultural barriers to adapt to their receiving community.

Additionally, we use the term migration rather than immigrant to emphasize that health research needs to move away from immigrant status as a fixed, individual-level label. Instead, the papers in this collection call for considering the health repercussions of migration as a set of dynamic processes, including health selectivity (negative or positive) into the migration flow, population movement (which may include displacement, the journey and its risks, and legal requirements for moving), and the two-way adaptation between immigrants and their receiving society. This dynamic way of studying migration, has been the subject of extensive sociological and anthropological scholarship, but immigrant health research has yet to fully integrate this perspective.

Why health?

Public discourse on immigration often focuses on its effects on economic development, employment, national identities, and “illegality”. However, other key aspects of immigration are not as prominent in the public discourse. In the US context, for instance, public discourse often ignores immigrants’ health and the demographic and social importance of children of immigrants who represent nearly one-fourth of US children (Mather, 2009). The lack of prominence concerning the health of immigrants in the US public discourse is surprising because health influences economic productivity and has critical implications for both sending and receiving countries. Health researchers can play an important role in bringing attention to the health of immigrants as a significant factor that affects not only immigrants’ economic contributions but also their overall well-being.

Additionally, we use the term health and not health of immigrants because place and migration processes influence the health of both immigrants and non-immigrants in sending and receiving communities, as well as population health. For instance, some research suggests that living in a neighborhood with a higher immigrant concentration may be health protective for all neighborhood residents, e.g., protective against parent to child physical aggression, and against crime victimization (Molnar, Buka, Brennan, Holton, & Earls, 2003; Sampson, Morenoff, & Raudenbush, 2005).

The significance of immigrants and their health

Migration between countries is at higher levels than ever before. In 2010, Europe hosted the largest immigrant population of all world regions, over 71.3 million, followed by Asia (61.3 million), North America (57.2 million), Africa (19.1million) and Oceania (6.8 million) (Migration Policy Institute, 2010).

From the perspective of immigrant-receiving developed countries such as the United States, the United Kingdom, Australia, and Canada, the significance of the immigrant population and their health patterns is clear. Immigrants have a younger age distribution than the populations of these countries as a whole, which means that immigrants influence the availability and productivity of the work force, and contribute to the social security system to support an aging population. In addition, the health and human development of the children of immigrants is largely dependent on the health of immigrants themselves. For example, in the United States, immigrants (i.e., foreign-born) and their children together represent about one-quarter of the population (Foner, 2009), births to immigrant women comprise 24% of all US births (Passell & Taylor, 2012), and children of immigrants account for 22% of all US children (Mather, 2009). Also, immigrants represent 15% of the labor force, 21% of low-wage workers, 45% of lower-skilled workers, and one-third to one-half of growth in the labor force through 2030 (Capps, Fortuny, & Fix, 2007).

In developed countries, the health of immigrants shows patterns distinct from those in the native-born population. An exemplar is the United States, where immigrants often have a health advantage over the US-born (Acevedo-Garcia & Bates, 2007). These patterns of better health among immigrants have also been documented in other countries such as Canada, the United Kingdom, and Australia (Aglipay, Colman, & Chen, 2012; Kennedy, McDonald, & Biddle, 2006). At the same time that there appears to be an initial immigrant health advantage, multiple factors threaten the health of immigrants. For example in the US, immigrants are disproportionately represented among the lower-skilled work force. Due to low socioeconomic status, limited English proficiency, and limited access to health insurance and social services, immigrant families face many risks to their health and barriers to health care (Derose, Escarce, & Lurie, 2007). This is especially true during economic crises typically accompanied by a political context that is increasingly polarized around the issue of high immigration levels.

From the perspective of immigrant-sending countries, the health of their migrating co-nationals is critical since their productivity in receiving countries is linked to their ability to send remittances back to origin countries, and has large implications for national economies, the development of sending communities, and individual families. For example, in 2010, remittances to India ($55 US billion), China ($51 US billion), Mexico ($22.6 US billion) and The Philippines ($21.3 US billion)—the four largest remittance-recipient countries—totaled nearly $150 billion US dollars—compared to $39.4 billion US dollars in US official development aid (Ratha, Mohapatra, & Silwal, 2011; Tarnoff & Lawson, 2011). Remittances constitute a key resource and potentially an engine for economic development in countries like India, China, Mexico, and The Philippines (Fajnzylber & Lopez, 2008; Ratha et al., 2011). The issue of remittances brings analytic issues to bear in scholarship concerning immigrant health, including whether and how remittances affect the socioeconomic status and health of immigrants in receiving societies, and of their families and communities back in their origin countries.

