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Familism and the Hispanic Health Advantage

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Familism and the Hispanic Health Advantage HSBXXX10.1177/0022146519869027Journal of Health and Social BehaviorDiaz and Niño 869027research-article2019 Original Article Journal of Health and Social Behavior 2019, Vol. 60(3) 274 –290 Familism and the Hispanic © American Sociological Association 2019 DOI:https://doi.org/10.1177/0022146519869027 10.1177/0022146519869027 Health Advantage: The Role jhsb.sagepub.com of Immigrant Status Christina J. Diaz1 and Michael Niño2 Abstract It is well known that Hispanic immigrants exhibit better physical and mental health than their U.S.-born counterparts. Scholars theorize that stronger orientations toward the family, also known as familism, could contribute to this immigrant advantage. Yet, little work directly tests whether familial attitudes may be responsible for the favorable health of foreign-born Hispanics. We investigate this possibility using biomarkers, anthropometrics, and mental health assessments from the Hispanic Community Health Study/ Study of Latinos (N = 4,078). Results demonstrate that the relationship between familial attitudes and health vary depending on the outcome assessed. While Hispanics with strong attitudes toward familial support have fewer symptoms of depression and anxiety, those who report high referent familism display worse mental health outcomes. We find little evidence that familism is linked to physical health or that immigrant generation moderates the relationship of interest. Our results challenge assumptions that familism is responsible for the comparably better health of foreign-born Hispanics. Keywords familism, Hispanic Community Health Study/Study of Latinos, Hispanic health advantage, immigration Though Hispanics disproportionately reside in be responsible for the Hispanic health advantage. underprivileged neighborhoods, lack adequate Instead, family-oriented behaviors and attitudes are health care, and accumulate limited financial invoked as residual explanations to account for for- resources, they experience more favorable health eign-born Hispanics’ relatively strong health profile. outcomes than non-Hispanics (Cunningham, Moreover, discussions surrounding how to appro- Ruben, and Narayan 2008; Heron 2013; Markides priately measure familism are notably absent or and Eschbach 2005). Scholars argue that this advan- inconsistent in the health literature. This omission is tage is driven by the comparably better health of particularly striking given claims that sociocultural Hispanic immigrants who settle in the United States practices likely play a nontrivial role in underlying (e.g., Hummer et al. 2000; Singh and Siahpush health disparities (Abraído-Lanza, Chao, and Florez 2002). While some stress that data misreporting 2005; Akresh 2007; Franzini and Fernandez-Esquer (Elo et al. 2004; Palloni and Morenoff 2001; Smith 2004; Hummer et al. 2007). The present study tests and Bradshaw 2006) and migrant selection (Palloni and Arias 2004; Riosmena, Wong, and Palloni 1University of Arizona, Tucson, AZ, USA 2013) can explain the advantageous health of the 2Willamette University, Salem, OR, USA foreign-born, others posit that strong orientations *Equal authorship toward the family—also known as familism— Corresponding Author: protect against threats to physical and mental well- Christina J. Diaz, School of Sociology, University of being (Almeida et al. 2009; Cook et al. 2009). Arizona, Social Sciences Building, Room 425, 1145 E. Despite such claims, demographers and health South Campus Drive, Tucson, AZ 85721, USA. scholars overlook the possibility that familism could Email: [email protected] Diaz and Niño 275 whether family orientation is associated with 2005; Hummer et al. 2007), the elderly (Elo et al. Hispanic well-being and by doing so, seeks to 2004; Markides and Eschbach 2005), and across advance a widely used but weakly scrutinized theory. multiple socioeconomic backgrounds (Braveman We rely on biomarker and anthropometric data et al. 2010; Kimbro et al. 2008). Given that Hispanic collected by the Hispanic Community Health immigrants earn lower wages and obtain fewer Study/Study of Latinos (HCHS/SOL) to investigate years of schooling than non-Hispanic whites and the relation between familism and physical health. that the link between health and socioeconomic sta- We also assess the association between family ori- tus is pervasive across industrialized nations (Adler entation and two measures of mental health: and Ostrove 1999; Buttenheim et al. 2010; Phelan, depressive symptoms and anxiety. Following con- Link, and Tehranifar 2010), their advantageous temporary studies on familism (Esparza and health is largely deemed paradoxical (Abraido- Sanchez 2008; Rodriguez et al. 2007; Villarreal, Lanza et al. 1999). Blozis, and Widaman 2005), we focus on familial Though fewer studies assess the mental health attitudes as opposed to reported behaviors. Although of Hispanics, the foreign-born may exhibit a lower attitudes are arguably more abstract, Hispanics risk for certain psychiatric disorders than their U.S.