Life-course and population health perspectives to fill gaps in migrant health research

Abstract

This article highlights categories and dichotomies used in the study of the health of migrants, including migrant motivation, migrant type, pre- and post-migration time periods, and health as biomedically or socially determined. The authors suggest that the full spectrum of migrants and migration be considered more thoroughly in order to improve our understanding of migrant health. This paper challenges simple conceptions of migration, mobility, and migrant experience. To fill gaps in knowledge left by these conceptions, researchers must recognize the decisions migrants make as a process which plays out both over time (in migrant life-courses) and also across personal, national, and international contexts which connect the individual to larger structures and phenomena. The authors argue that, in this reality, research questions related to migrant health are best addressed using life-course perspectives which recognize health as a continuum of socially-constructed statuses.

The health of migrants is a subject potentially as large as it is vital. The number of people who leave their habitual location of residence for another – be it across an international border or within national boundaries (Key Migration Terms, 2015) - is large and growing (International Labour Office et al., 2015). In this article, we call these people movers and migrants interchangeably. The potential burden of ill health associated with this movement is both substantial and global in scope. Better understanding through research (Sweileh, 2018) is warranted in order to inform the sort of prevention efforts necessary to avoid ill health for both migrants and receiving communities (Ahonen, 2019). Therefore, we are honored to write the opening article for this special issue titled the Health of Migrants, which aims to explore migrant health and its influences both in places of origin and destination. This issue also addresses the ways in which migrant populations may experience poorer heath than non-migrant groups because health-supporting or harming factors are distributed unevenly along the structural and social lines of demarcation movers may cross.

Health is “a structural, functional and emotional state that is compatible with effective life as an individual and as a member of society” (McCartney et al., 2019). What is required for this compatibility will change as movers’ lives change, and as societies change in ways which support the health of mover populations to a greater or lesser degree. In a broader sense, an individual project of human movement has associated life-building goals, hopes, and aspirations which, like the project itself, are subject to change within historical and social context. In turn, the degree of fulfilment of these hopes and aspirations may be contributors to migrant well-being, an idea which encompasses subjective judgments of health, happiness, comfort, and satisfaction (Schulte & Vainio, 2010). At any given time point, hardships, frustrations, advances, acceptance, and more can influence the well-being of individual migrants. These dynamics associated with movement matter very much to them, and are also subject to intervention whether or not diagnosable disease or injury has developed. As such, we consider both health and the more inclusive concept of well-being to be important factors in research on the health of migrants.

We have approached the opener to this topic by thinking about categories used in migrant health research which limit a fuller understanding of challenges that mobile populations may face if these categories are employed without reflection about their relevance to the health or well-being concern under study. Both status as a mover and movement itself can be powerful social organizers; as such, both have relevance for the health and well-being of mobile people, and their influences span time and location. Likewise, health is a central component of the human capital that contributes to successful migration, which is a social mobility project tied to well-being. Yet, studies of migration and health are sometimes limited in their capacity to explore the complex intertwining of movement, health, and well-being for several reasons. First, research on the drivers of migration has often focused exclusively on macro-economic factors, meso-level migrant networks, or the intrapersonal factors which are assumed to drive human movement, when all sets of influences are in play and relevant to migrant well-being. Second, while migration scholars have studied the movement of the poor and the so-called ‘global elite,’ with additional sub-literatures on specific types of migrants (e.g., asylum seekers, international students), there is a hole in our understanding of migrants who defy category; those who are educated and relatively well-off both in the global order and in their countries of origin. This understudied group of movers has options; while affected by larger contextual factors, they also have enough privilege to exercise their individual agency in decision-making. Consideration of such migrants more fully illustrates our understanding of human movement, and therefore possible influences on migrant health and well-being. Third, research on the health of movers tends to bifurcate connected phases of life into before- and after-migration, and compare immigrants (i.e., post-migration movers) to long-term residents, when migration might be best viewed as an ongoing process, and individuals’ health evolves in a continuous fashion.

Instead of adhering to rigid categories, we suggest softening intellectual lines between who is defined as a migrant and who is a non-migrant, as this issue proposes to do. There is also utility in blurring the lines between migration and social mobility studies, favoring instead a perspective which sees movement as an evolving life process which people in varied circumstances undertake. Using this perspective, we can then employ a life-course view of health as something which is continually socially created by people in specific places and times. We elaborate on these points below, using examples from our own work to illustrate.

