achievement and eventual educational attainment (e.g., Jackson 2010). Though ... children and to breastfeed (Anderson et al. 1997; Kimbro et al. .... children of low-skill immigrant mothers vs. children of low-skill natives (0.117 vs. 0.167), and.
Immigrant-Native Differences in Child Health: Does Maternal Education Narrow or Widen the Gap?
Margot Jackson, Brown University Kathleen Kiernan, University of York Sara McLanahan, Princeton University
March 2011
Immigrant-Native Differences in Child Health: Does Maternal Education Narrow or Widen the Gap?
Abstract In the United States, abundant research documents an “immigrant advantage” in children’s physical health. In this article we use two nationally representative samples of children born in the United States and United Kingdom to examine whether the immigrant advantage is strongest among low-skill populations. We focus on children around the time of school entrance; consider both physical and mental health; and examine children in two societies with immigrants from disparate regional and socioeconomic backgrounds. Our approach allows us to uncover whether the immigrant health advantage is “paradoxically” strongest among children whose parents have fewer resources, or if it is universally strong among low and high resource families. The findings suggest that the children of immigrants are not uniformly, paradoxically better off than their peers. Instead, there is heterogeneity across physical and mental health outcomes and evidence for both advantage and disadvantage in immigrant families, which in both cases is most pronounced among low-skill families.
Immigrant-Native Differences in Child Health: Does Maternal Education Narrow or Widen the Gap? INTRODUCTION In the United States, abundant research documents an “immigrant advantage” in children’s physical health, with striking advantages in birth outcomes and infant health among the children of foreign-born mothers (Hummer et al. 1999; Landale, Oropesa and Gorman 1999). Of particular interest has been the U.S. Hispanic population, among whom the advantage in infant health in a population more likely to be socioeconomically disadvantaged has been described as a “paradox” (Abraido-Lanza, Chao and Florez 2006). In this article we use two nationally representative samples of children born in the United States and United Kingdom to make several contributions to the literature. First, we focus on child health at age five, around the time when most children are preparing to enter school. This is an important age to examine, given the strong and lasting influence of health early in the school years on academic achievement and eventual educational attainment (e.g., Jackson 2010). Though nativity differences in birth outcomes related to physical health are large and robust in the U.S., there is less evidence on later childhood. Secondly, we examine both physical and mental health. Though children’s mental health is associated with academic achievement (e.g, Currie and Stabile 2006), this dimension of child health has received less attention than physical health in the literature on immigrant-native differences. Third, we extend the analytic lens to the United Kingdom, where a diverse composition of immigrants from very different regions than U.S. immigrants offers a chance to examine how broadly the immigrant advantage is observed. Finally, we test an interaction model that allows us to determine how the immigrant health advantage varies across skill groups, and whether it is strongest among low-skill populations.
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BACKGROUND The Immigrant Paradox in Children’s Physical and Mental Health The use of the word “paradox” to describe immigrant children’s sometimes favorable developmental outcomes relates to researchers’ surprise that children in immigrant families do well despite their parents’ low levels of income and education, given the strong impact of parents’ resources on virtually all aspects of child development (Duncan and Brooks-Gunn 1997; Hayward and Gorman 2004; Hobcraft 2004; Walker et al. 1994). Early descriptions of the epidemiologic paradox reflected this idea in establishing that the health of economically disadvantaged Hispanics in the Southwestern U.S. was more similar to more advantaged nonHispanic whites than to disadvantaged blacks (Markides and Coreil 1986). Although the initial formulation of the paradox involved simultaneous consideration of nativity and socioeconomic status, over the last few decades the term “paradox” has also been used more loosely to describe favorable outcomes among immigrant families and their children, regardless of socioeconomic resources (e.g., Beiser et al. 2002, Palacios, Guttmannova and Chase-Lansdale 2008). This body of research, which relies on multivariate models to examine the main effect of parents’ immigrant status on children’s development, has produced important findings that are more compelling for physical health than for mental health. Net of socioeconomic status, nativity differences in birth outcomes are large and robust in the U.S.: foreign-born Hispanic mothers are more likely than native-born mothers to fully immunize their children and to breastfeed (Anderson et al. 1997; Kimbro et al. 2008). Similarly, the occurrence of infant mortality and low birth weight is significantly lower among foreign-born, Hispanic mothers (Hummer et al. 1999). A smaller literature on later childhood suggests that children of foreign-born parents have fewer acute and chronic health conditions (Kandula, Kersie and Lurie