In response to high immigration, in the last decade there has been a surge in governmental and non-governmental initiatives to assist their immigrant co-nationals, improve data on the immigrant population, highlight their contribution to their sending countries, and bring attention to the policy context of immigration (Zimmerman, Kiss, & Hossain, 2011). For example, the European Union has developed a Migrant Integration Policy Index that tracks progress toward policies that aim to facilitate immigrant incorporation (defined as equal rights, responsibilities and opportunities for immigrants and non-immigrants) in all European Union Member States plus Australia, Canada, Japan, Norway, Switzerland and the US (British Council & Migration Policy Group, 2012). The increased attention to immigration is also evident through activities by the Inter-American Development Bank, which tracks flows of remittances (money sent by immigrants to their home countries) between countries (Inter-American Development Bank, 2009).

Simultaneously, and as a result of high immigration, strong anti-immigrant political and policy responses have been on the rise in developed countries such as in the US and in Europe (Bauer, 2009; Collete, 2011). Research on immigrant health during these times has increased considerably, but it has not kept pace with the rapidly changing societal and political context of immigration. For example, increasingly discrimination (both legally sanctioned and not) has been a response to immigration (Bauer, 2009), yet research on the study of discrimination and its health consequences among immigrants is relatively new (Edge & Newbold, 2012; Viruell-Fuentes, 2007, 2011). Health research has typically emphasized cultural factors as determinants of immigrant health, though the complexity of migration experiences calls for enhanced theoretical perspectives and analytical strategies to capture as much as possible the complex influences on immigrant health.

Contributions of the Special Issue

The papers in this Special Issue address the questions and concerns discussed above and suggest directions for future research on place, migration and health. Together, they provide recommendations for how to advance the fields of social epidemiology and immigrant health research, as summarized below. Two conceptual papers, (Acevedo-Garcia, Sanchez-Vaznaugh, Viruell-Fuentes, & Almeida, 2012 and Viruell-Fuentes, Miranda, & Abdulrahim, 2012) present ideas that are examined empirically by the other authors.

Acevedo-Garcia et al. (2012) developed a conceptual framework rooted in social epidemiology for examining sending and receiving country influences on immigrant health. The empirical papers by Almeida, Johnson, Matsumoto, and Godette, (2012), Hill, Angel, Balistreri, and Herrera, (2012) and John, de Castro, Martin, Duran, and Takeuchi, (2012) examine health outcomes among immigrants using social epidemiologic constructs such as social determinants of health (gender, SES) and life course trajectories, as well as differential effects between immigrant status and other factors.

Viruell-Fuentes et al. (2012) elaborate on the issue of social determinants by providing a constructive critique of the overreliance on cultural constructs in immigrant health research, and by making a compelling case for including other factors such as interpersonal and institutional discrimination against immigrants, as well as immigration policies that may hinder social integration and health. In their empirical papers Abdelrahim, James, Yamout, and Baker (2012) and Becares, Nazroo, Jackson, and Heuvelman (2012) apply a discrimination and health framework to examining the health outcomes of Arab immigrants in the U.S. and Caribbean immigrants in the US and the UK.

Integrate immigrant health research into social epidemiology

Acevedo-Garcia et al. (2012) make a case that conceptually and methodologically, immigrant health research needs to be better integrated into social epidemiological research. For example, we need to question the reliance on theories of immigrant adaptation that emphasize cultural factors to the detriment of structural factors such as the socioeconomic and policy context of immigrants in sending and receiving societies. A common theme among the seven articles is the call for a greater use of a social-determinants-of-health framework in immigrant health research. Acevedo-Garcia et al. (2012) explain the need for such a framework and the need to combine it with a cross-national perspective which, calls for considering the social determinants of health in both the sending and the receiving country across the life course. Acevedo-Garcia et al. (2012) and Viruell-Fuentes et al. (2012) offer a constructive critique of the acculturation perspective which has been heavily utilized in health research. They build on research published in the last decade in Social Science & Medicine, ranging from Hunt’s critique of the acculturation construct (Hunt, 1999; Hunt, Schneider, & Corner, 2004) to recent work on the effects of “illegality” on the health of immigrants (Willen, 2012).

Consider interactions between migration and social determinants of health across the life course

The experience of immigration and its effects on health may be modified by social factors such as gender. Acevedo-Garcia et al. (2012) propose examining such interaction effects and for using a life course perspective, while Viruell-Fuentes et al. (2012) explicitly call for the application of intersectionality theory to analyze how immigrant status interacts with other social positions such as race, ethnicity, class, and gender (Almeida et al., 2012).