- encounter numerous barriers to physically interact- born and white counterparts (Breslau et al. 2006; ing with immediate and extended family mem- Vega et al. 1998). Alegría and colleagues (2006) bers—many of whom live across borders that are argue that immigrants—Mexicans in particular— increasingly militarized (Dreby 2015; Slack et al. are less likely to experience depression, social pho- 2015). While it may be difficult for all individuals bia, and anxiety than U.S.-born Hispanics. Others to physically engage with family members who posit that psychiatric differences are driven by con- reside in a foreign country, this is even more diffi- founders, such as English language ability and cult for the nearly 12 million unauthorized immi- socioeconomic background, as the correlation grants living in the United States—the majority of between mental health and immigrant generation whom fall underneath the Hispanic pan-ethnic disappears after the inclusion of such characteris- umbrella (Baker 2018). tics (Cook et al. 2009). However, a wide range of We then ask whether higher rates of familism mental health assessments have been employed could explain the health advantage of foreign-born over time and across studies (Perreira et al. 2005; Hispanics relative to their U.S.-born counterparts. Rogler, Cortes, and Malgady 1991), and estimates We distinguish between the first and 1.5 genera- can vary widely. Nevertheless, the balance of evi- tions to better understand variation in health and dence demonstrates that Hispanics’ advantageous familistic attitudes. Our unique data source captures health also extends to mental well-being. multiple dimensions of familial attitudes and allows us to control for cultural and socioeconomic attri- butes that likely confound the relationship of inter- The Paradox Explained? est. Findings from this study thus inform ongoing In attempting to reconcile the Hispanic health theoretical and empirical developments in the med- advantage, scholars generally emphasize three ical and social sciences that center on familism and explanations. The first possibility is that data Hispanic well-being. inaccuracies—such as age and ethnic misclassifica- tions (Palloni and Morenoff 2001) or the underre- porting of chronic conditions—create an artificially BACKGROUND advantageous health profile. Though results are mixed (Eschbach, Kuo, and Goodwin 2006; Smith Hispanic Health and Well-Being and Bradshaw 2006), classification errors are A large and growing body of work argues that unlikely to be solely responsible for the elevated foreign-born Hispanics exhibit more favorable health of Hispanic immigrants (Arias et al. 2010; health outcomes—including lower mortality rates Palloni and Arias 2004). And while limited access to (Lariscy, Hummer, and Hayward 2015; Palloni and medical professionals and health insurance prohibit Arias 2004), fewer chronic conditions (Bostean Hispanic-origin immigrants from receiving diagno- 2013; Rubalcava et al. 2008), and more positive ses of underlying conditions, their attributes and self-assessed health (Acevedo-Garcia et al. 2010; biomarkers are more likely to fall within a normal Cunningham et al. 2008)—than their U.S.-born range (e.g., blood pressure, body mass index [BMI]) counterparts. This advantage is documented among than U.S.-born whites and nonwhites when sur- infants (Acevedo-Garcia, Soobader, and Berkman veyed by trained interviewers (Gordon-Larsen et al. 276 Journal of Health and Social Behavior 60(3) 2003; Kaplan et al. 2004; Riosmena et al. 2013). Put Theories of Familism, Measurement differently: The Hispanic advantage persists in set- Issues tings where underreporting is unlikely to pose a Broadly defined, familism is a multidimensional threat. construct that emphasizes the needs of the family Another possibility is that health-related migra- over the needs of the individual. One of the earliest tion results in overly optimistic estimates of well- definitions argued that familism is made up of shared being. The healthy migrant hypothesis suggests that goals, family-based socioeconomic resources, and individuals who engage in migration are in better retention of the family unit (Burgess and Locke health than those who remain in their country of 1945). A multidimensional scale was later advanced origin. Health may directly influence the probabil- to reflect five aspects of the nuclear family: belong- ity of migration (Chiswick, Lee, and Miller 2008), ingness, unconditional support, economic and social or health may be associated
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