Motivations

Researchers from fields as diverse as economics, sociology, demography and social psychology have pointed to multiple, macro-level reasons people might choose to migrate to another country. Often referred to as “push-and-pull” factors, these reasons include the potential for economic improvement (Massey et al., 1993), social networks in the destination country, norms about migration (De Jong 2000; De Jong et al. 1983), and existing migrant flows (Epstein & Gang, 2006; Kritz & Zlotnik, 1992; Massey, 1999). Recognizing that macro-level theories, particularly macro-level economic theories, ignore the role of individual agency, some researchers have also identified intra-personal factors that relate to migration decision-making. These include: sensation-seeking, risk aversion (Gibson and McKenzie 2011; Van Dalen and Henkens 2013), self-efficacy (Hoppe and Fujishiro 2015; Jasinskaja-Lahti and Yijälä 2011), anticipated job benefits, career aspirations (Hoppe & Fujishiro, 2015), expectations related to the achievement of goals (De Jong 2000), and anticipation for adapting post-migration (Jasinskaja-Lahti and Yijälä 2011), which variously predict intention to migrate and actual migration.

Interdisciplinary migration scholars have increasingly recognized that decision-making about migration, and migration itself, occur not simply because of strong push-and-pull factors. Rather, they occur within a multi-layered milieu which incorporates the macro (the social, economic, legal, and political contexts of both sending and receiving countries); the meso (community and family needs and norms both in the sending country and in migrant networks in receiving locales); and the micro (aspirations, goals, and personal traits of the individual migrant) (see, for example, Massey et al. 1993; Arango 2000). Recognizing complex negotiations among these factors across multiple layers, this body of literature sees migration as a dynamic and multi-layered phenomenon. While the idea of problematizing the binary of push-pull factors is not a new one, the literature which considers multi-layered influences on migrant health or well-being is still relatively limited in size.

Types

Creating categories in motivations of movers leads to studying those with different ostensible reasons for movement separately, creating “types” of movers. Within the push-and-pull framework, for instance, migration research has largely focused on poor and less formally educated people; movers with few resources moving from poor countries to wealthy ones or rural to more urban areas within-country. Very high-resource movers, sometimes called the global elite, are studied in a separate literature, as are highly-skilled migrants and regional movers (e.g., within-Europe mobility). In these cases, research interests are not on the influence of movement on the movers or their health, but rather on the impact that migration has on the country or area movers have left (e.g., the health of societies left behind by movement of medical care workers; “brain drain”). Furthermore, many of the distinctions we make between types of movers are based upon legal notions about their status in the new locale. Conversations about the health of these specific groups are then often limited to the needs and demands that arise from that legal status (e.g. asylum seekers’ access to adequate environments; pensioners’ becoming burdens to medical systems; unauthorized migrants’ access to medical care).

As a result, studies of movers’ health tend to exist in completely separate bodies of literature that reflect such sub-categories as internal/domestic migrants, labor/economic migrants, asylum-seekers, or refugees. These categorized movers are often combined with additional social category distinctions which may be relevant for the receiving location (eg., language, gender, religion). In some research situations, these distinctions of motivation and type are likely useful. For instance, a research question about whether conditions in housing camps for refugees put the movers at risk for increased anxiety would be best answered by studying that particular group and how the amount of time they are in those conditions relates to their status. But in other circumstances, these distinctions are likely to be less useful. For example, movers from rural to urban areas are, crossing national borders or not, likely to be motivated by similar individual and contextual factors and have similar hopes and aspirations tied to the move. Thus, unless the research question is related to national borders (e.g., different language, different medical care system), distinguishing international and domestic migration could make some research efforts redundant.