Hill et al. (2012) apply this strategy in an empirical analysis of the interplay between immigrant status and gender in the cognitive functioning of Mexican Americans. They find that although both men and women who migrated in middle-life exhibit higher levels of baseline cognitive functioning than their US-born counterparts, immigrant men maintain this advantage for a longer period of time than women. Almeida et al. (2012) investigated the interaction between generation and duration in the US and gender in substance use among youth in Massachusetts, US. They observed that recent immigrant status is protective, and contingent upon gender: among adolescent boys, it is protective against the use of more substances than among adolescent girls. Simultaneously, the authors applied a life course perspective by evaluating whether the protective effect of first-generation immigrant status diminishes over time and whether it does so faster for the use of some substances. They found that the protective effect of immigrant status against substance use wears off more quickly for alcohol than for tobacco and marijuana, which has implications for prevention strategies.

Similarly, Viruell-Fuentes et al. (2012), Abdelrahim et al. (2012), and Becares et al. (2012) draw attention to the intersections between race, ethnicity, and immigration. Abdelrahim et al. (2012) studied the interaction between immigrant status and racial discrimination among Arab Americans. The authors document that Arab Americans who are closer to a “white” US identity report less discrimination than those who identify as non-white. However, when the former experience discrimination, they suffer more adverse health effects. The study by Becares et al. (2012) illustrates how the racialized meanings attributed to race and ethnicity and their health consequences vary across countries. Abdelrahim et al. (2012) discuss several conceptual considerations to help guide future research on the intersections between immigration, race, and health and point to the importance of addressing structural racism and their manifestations in immigration policies and residential segregation.

Critically examine whether constructs and measures used in health research apply to immigrants

Measures commonly used in health research may fail to capture the experiences of immigrants and their health implications. The measurement of immigrants’ socioeconomic status presents complex issues (Fuligni & Yoshikawa, 2003). For instance, immigrants’ income is often not a true reflection of disposable income available to purchase food, housing, health care and other inputs to health as immigrants often send remittances to their countries of origin, which diminishes their disposable income. Also, educational status among immigrants may reflect that attained in the country of origin, which is often not translatable into an equivalent occupational or educational status in the receiving country due for instance to between-country differences in occupational licensing and credentialing requirements. Additionally, more often than not the validity of commonly used, predictive health measures—for instance, self-rated health—have not been established in immigrants.

Several papers in this Special Issue illustrate how broad social categories such as race need to be unpacked, in the case of immigrant groups (Abdelrahim et al., 2012; Becares et al., 2012; Viruell-Fuentes et al., 2012). Abdelrahim et al. (2012), for instance, suggest that in the case of, Arab Americans, finer constructs such as religious identity, skin color and residence in ethnic enclaves need to be examined. In addition, Viruell-Fuentes et al. (2012) point out the importance of applying a more refined theoretical lens to existing immigration-related measures in order to better understand the meaning of markers such as generational status, language, and age at migration under specific contexts. Therefore, there is a need to apply intersectionality theory and to examine whether constructs developed and applied for non-immigrant populations hold for immigrants, whether they need to be revised, or whether new constructs need to be developed. Authors in this Special Issue also caution against assuming that commonly used health measures have validity among immigrants. John et al. (2012) observed seemingly contradictory effects of nativity for two health outcomes, self-rated health (detrimental effect) versus DSM-IV diagnosed mental disorder (protective effect), which raised concerns about the applicability to immigrant populations of assessment tools based on Western expressions of mental well-being.

Take a closer look at epidemiological paradoxes

In health research, studies involving immigrants often allude to the issue of epidemiologic paradoxes, e.g., patterns in which immigrant health does not conform to relationships observed in the population at large, such as socioeconomic gradients in health which are generally strong in the general population (though vary based on specific outcomes and social determinants such as gender), but less so among immigrants.

An improved understanding of the socioeconomic patterning of health among immigrants can help us distinguish between influences of the country of origin and those of the receiving country. Acevedo-Garcia et al. (2012) point out that more sophisticated research on SES gradients, especially among US Latino immigrants, is contributing to enhanced knowledge of, for example, whether immigrants import SES gradients from their countries of origin and whether over time the shape of these gradients converges toward those in the receiving society. John et al. (2012) examined socioeconomic gradients in health and mental health among Asian Americans, a population on which there is limited research due to data limitations such as small sample size. These authors were able to overcome such limitations by using the National Latino and Asian American Study, a uniquely rich data set (Alegria et al., 2004). They reported that among US Asians, a largely immigrant population, there was a protective effect of immigrant status on health and flat occupational health gradients. Despite these flat socioeconomic gradients, which mean that low SES does not increase the risk of poor health compared to high SES, limited English proficiency was a risk factor for poor health. Therefore, the authors cautioned against simplistic characterizations of immigrants as “healthy” because they may lead to overlooking and thus not addressing factors, for instance, limited English proficiency, that may place some immigrants at risk of poor health outcomes.

