1In an era of an increasingly diverse national population, researchers have had to turn to expanded models of public health promotion. In 2009, the University of California established the UC Global Health Institute with three Centers of Expertise. The Center of Expertise on Migration and Health (COEMH) formed with the multidisciplinary mission of to better understand coupled migration and health issues. This special issue represents the work of four scholars who participated in the 2013 COEMH Summer Institute. The articles that follow offer multivalent perspectives on the field of immigrant health. These authors provide nuanced ways to operationalize health, they complicate our understanding of the factors and systems that shape health outcomes, and utilize a range of disciplinary and methodological approaches to examine these complex relationships.
2Public health research has relied on a range of approaches for understanding and operationalizing immigrant health. Much of this focus has been on specific disease incidence, such as diabetes, heart disease, and obesity, or on more aggregate indices such as self-rated heath (Hsueh et al.). However, while a great deal of immigrant policy debates focus on physical disease prevalence and prevention factors, the articles in this special issue invite a broader conception of immigrant health. To begin, Schapiro et al. shift the popular immigration debate away from the cost-benefit analysis of immigration, to also assess the mental health impacts of family separation. The authors provide a transnational and family-based approach to understanding how these adolescents cope with the departure and return of their migrant parents. Similarly, Hsueh et al.’s systematic review of the research on health and acculturation suggest a need for a broader range of methodological approaches to immigrant health. Focusing specifically on the use of the popular Suinn-Lew Asian Self-Identity Acculturation Scale, the authors find that while mental health studies using the SL-ASIA tend to be more varied in methodology, none of the studies they reviewed relied on objective medical record or clinician administered assessments.
3Particularly in the wake of the Affordable Care Act, most health-related policy debates tend to focus on the crucially important outcomes of access to, and utilization of, routine medical care in high immigrant receiving areas. While some research has examined these issues in the nation’s interior, surprisingly little has been researched on the topic in urban border areas. Garcini et al. begin to fill this gap in their examination of preventative healthcare among Mexican immigrants and Mexican Americans living along the under-served California-Mexico border. Latinos are some of the fasted growing populations in the country. However, these communities face some of the greatest difficulties accessing health care, with pejorative implications for morbidity and mortality. While studies of the rapidly growing border region may not generalize to Mexicans in other parts of the country, the unique conditions facing the urban communities that are often overlooked by researchers who remain focused on traditional immigrant destinations in the country’s interior remain poorly understood.
4Another gap in the migration-health literature is the lack of research in international (non-US) settings. Chang and Green’s research emphasizes the need for a transnational lens, and for continued work in sending countries. The authors’ research in the Dominican Republic -- currently the 9th largest sending country to the U.S.(Migration Policy Institute 2014) -- reveal how individual practices outside the traditional medical setting are constructed, and how individual perceptions of health evolve. The flow of information, however, is neither one-way from sending to receiving country, nor static over time. Schapiro et al.’s research with adolescents in transnational families also emphasizes the need to examine not only the effect of a parent’s departure to the U.S., but also the later migration of adolescent children to rejoin them. Such a perspective complicates our typical understanding of family units, which as the authors point out, not only cross borders, but can include multiple generations of caregivers within and beyond the nuclear family.
5This collection of research highlights the importance of a wide range of factors, beyond nativity, that we must assess in order to gain a full understanding of the diverse immigrant population.
6The particular racialized approach to understanding difference in the United States has often led to a focus on pan-ethnic groups, or majority groups. Hsueh et al. find a predominance of research is focused on Chinese, Korean and Vietnamese migrants (88 percent of studies). Such a geographic and ethnic focus has seemingly been associated with a greater degree of generalization, creating major limitations to providing detailed socio-demographic information of study participants. These generalizations have led the researcher community to often elide important sub-group differences. Even within national origin groups, Chang and Green’s findings showcase the importance of distinct cultural influences, such as the impact of Afro-Caribbean syncretic folk beliefs on hypertension management.