Time

The way scholars of migration approach time is also relevant to how we might frame the health of movers. Many studies document migration as a time-limited action and focus on what happens to people after they have migrated. They often compare the health of the newly-arrived to longer-standing or “native” groups. These studies are often contributing to literature on the so-called healthy migrant effect – the observation that newcomers often start out with better health status than the population that is already there, and over time their health status more closely approximates that of the broader receiving population. More recently, a few researchers have considered the sort of pre-migration adaptation processes which occur in individuals prior to a move (Arévalo et al., 2015; Hoppe & Fujishiro, 2015; Jasinskaja-Lahti & Yijala, 2011; Yijala et al., 2012; Yijala & Jasinskaja-Lahti, 2010). These studies highlight that it is important to understand migration as a process with phases which begin even before a person has gone anywhere (Tabor and Milfont 2011). Exploration of pre-movement phases is especially important because researchers, despite greater recognition of migration as a process, usually do not know if the health status of eventual migrants resembled the overall population in their places of origin. This frame of reference is important for understanding whether observed changes in a new locale represent a turn in the health trajectory or not. Likewise, these processes may function differently for physical and psychological aspects of health (Fujishiro & Hoppe, 2020).

A second reason that time is important concerns the post-migration phase. Studies of migrant health tend to consider them as a sub-population of the broader society they have moved to be part of. For some research questions, factors which separate the experiences of newcomers from the experiences of longer-standing populations may be relevant (Zion et al., 2010). But if the newcomers stay for any period of time, how long ought they to be considered as a distinct sub-group from the receiving population? Such distinctions between migrant and non-migrant populations must be made consciously as they have implications for the inclusion, and the health, of the more recently arrived groups (Ahonen, 2019; Hankivsky & Christoffersen, 2008).

The value of greater categorical flexibility for understanding movement

Softening lines between varying migrant motivations and resulting migrant types, as well as avoiding binaries of before and after migration, prompt a more continuous perspective on the movers themselves and on their movement. In a globalized world where both capital and people cross internal and international boundaries, more thoroughly considering the full spectrum of movers and movement is key. This movement process is one that interacts with social categories that movers occupy (eg., gender identity, ethnicity) and with their life phases (eg., youth, prime reproductive and working ages), and unfolds within broader societies and macro political, social, and economic settings. Some scholars have argued that we might better describe the complexity of this movement using a mobility, rather than a traditional transnational migration lens, because it “helps [us] to move away from bipolar and frictionless conceptualizations of transnational migration” (Schapendonk & Steel, 2014, p. 263)Such a perspective may be additionally helpful because internal movement and international migration, whatever the motivations and resources of the movers, might be considered continuous trajectories of social mobility. Indeed, in the discussion of potential moves with people, descriptions of the thoughts and plans movers provide may begin to overlap and challenge the categorization of them as one sort of migrant or another (Ackers, 2005; King, 2002; Schapendonk & Steel, 2014)

Some of these ideas are exemplified in our own work. As part of a larger project about migration, we interviewed Spaniards in various phases of intention, planning, and movement to Germany in the wake of the global economic crisis of 2008–9. As relatively well-educated people native to a European country with the options that the open borders of the continent permit, the people we interviewed occupied the realm of space between the global elite and the capital-constrained (Paul, 2015), a middle category (Conradson & Latham, 2005; Paul, 2011) of people who thought of themselves as both limited by, and able to move within, the larger social, political, and historical global moment in which they lived. We analyzed the narratives provided by the Spaniards as they spoke about their moving plans. The analysis showed that these potential migrants, although their backgrounds and personal situations were similar in many ways, could not be neatly categorized as one type of migrant or said to have one type of motivation; they spoke in ways which crossed categories of motivation and type of migrant. Our participants described both classic “push-and-pull factors” as well as their efforts to mobilize capital and reconfigure it over space and time (Erel, 2010; Paul, 2015) to support their migratory goals and aspirations. Goals and aspirations were deeply tied to their projects of life-building, and the life-building project might eventually bring them back to Spain. What motivated these potential movers, the macro- or the intrapersonal? Is theirs a specific type of migration? Is it intra-European mobility of educated professionals? And do these distinctions matter to the health of the potential movers? If so, how? These types of questions should guide researchers as they frame research questions and decide what categories and distinctions are useful to the research questions and which are not, rather than beginning with rigid categories in mind.