Unpack place in research on immigrant health

The role of place in immigrant health may vary by generational status or duration in the receiving country, and may also be modified by other contextual influences. For example, while ethnic enclaves have been shown to be functional and protective among first generation immigrants, among second generation immigrants they may be detrimental, and an indication of blocked social mobility (Osypuk, Bates, & Acevedo-Garcia, 2010). Also, while place often denotes neighborhoods, contextual influences at other geographic levels may be consequential for immigrant health and/or may modify neighborhood effects. For example, increased devolution to and enforcement of immigration laws by municipal jurisdictions may result in increased police presence in immigrant neighborhoods with negative consequences for the health of immigrants (Hacker et al. 2011).

Some papers in this Special Issue consider the role of place in shaping immigrant health and the need to examine the conditions under which ethnic/immigrant enclaves might be protective of health (Becares et al., 2012; Viruell-Fuentes et al., 2012). Becares et al. (2012) studied context at two levels, neighborhoods and receiving country, by examining the influence of neighborhood ethnic density on the health of Caribbean immigrants in the United States and England. They observed that in England, where Caribbean immigrants are more racially stigmatized than in the US, neighborhood ethnic density did not confer a protective effect against experiencing racism and detrimental health outcomes, but the opposite was found in the US. Their methods underscore the importance of international comparisons as an analytic strategy that can help understand the differential role of the context of reception on immigrant health. Viruell-Fuentes et al. (2012) additionally point out the need to attend to the growing dispersion of immigrants into new, mostly rural, destinations in the US, where new and unexamined aspects of context may need to be considered.

Consider public policy

The well-being and adaptation of immigrants is shaped by public policies in both sending and receiving societies (Jones-Correa, 2012; Viruell-Fuentes et al., 2012; Zimmerman et al., 2011). The receiving policy environment varies from country to country as well as across time. For example, as documented by the Migrant Integration Policy Index, developed countries vary in the extent to which they promote immigrant integration in seven policy areas: labor market mobility, family reunification, education, political participation, long-term residence, access to nationality, and anti-discrimination (British Council & Migration Policy Group, 2012). Despite the recognition of the importance of the policy context for immigrants and the geographic and historical variation in policy environments, which offers the opportunity to conduct natural experiment or case studies, the examination of policy influences on immigrant health is just beginning (Zimmerman et al., 2011).

Echoing trends in public health research which advocate for the examination of the potential health effects of all policies (Stahl, Ollila, & Leppo, 2006)—not only explicit health policies such as health care and health insurance—Viruell-Fuentes et al. (2012) point out the importance of attending to immigration policies as health policy. Acevedo-Garcia et al. (2012) remind us of the importance of both the policy context of reception and the policies enacted by sending countries to support their immigrants abroad. Future research should address policies and programs affecting immigrants to assess whether they promote immigrant incorporation and protect immigrant health.

Conclusion

In editing this Special Issue, we hope to stimulate interest in new ways to advance health research on immigrants, and draw attention to the importance that place, as well as the complex process of migration, have on the health of immigrants themselves, and on population health in both origin and destination societies. Additionally, we hope that the articles in this Special Issue encourage researchers to expand their investigation of health among immigrants from one that focuses solely on cultural factors, to one that considers the social determinants of health, including a life course, as well as a cross-national perspective. Collectively, the papers in this Special Issue provide an overview of the state of the art in conceptual and methodological approaches to immigrant health. They also propose new ways to operationalize and investigate patterns of health among immigrants, for example, using a cross-national perspective, present empirical analyses aimed at uncovering heterogeneity in immigration and health trajectories, and urge us to investigate the population-level implications of immigrant health for both receiving and sending countries.

Acknowledgments

The guest editors of this special issue are founding members of Place, Migration and Health: A Cross-national Research Network (PMH) www.placemigrationandhealth.org. They gratefully acknowledge the support of other PMH members, especially Barbara Krimgold, Debra Perez, Emma Sanchez-Vaznaugh and Edna Viruell-Fuentes, and of Ana Lucia Ruggiero of the Pan American Health Organization, as well as grant support for PMH from the Center for Advancing Health, The Robert Wood Johnson Foundation, and the David Rockefeller Center for Latin American Studies at Harvard University.

The authors also acknowledge support from the W.K. Kellogg Foundation to Dr. Acevedo-Garcia, and from The Eunice Kennedy Shriver National Institute of Child Health and Human Development (1L40 HD066672-01) to Dr. Almeida.

Contributor Information

Dolores Acevedo-Garcia, Institute for Child, Youth and Family Policy, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, 02454-9110, USA.

Joanna Almeida, Email: joanna.almeida@simmons.edu, Simmons School of Social Work, Boston, MA, USA.

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