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2004) than children of native-born parents, and research on adolescents demonstrates a lower likelihood of overweight and obesity among foreign-born and second-generation youth (GordonLarsen et al. 2003). Evidence for mental health is more mixed. Some research demonstrates higher levels of socioemotional adjustment and psychological well-being among first- and second-generation children and adolescents (e.g., Crosnoe 2006; Goodman et al, 2008; Harker 2001), while other research finds no differences (Fuligni, Yip and Tseng 2002), or even poorer psychological development and social interaction among these children (e.g., Sam et al. 2008). We examine how the immigrant advantage varies across skill groups in a manner analogous to the original identification of the paradox, by testing an interaction between parents’ nativity status and parental resources. Given the high socioeconomic resources possessed by many contemporary migrants to Western nations, it is useful to jointly examine nativity and socioeconomic resources in order to distinguish among three possible patterns: 1) a universal “healthy immigrant” pattern in which all children in immigrant families have healthier outcomes than natives, on average; 2) an immigrant advantage that is driven by low-resource immigrant families—that is, a paradoxical pattern of healthier outcomes among children in low-resource families than among children in low-resource native families; and 3) an immigrant advantage that is driven by high-resource immigrant families, in which children in high-resource families are healthier than their similar peers with native-born parents. Extending Examination to the United Kingdom The majority of research on nativity-based inequalities in child development has been conducted in the United States. In this study we turn the lens on the U.K., which allows us to examine whether patterns of child development found among U.S. migrant groups—who are largely from Latin American countries—extend to a foreign-born population that has very
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different regional origins, including Europe, South Asia (India, Pakistan and Bangladesh), Africa and the Caribbean (White 2002). Despite a longstanding interest in U.K. migrant health (Marmot 1993), research on migrants' health is limited because survey data allowing researchers to examine these issues have only recently become available (Hawkins et al. 2008; Panico et al. 2007). Alongside the expanded range of immigrant groups who can be examined by considering the U.K. come several important cross-national differences. First, differences in geography and policies related to immigration have resulted in a much smaller undocumented foreign-born population in the U.K. than in the U.S., where 29% of immigrants have been estimated to be undocumented (Van Hook, Bean and Passel 2005). Immigration policy also plays a role in immigrants' migration decisions, producing potentially important differences in migrants' composition in each country. More immigrant families come from high income countries in the U.K. than in the U.S. and the distribution of migrants who migrate for economic or family reunification reasons may vary across the two nations (Hernandez et al 2009). Secondly, despite broadly similar patterns of family formation (Platt 2009) and income inequality (Banks et al. 2003; Wilkinson and Pickett 2009) to the U.S., the two countries have very different health care and social welfare systems. The U.K. provides more universal health services than the U.S., including free health care through the British National Health Service, home visits for new mothers, priority in scheduling medical appointments for children, and child centers with integrated child care services. Welfare state policies in the U.K. are also more generous with respect to family cash assistance, social housing and childcare (Gornick and Myers 2005; Hills 2007).
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The multitude of compositional and structural differences between the two countries could produce cross-national variation in the degree of the immigrant advantage that we observe, making it difficult to attribute any differences to a particular source. However, evidence of similar patterns across countries would suggest a “universal” pattern of immigrant-native differences in child development in these two societies.