Our findings supported an understanding of movement which transcends categories of motivation, migrant type, and time. The interviewees thought about the broad social and economic circumstances of the time they lived in, as well as how those circumstances interacted with their personal goals and aspirations for their individual lives. They thought about moves which might be domestic or international; in fact, some potential movers said they probably would not go abroad, but they might move to a larger city within Spain. Their motivations, however, were the same as those considering a move to Germany. Their thoughts described the purposeful ways in which migrants undertake moves and the emergent nature of the process (Paul, 2011, 2015). The potential migrants in our study had goals which they hoped to achieve through purposeful moves over the long term, and these moves required the building of social and human capital along the way and an iterative process of taking stock of circumstances to consider the next move. Furthermore, as middle migrants, they recognized their place in a globalized world, both their ability to compete as well as the limits of their power, knowing they were neither the global poor nor the global élite.

We were also able to overcome binary thinking about before/after components of a move because we queried participants about their migration intentions before they had gone anywhere. We furthermore asked participants about previous moves they might have undertaken, allowing us to consider their current migration thinking within the context of any previous migratory decisions. These strategies pushed us to think in parallel about motivators and the agency participants had to pursue movement as a way to meet goals that were part and parcel of their hopes for the lives they wanted, which would unfold in a broader context over which they had less control. While neither health nor well-being outcomes were the primary aims of analyzing these interviews, both are tied to motivations and migratory goals; health is an important asset in migration/self-actualization process. Likewise, the relative success of efforts toward self-actualization is also likely to influence well-being over time (Fujishiro & Hoppe, 2020).

The value of greater categorical flexibility for understanding health

Disease endpoints, often the outcome of choice in health studies, are important, but the experience of health fluctuates frequently in response to both individual and contextual circumstances in ways that challenge traditional biomedical perspectives on risk factors and disease. In combination with greater intellectual flexibility about mover motivations, types, and time, a more complex understanding of health is necessary. Such an approach encourages a life-course perspective for migration research. Or, as King (2012) put it, to study migration (or its absence) as a phenomenon embedded in “global processes of social, economic, and political transformation, and within biographies of migrants’ life courses”. In such a process-oriented perspective, trajectory is as important as any starting or ending point, and motivations, challenges, and facilitators at any given moment encompass multiple levels of influence. Considering the life-courses of movers and the layered contexts in which they make decisions reminds us that lives, and moves within them, are processes of ongoing change and adaptation to change which are relevant to mover health, well-being and to their movement projects.

Considering the experiences of movers without the hindrance of unnecessary categories may help us better understand migration and health in the contexts of life and society. Revisiting key ideas first put forth by epidemiologist Geoffrey Rose, Valles (Valles, 2018) argues that in migrant health research, choices for “lumping vs. splitting” of migrant populations as analytic groups should be determined by which choice will illuminate the causes of incidence of ill-health in a population, rather than the causes of ill-health for individuals (Schwartz & Diez-Roux, 2001). It is not our argument here that causes of ill-health for the individual mover should be ignored. Rather, we point out that societies’ characteristics that determine how ill-health is distributed in a population (i.e., causes of incidence) can offer population-level avenues for intervention to reduce health inequity. An effective first step is to see movers as one group (i.e., lumping, (Valles, 2018)—defined by their movement alone—have a disproportionate burden of ill-health in the total population. If so, then we should ask what characteristics of the receiving society place the burden to movers. This initial lumping step does not preclude later exploration of the experience of subgroups if that is warranted. In fact, it may sometimes be important that after initial lumping, researchers conduct further analyses of migrant subgroups with potentially different disease risks or determinants of health, in order to identify subgroups with particular needs. But a first broader grouping of movers would help distinguish between the movement itself from the social response to movers (eg., stigma, discrimination) for their influences on health.

Such questioning ought to lead us to consider the societal power structures in sending and receiving locales, and where migrants, in combination with other categories they occupy according to their gender, ethnicity, or other social demarcations (Bowleg, 2012), fall in those systems of power and protection (Ahonen, 2019). Migrant health can reflect how society is structured to create ill-health for those with less power. Attention to if and how societal systems sort movers into less or more healthy economic, physical, and social conditions, all of which impact health, is key to health equity; researchers and those who aim to support movers do not have to wait for movers to become “sick” before improving these conditions. Finally, attending to root causes in the society has the potential to usefully soften distinctions between movers and other members of the society in ways which may improve health for all. Such a perspective recognizes the interconnections that make health and well-being a collective state (Valles, 2018). Therefore, improving root causes improves things for all of the population – the movers and the less mobile.