SUPPLEMENT ARTICLE Health Disparities and Children in Immigrant Families: A Research Agenda AUTHOR: Fernando S. Mendoza, MD, MPH Division of General Pediatrics, Department of Pediatrics, School abstract of Medicine, Stanford University, Lucile Packard Children’s Children in immigrant families now comprise 1 in 5 children in the Hospital, Palo Alto, California United States. Eighty percent of them are US citizens, and 53% live in KEY WORDS immigrant children, immigrant families, health disparities, mixed-citizenship families. Their families are among the poorest, least acculturation, immigrant paradox, health policy educated, least insured, and least able to access health care. Nonethe- ABBREVIATION less, these children demonstrate better-than-expected health status, a SCHIP—State Children’s Health Insurance Program finding termed “the immigrant paradox” and one suggesting that cul- The views presented in this article are those of the authors, not tural health behaviors among immigrant families might be protective the organizations with which they are affiliated. in some areas of health. In this article the strength of the immigrant www.pediatrics.org/cgi/doi/10.1542/peds.2009-1100F paradox, the effect of acculturation on health, and the relationships of doi:10.1542/peds.2009-1100F acculturation, enculturation, language, and literacy skills to health dis- Accepted for publication Jul 20, 2009 parities are reviewed. The current public policy issues that affect the Address correspondence to Fernando S. Mendoza, MD, MPH, health disparities of children of immigrant families are presented, and Lucile Packard Children’s Hospital, Division of General a research agenda for improving our knowledge about children in Pediatrics, 770 Welch Rd, Suite 100, Palo Alto, CA 94304. E-mail: immigrant families to develop effective interventions and public poli- [email protected] cies that will reduce their health disparities is set forth. Pediatrics PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). 2009;124:S187–S195 Copyright © 2009 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The author has indicated that he has no financial relationships relevant to this article to disclose. PEDIATRICS Volume 124, Supplement 3, November 2009 S187 Downloaded from www.aappublications.org/news by guest on October 2, 2021 In recent decades, the large growth in or second generation (US-born). The THE HEALTHY IMMIGRANT the number of children living in immi- current census data show that 80% of PHENOMENON grant families, whether born abroad children in immigrant families are US The “healthy immigrant phenomenon,” or in the United States, has produced citizens because they were born in the also known as the “immigrant para- problems with health care that are a United States, and 28% have at least 1 dox” or the epidemiologic paradox, is 3 concern. These children and their fam- US-born parent. The result is that that although Hispanic immigrants ilies can be characterized by their more than half of the children in immi- have higher poverty rates, lower edu- country of origin, culture, religious grant families (53%) live in a mixed- cation levels, and less access to health background, social class, reason for status family, with at least 1 citizen and care than US-born Hispanics and non- immigrating, health status before im- 1 noncitizen family member (parent or Hispanic whites, they have similar or migrating, access to resources, and sibling). better health outcomes for several receptiveness of the US sociopolitical Children in immigrant families have health parameters.5 Since the 1980s, environment. The common factors of different social and economic risk fac- the best substantiated findings sup- poverty and racial or ethnic biases can tors from native families. For example, porting the immigrant paradox are the affect health status and access to first- and second-generation children prevalence of low birth weight infants health care for these children. The are more likely than children from na- and infant mortality rates.6–8 In 1984, the characteristics of their immigrant tive families to live in a family headed prevalence of low birth weight infants family can also influence the health by a married couple (78.9%, 81%, and in first-generation Mexican American disparities they experience. Thus, it is 69.8%, respectively) and to live in a women (3.9%) was lower than that in US- imperative that the pediatric commu- multigenerational household (13.2%, born Mexican Americans (5.5%).9 Even nity understand the health disparities 12.9%, and 7.8%, respectively).4 First- after researchers controlled for the ef- among immigrant children and the im- and second-generation children are fects of smoking, drinking, marital sta- pact of current and future