DATA AND METHODS Data We analyze two national birth cohort studies well suited to studying immigrant-native differences in child development: the U.S. Fragile Families and Child Wellbeing Study (FFS) and the U.K. Millennium Cohort Study (MCS). The FFS follows approximately 5,000 children born in large U.S. cities between 1998 and 2000. Mothers, and most fathers, were interviewed in the hospital soon after birth, with additional interviews at ages one, three, five and nine years. When weighted, FFS data are representative of births in cities with populations over 200,000. The FFS sample of immigrant and native-born mothers is very similar to national samples (vital statistics), as are multivariate relationships between our variables of interest. Moreover, the FFS is likely to be more representative of immigrant and native-born mothers than other surveys. A key component of the FFS study design was the use of a hospital-based sampling frame. By starting at the hospital, the FFS was able to obtain much higher response rates than studies that sample from birth records and then try to interview mothers in their homes. The MCS is a nationally representative sample of births and is the fourth of Britain’s national birth cohort studies. The first wave (2001-2002) included 18,818 children (in 18,552 families) born in the
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U.K. between September 2000 and January 2002. Information was first collected from parents when children were nine months old, with follow-up interviews at ages three, five and seven. Measures Child Health. We examine two indicators of children’s physical health at age five: whether a child has ever been diagnosed with asthma, and whether the child is overweight or obese. We also examine two indicators of children’s mental health: the frequency of internalizing (withdrawn, sad) and externalizing (aggressive, angry) behavior problems. U.S. measures are derived from the Child Behavior Checklist (Achenbach 1992), and U.K. measures come from the Strength and Difficulties Questionnaire (Goodman 1997), which has been shown to be highly correlated with the Child Behavior Checklist (Goodman and Scott 1999). We convert the internalizing and externalizing scales to z-scores in order to provide a relative and comparable assessment of mental health. Nativity and Race/Ethnicity. All FFS and MCS children are native-born, but parents can be foreign-born. Children born to immigrant mothers are combined into a single group, in order to maintain adequate sample sizes for examining the immigrant paradox. In the U.S., this group is composed of Hispanic, Asian and other immigrants (European and Middle Eastern) immigrants. In the U.K., it is composed of South Asian (Indian, Pakistani, Bangladeshi), black (African, Caribbean), white and other foreign-born mothers. We control for race/ethnicity in all analyses (reference category in both countries is native-born whites). Maternal Skill. We use mothers’ education to distinguish between those with high and low skills. For the U.S., the measure of maternal education separates mothers with less than a high school education or a high school diploma from those with some college or a college diploma/higher. In the U.K., we use a comparable measure, separating mothers with no
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qualifications or O-level exams from those completing A-level college entrance exams and vocational equivalents or with a university degree. In both samples, the reference category is comprised of higher-educated mothers. We also test the sensitivity of our analysis to a measure of family income in place of maternal education—the results are substantively identical. Other Controls. In addition to race/ethnicity, we control for mothers’ age at birth and children’s sex. Inclusion of several endogenous measures—family income, family structure and the language spoken at home—does not alter the substantive findings. Analytic Procedure For each outcome we use ordinary least squares or binary logistic regression models to predict children’s health. Missing values on predictor and outcome variables are imputed using multiple imputation, producing complete data from theoretically relevant predictor variables to fill in missing values (Allison 2002). We first examine the main effects of nativity and maternal education to establish baseline differences across average children in immigrant vs. native families. Next, we examine interactions between nativity and maternal skill to test how the immigrant advantage varies across skill groups in each country. To ease interpretation, we calculate adjusted predicted values from our parameter estimates to compare across nativity groups, maternal skill, and countries. A pattern of healthier outcomes among children of lowskill immigrants than among children of low-skill natives would suggest that low-skill families drive the immigrant advantage. Conversely, a pattern of healthier outcomes among the children in high-skill immigrants relative to those of high-skilled natives would suggest that high-resource families produce the immigrant advantage.
