The Hispanic health paradox across generations: the relationship of child generational status and citizenship with health outcomes

doi:10.1016/j.puhe.2015.04.007

Public Health

Volume 129, Issue 6, June 2015, Pages 691-697

https://doi.org/10.1016/j.puhe.2015.04.007 Get rights and content

Highlights

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A healthy immigrant advantage lasts until the 3rd generation for asthma.
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A healthy immigrant advantage lasts until the 2.5 generation for bronchitis.
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A healthy immigrant advantage lasts until the 2.5 generation for allergies.
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Citizenship was not an influence on having a respiratory health condition.

Abstract

Objectives

In examining the Hispanic health paradox, researchers rarely determine if the paradox persists across immigrant generations. This study examines immigrant respiratory health disparities among Hispanic children in terms of current asthma, bronchitis, and allergies using an expanded six-group immigrant cohort framework that includes citizenship and the fourth-plus generation.

Study design

Cross-sectional primary survey data from 1568 caretakers of Hispanic schoolchildren in El Paso, Texas (USA), were utilized.

Methods

Data were analyzed using generalized linear models.

Results

Results indicate that a healthy immigrant advantage lasts until the 2.5 generation for bronchitis and allergies (P < 0.05), and until the third generation for asthma (P < 0.10). Citizenship was not an influence on the likelihood of a child having a respiratory health condition.

Conclusions

Findings demonstrate the utility of the expanded six-group cohort framework for examining intergenerational patterns in health conditions among immigrant groups.

Introduction

In spite of low socio-economic status and limited access to healthcare, Hispanic immigrants tend to have better health outcomes than their US-born and white counterparts.¹ For example, Hispanics have the lowest prevalence of asthma in the United States when compared to other racial and ethnic groups.¹ Possible explanations for this Hispanic health paradox include low levels of acculturation (including maintenance of specific cultural practices and strong family support systems), healthier lifestyles of immigrants (e.g. diet), selective migration, and genetic heritage.2, 3 Specific to respiratory health, the immigrant advantage may be due to general environmental and socio-economic conditions in the country of origin.⁴ For example, early life experiences in agricultural areas may protect against the development of asthma and allergies (the hygiene hypothesis).⁵

The Hispanic health paradox has been well-documented in terms of health advantages for foreign-born children and those living in the US for fewer years, but less often across immigrant generational cohorts, even though limited evidence suggests that protective effects can pass from one generation to the next.⁶ To our knowledge only one study has examined asthma and allergies across generational cohorts.⁷ This study found that US Hispanic children's unadjusted asthma and allergy prevalence increased across first, second and third generations; however, it was limited in that subsequent Hispanic generations were not compared to each other, but to third-plus generation non-Hispanic whites.⁷ This means the effect of Hispanic generational status on Hispanic respiratory health disparities was not assessed, which is our primary goal here. This dearth of research on asthma is a critical gap because nine percent of US children suffer from asthma⁸ and asthma is a health condition for which a Hispanic health paradox has been identified.⁴

Children's immigrant generational status has usually been conceptualized based on the child's and parents' nativity in a three-group generational framework.7, 9, 10, 11, 12, 13 This three-group framework is based on the classical immigrant assimilation model, which posits that immigrants gradually adopt the behaviors of the dominant cultural group over time, with linear increases in assimilation occurring progressively across successive generations.¹⁴ More recent models seek to account for alternative immigrant assimilation paths by expanding on the three-group framework. Some have separated out a 2.5 generation, which includes US-born children with one foreign-born and one US-born parent.15, 16 Others have refined the first generation by considering both nativity and citizenship.17, 18 While citizenship confers entitlement to federal healthcare assistance programs,² how it translates into actual health advantages has rarely been investigated (see only19, 20).

In addition to underemphasizing citizenship, the literature lacks consideration of a fourth generation. i.e., those who are US-born with US-born parents and grandparents (see only²¹). The common practice of aggregating higher generational cohorts within a ‘third-plus’ generation may mask significant differences between later generational cohorts, especially among immigrant groups with substantial racial/ethnic minority composition that have not generally experienced linear assimilation paths across generations. This has led to a need for a more nuanced framework. Our six-group framework incorporates novel elements as well as facets of previous approaches by distinguishing a fourth generation from the third generation, the 2.5 generation from the second and third generations, and first generation non-citizens from first generation naturalized citizens.