public poli- more likely to live in families that live tus, Medicaid coverage, access to care, cies on their health status. below the poverty line than children and levels of obesity, US-born Mexican In this article the demographic charac- from native families (28.3%, 19.4%, and American mothers were 1.73 times more teristics of children in immigrant fam- 16.7%, respectively). In addition, first- likely to have a low birth weight infant ilies, their health status and its rela- (55%) and second-generation (47.3%) than foreign-born Mexican American tionship to the “immigrant paradox,” children are more likely than native mothers.10 the roles of acculturation and encul- children (17%) to live in families in Several investigators have found that turation in their health outcomes, the which at least 1 parent has not gradu- the immigrant paradox’s effect varies legal issues that contribute to dispari- ated from high school and that have among immigrant groups but is most ties, and research priorities are pro- Ն1 parent who is not fluent in English consistent among Hispanic immi- filed. (76.4%, 55.2%, and 2.2%, respectively). grants.11–13 However, some of the larg- Although a significant proportion of est differences in low birth weight THE DEMOGRAPHIC SHIFT immigrant families own their home, (11.8% vs 8.0%) and infant mortality In 2030, non-Hispanic white children 60% of first-generation and 44% of rates (12.9 vs 10.5 per 1000) have oc- will constitute less than half of US chil- second-generation children live in curred between foreign- and US-born dren.1 Although higher birth rates crowded housing (Ͼ1 person per non-Hispanic blacks. The immigrant among minority groups will account room) versus 11% of children from na- paradox with respect to low birth for most of this demographic change, tive families. weight seems to be partially related to immigration will also contribute. Cur- Traditionally, the low economic and ed- drinking, smoking, and weight gain rently, 1 in 5 US children lives in an ucational achievement profile of immi- during pregnancy, although other fac- immigrant family, defined as a family grant families would indicate that tors might also be involved. The use of with at least 1 immigrant parent.2,3 The their children are at increased risk of prenatal care does not necessarily de- greatest proportions of immigrants health disparities. However, observa- crease the prevalence of low birth come from Latin America (57% in 2000) tions on their health status suggest weight among immigrant mothers, and Asia; among those from Latin Amer- that these relationships might be which seems to contradict our notion ica, ϳ75% are from Mexico.4 weaker than would be predicted from that prenatal care is essential for Children in an immigrant family can be models of health risk that focus solely healthy infants.13 The association of in- either first generation (foreign-born) on socioeconomic factors. fant mortality with the mother’s immi- S188 MENDOZA Downloaded from www.aappublications.org/news by guest on October 2, 2021 SUPPLEMENT ARTICLE grant status is less well understood, Public Health Services (population) but as with low birth weight, multivar- iate analyses have indicated that immi- 13 grant status plays a significant role. Genetics Behavior Health After infancy, the immigrant paradox Outcome is less well documented, primarily be- cause limited data are available on children beyond infancy in immigrant Medical Services families, and postinfancy samples usu- Socio-Physical (individual) Environment ally include children born outside the (Poverty) United States. Samples of immigrant groups other than Mexican Americans SES are usually small and frequently ag- FIGURE 1 gregated into general categories Traditional health model. SES indicates socioeconomic status. (Reproduced with permission from rather than country-specific groups Mendoza FS, Fuentes-Afflick E. West J Med. 1999;170(2):86.) (eg, Asian instead of Chinese, Vietnam- ese, Filipino, etc), thereby limiting A national study found that first- to immigrant mothers; the data for older analyses.14 Nonetheless, some insights generation adolescents were less likely children are less conclusive. Nonethe- can be drawn from the current litera- to report fair-to-poor health; missing less, taken as a whole, the current infor- ture. Depending on their country of or- school because of health or emotional mation suggests that when the immi- igin, children born outside the United problems; experiencing learning difficul- grant paradox occurs, it is associated States frequently experience several ties; having obesity or asthma; or engag- with positive health behaviors that, pre- health problems, including malnutri- ing in risky health behaviors involving sumably, the family and