7One of the most pressing factors concerning immigrant health is immigration legal status. According to Garcini et al., it is important to look beyond the documented/undocumented dichotomy, as a range of categories provides a more nuanced understanding of an immigrant’s position in U.S. society. Consistent with previous research, the authors observe that citizens are more likely to utilize health services, while undocumented immigrants have the lowest levels. However, they also report findings that challenge orthodox theory. For example, while being documented has clear and consistent impacts for utilization in general, even when controlling for other key factors, some elements of healthcare utilization, such as delaying use of medical care, did not appear to benefit citizens. These findings suggest that structural factors such as financial assets and insurance coverage may present greater barriers in some contexts.
8Beyond national origin and legal status, the immigrant-origin population also varies significantly by generation. Hseuh et al. warn that while generation status is not co-terminous with more specific measures of acculturation, it remains an important covariate for understanding health outcomes. Yet, as the health paradox literature has emphasized (e.g. Rumbaut 1997), it is premature to assume that nativity necessarily predicts more favorable outcomes. When compared to U.S.-born citizens, Garcini et al. find that in fact, naturalized foreign-born immigrants sometimes come out ahead. Beyond having a direct effect, generational status may also operate as a mediator variable for other key factors that impact immigrant health, such as gender. Schapiro et al.’s findings highlight this dynamic with regards to gender roles and intergenerational relations.
9The four special edition articles expand the migration-health research agenda to a range of factors impacting immigrant health, using both traditional quantitative methods, as well as ethnographic approaches. Survey analysis will continue to be a crucial data collection tool, as is the case with Garcini et al.’s cross-sectional analysis of the 2009 San Diego Prevention Research Center (SDPRC) community survey. While some studies like those highlighted in Hsueh et al. will continue to rely on mail-in and telephone interview methods, surveys like the SDPRC reinforce the need for resources to train bicultural and bilingual researchers to conduct home visits in marginalized and hard to reach communities. Research in farmworker communities has also reiterated the need for an even greater linguistic access amongst indigenous communities (Farquhar et al. 2008).
10Other forms of non-randomized tabulated data are also crucial for health research, as witnessed by Chang and Green’s innovative examination of medical chart reviews to understand the management of la presión in a community in the Dominican Republic. Triangulating such information with qualitative interview data allows researchers to correlate categorical outcomes and behaviors with respondents’ interpretations and perspectives of their health practices. Conversely, Schapiro et al.’s work with immigrant families relies on a grounded theory approach to understanding family relationships. This study reaffirms the importance of the positionality and subjectivity of the researcher. In this case, the utility of having a practitioner background with over two decades of experience working with immigrant adolescents is an asset that cannot be duplicated by traditional academic training.
11These varied approaches raise important questions regarding the tradeoff of recruitment and sampling, generalizability, indicator validity, response rates, and the often-overlooked issue of language and translation. While often disparaged for its lack of rigor, qualitative work (including focus groups, interviews, participant observation and content analysis), must continue to have a place in public health research. The divide between theoretically informed analysis, and descriptive applied work, must also dissipate, as the two can continue to inform each other. Sociological theories of exclusion and marginalization (e.g. via race, gender, and legal status) have direct implications for the key policy questions of our time, such as the economic cost of unequal health care access, the psychological toll of t the current impasse over immigration reform, and whether our country’s diversity can become an asset for progress rather than a mark of continuing inequality.
12We have made a leap forward in coupled health-migration research in expanding the ubiquitous single-method quantitative model to a mixed methods approach. It will remain critical to forge a suitable balance between methods and theory. A strong qualitative component may be a outcome in its own right; they may also determine the quantitative model variables employed. Similarly, research is insufficient at one scale of analysis and work that nests individuals within households and larger community, cultural, and regional contexts have great promise to extend the frontiers of immigrant health research. Immigrant health will always have an individual outcome at its root, and yet it cannot be extricated from the social, political and cultural institutions that encapsulate it. The articles that follow begin to showcase a new way forward