The general aim of this study is to determine if a Hispanic immigrant respiratory health advantage exists across generations and, if so, for how many generations. Surprisingly few studies have examined generational differences in common childhood diseases beyond obesity and developmental delays,21, 22 despite the relevance for understanding the Hispanic health paradox. We contribute to the immigrant health disparities knowledge base by examining understudied respiratory health outcomes among children using a more nuanced immigrant generational cohort framework.

This study addresses three research questions using data from a population-based sample of fourth and fifth graders in the El Paso Independent School District (El Paso, Texas, USA): (1) What is the relationship between immigrant generational status and Hispanic children's health outcomes, adjusting for relevant covariates? (2) Into which generational status cohort does the healthy immigrant effect persist? (3) Is having citizenship associated with significantly better health outcomes among first generation children?

Section snippets

Participants and study area

Participants are primary caretakers of fourth and fifth graders attending school in the El Paso Independent School District (EPISD). A total of 6295 households, containing all fourth and fifth graders, were included in our sampling frame. We selected the 1568 Hispanic children whose caretakers responded to the survey for analysis.

EPISD is the largest school district in El Paso County (Texas), which is located on the US-Mexican border, and has an estimated population of 827,398 (2012). El Paso

Sample characteristics

Table 2 reports the descriptive statistics of the Hispanic sample (using the non-imputed data) in terms of health outcomes and the control variables. Parents reported that 8% had current asthma, 9% had bronchitis, and 50% had allergies.

Bivariate results

Table 2 also reports Chi-squared test for associations between generational cohorts and other variables. All variables are significantly different between cohorts with the exception of age and sex. Across generations, there is an increase in the prevalence of

Discussion

As compared to Hispanic children nationwide, El Paso children were more likely to have allergies (50% vs 8%), but they had similar rates of current asthma (8% vs 9%).⁸ The unusually high rates of allergies among El Paso children may relate to the urbanized, windswept desert environment of El Paso. A generational Hispanic health paradox was visible for asthma, bronchitis, and allergies with the prevalence of each illness increasing with each successive generation. This is consistent with other

Acknowledgements

We thank Bibi Mancera and Zuleika Ramirez at the Hispanic Health Disparities Center and the staff at the Campus Post Office for their assistance in carrying out the survey. The research participants are also gratefully recognized for taking the time to complete the survey. The work of student research assistants Anthony Jimenez, Marie Gaines, Stephanie Clark-Reyna, Paola Chavez-Payan, and Young-an Kim is gratefully recognized.

Ethical approval

The study was approved by the University of Texas at El Paso

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The longevity of the “Hispanic paradox” effect has undergone investigation as these patients experience acculturation. An immigrant health advantage of up to three generations for asthma, bronchitis, and allergies is noted in Hispanic children,36 while more favorable inflammatory profiles have also been seen in adult Hispanic patients with shorter “immigration histories.”37 Beyond physiologic differences, Hispanic children among earlier immigrant generations were found to have higher rates of being uninsured38 and had decreased access to healthcare.39
Lower screening rates and poorer outcomes for colorectal cancer have been associated with Hispanic ethnicity and Spanish-speaking status, respectively.
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Our findings also replicate studies that demonstrate a lower incidence of CPA in Hispanic children compared to either black or white children. These findings align with the well-described “Hispanic paradox” in the U.S., where Hispanic persons appear to have relatively better health outcomes compared to non-Hispanic whites despite their relatively lower socioeconomic status (Acevedo-Garcia & Bates, 2008; Balcazar, Grineski, & Collins, 2015; Franzini, Ribble, & Keddie, 2001; Hamilton, Cardoso, Hummer, & Padilla, 2011; Lariscy, Hummer, & Hayward, 2015; Palloni & Morenoff, 2001; Schmeer, 2012). The reasons for the steady reduction in hospitalizations coded as CPA-related among Hispanic children prior to the ICD-10-CM transition are unclear, but cannot be related to medical coding as there were no major alterations to coding guidelines for CPA during this time period.
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Of 9715 hospitalizations coded for CPA, 2797 (29%) occurred after the coding transition, including 51% coded for suspected CPA and 49% coded for confirmed CPA. There was a marginally-significant increase in the trend in CPA-related hospitalization after the coding transition among all children (0.09 per 100,000 children-per-quarter, p = 0.06), a significant increase in the trend among white children (0.15 per 100,000 children-per-quarter, p = 0.01), and no change among Black or Hispanic children. After the coding transition, hospitalizations coded for suspected CPA increased significantly overall (0.10 per 100,000 children-per-quarter, p < 0.001), and in particular among white children (0.12 per 100,000 children-per-quarter, p = 0.01) but not among Black or Hispanic children.
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Although different definitions of acculturation are engaged throughout wide ranging research approaches, in this piece we apply acculturation defined as “the process by which individuals adopt the attitudes, values, customs, beliefs, and behaviors of another culture” (Abraido-Lanza et al., 2006, p. 1342). Acculturation, as well as Latino immigration trajectories, are of great interest because of their paradoxical effects on health: recent Latino immigrants to the U.S. demonstrate better health outcomes than non-Hispanic whites in the U.S., but the protective effects of immigration disappear in later generations (Balcazar et al., 2015). While researchers point to the association between greater acculturation and unhealthful behavior to explain the differing health outcomes between immigrant and non-immigrant Latinos, ethno/racial discrimination may also play a role (Abraído-Lanza et al., 2016).
Although the reasons for immigrating to the U.S. vary by Latino groups, many Latinos cite economic or political motivations for their migration. Once in the United States, Latino immigrants may face many challenges, including discrimination and blocked opportunities for social mobility, and difficulties in obtaining health services and quality health care. The purpose of this study was to explore how changes in social mobility from the country of origin to the U.S. may relate to Latina women's health care interactions. We examined whether self-reported social mobility among 419 Latina women immigrants is associated with satisfaction with health care. We also examined the association among social mobility and self-rated health, quality of care, and medical mistrust. Upward social mobility was associated with greater number of years lived in the U.S., and downward social mobility was associated with more years of education. Those who reported no changes in social class (stable social mobility) were older and were the most satisfied with their medical care. Multiple regression analyses indicated that downward social mobility was associated with less satisfaction with care when controlling for demographic covariates, quality of care, and medical mistrust. Results suggest that perceived social mobility may differentially predict Latina immigrants' satisfaction with the health care system, including their trust in U.S. medical institutions. We conclude that perceived social mobility is an important element in exploring the experiences of immigrant Latinas with health care in the United States.

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Original ResearchThe Hispanic health paradox across generations: the relationship of child generational status and citizenship with health outcomes

Highlights

Abstract

Objectives

Study design

Methods

Results

Conclusions

Introduction

Section snippets

Participants and study area

Sample characteristics

Bivariate results

Discussion

Acknowledgements

Ethical approval

Chest

Beyond the epidemiological paradox: the health of Mexican-American children at age five

Soc Sci Q

The immigrant and hispanic paradoxes a systematic review of their predictions and effects

Hispanic J Behav Sci

The health of Hispanics in the southwestern United States: an epidemiologic paradox

Public Health Rep

Contribution of race/ethnicity and country of origin to variations in lifetime reported asthma: evidence for a nativity advantage

Am J Public Health

Population disparities in asthma

Annu Rev Public Health

The physical and psychological well-being of immigrant children

Future Child

Assimilation and emerging health disparities among new generations of US children

Demogr Res

Summary health statistics for U.S. children: national health interview survey, 2012

Language and immigrant status effects on disparities in Hispanic children's health status and access to health care

Matern Child Health J

Importance of generational status in examining access to and utilization of health care services by Mexican American children

Pediatrics

Acculturation and cross-border utilization of health services

J Immigr Minor Health

Generation status, health insurance, and public benefit participation among low-income Latino Children

Matern Child Health J

Health care for Latino children: impact of child and parental birthplace on insurance status and access to health services

Am J Public Health

Assimilation in American life

Second-generation immigrants? The “2.5 generation” in the United States

Soc Sci Q

Generational cohorts, age of arrival, and access to health services among Asian and Latino immigrant adults

J Health Care Poor Underserved

Left out: immigrants' access to health care and insurance

Health Aff

Health status and health service access and use among children in U.S. immigrant families

Am J Public Health

Exploring the latino paradox how economic and citizenship status impact health

Hispanic J Behav Sci

Original Research
The Hispanic health paradox across generations: the relationship of child generational status and citizenship with health outcomes