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FINDINGS Table 1 presents weighted sample characteristics by nativity. The foreign-born sample is nationally representative in the two surveys: 25% in the U.S. (representative of large U.S. cities) and 10% in the U.K. Mothers vary by nativity in their levels of education. In the U.S., foreignborn mothers are more likely to be low-skill than native-born mothers (70% vs. 55%)—a difference driven by Hispanic immigrant mothers. In the U.K, immigrant mothers have about the same level of education as their native-born peers, on average (47% vs. 49%)—South Asian mothers are the most poorly educated immigrants. Table 1 also reveals evidence of both advantages and disadvantages in child health in immigrant families. Children in immigrant families are less likely to have been diagnosed with asthma than their peers with native-born mothers. Overweight/obesity does not follow this pattern, though, with no disparity in the U.K., and an immigrant disadvantage in the U.S. There are also mixed patterns for children's mental health. In both countries, there is an immigrant disadvantage (higher z-score) in children’s internalizing behaviors, and an immigrant advantage in externalizing behaviors. Assessing Immigrant-Native Differences in the U.S. and U.K. Table 2 presents parameter estimates from multivariate models of nativity differences in children’s physical and mental health in the U.S. and U.K. The estimates are taken from main effect models, with each column containing a different outcome. The first panels of Table 2 show differences in physical health among U.S. children. In both countries, the odds of a child having asthma are significantly lower among children of immigrant mothers than among children of native-born mothers—45% (e-0.579) in the U.S. and 22% (e-0.247) in the U.K. Immigrant-native differences in overweight and obesity are insignificant. The findings are more mixed for children’s mental health. In the U.S., children of foreign-born mothers have significantly fewer
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externalizing behaviors than their peers; this pattern is negligible in magnitude and statistically insignificant in the U.K. Conversely, children of foreign-born mothers in both countries have significantly more internalizing behaviors. Testing Immigrant-Native Differences across Skill Groups Table 3 presents estimates from an interaction between nativity and maternal education, revealing whether the immigrant advantage is driven by low or high-skilled families, or if there is a universal "healthy immigrant" effect. As before, there are no meaningful differences in children’s likelihood of being overweight or obese. The immigrant advantage in asthma, however, is strongest among children with low-skill mothers. Patterns in the U.K. mirror those in the U.S. Coefficient equality tests (shown below the coefficient estimates) show that these differences between children of low-skill immigrant and native mothers are significant in both countries. These patterns are more readily understood in the form of predicted values—Table 4 presents predicted values of each outcome in the U.S. and U.K. across maternal skill groups. The predicted probability of asthma is 29% lower among U.S. children of low-skill foreign-born mothers than among children of low-skill native mothers (0.22 vs. 0.31), whereas the difference between children in high-skill immigrant and native families is small and insignificant (0.33 vs. 0.31). The pattern is very similar in the U.K., with a 30% lower probability of asthma among children of low-skill immigrant mothers vs. children of low-skill natives (0.117 vs. 0.167), and an insignificant (and conversely-patterned) difference between children in high-skill immigrant vs. native families (0.123 vs. 0.128). Patterns are mixed for children’s mental health. Beginning in Table 3, the immigrant advantage in U.S. children's externalizing behaviors is strongest among low-skill families, but there is an immigrant disadvantage in internalizing behaviors among children in both low and
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high-skill families. In the U.K., there is also an immigrant disadvantage in children's internalizing behaviors that is driven primarily by low-skill families. In a departure with U.S. patterns, there is an immigrant disadvantage in children's externalizing behaviors among lowskill families; patterns among high-skill families are similar to the U.S. but not statistically meaningful. Table 4 demonstrates these patterns clearly in the form of predicted values. In the U.S., children of low-skill immigrant mothers have fewer predicted externalizing behaviors— more negative z-scores—than children of low-skill natives (-0.190 vs. 0.117). Similarly, children in high-skill immigrant families have fewer externalizing behaviors than their peers in high-skill native families (-0.221 vs. -0.123), though the gap is less pronounced than it is within low-skill families. In contrast, among low-skill children, those born to immigrant mothers have higher predicted internalizing z-scores than children of low-skill natives (0.247 vs. 0.099 in the U.K and 0.244 vs. 0.078 in the U.S.). This is also true, though in a less pronounced magnitude, for externalizing behaviors in the U.K.
DISCUSSION Using data from two diverse populations of children, we examine how the immigrant advantage varies across skill groups and whether it is strongest among low-skill populations. We do so while focusing on children around the time of school entrance; considering both physical and mental health; and examining children in two societies with immigrants from disparate regional and socioeconomic backgrounds. Our test of the immigrant advantage allows us to uncover whether the immigrant health advantage is “paradoxical,” i.e., strongest among children whose parents have fewer resources, or if it is universal, i.e., equally strong among low and high resource families—an important consideration in two countries with great diversity in the
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socioeconomic profiles of their immigrant population. Before summarizing our findings and their implications, it is important to acknowledge the primary limitations of this study. First, it will be useful in future research to better account for the substantial ethnic and cultural diversity that exists among the foreign-born, as sample size concerns required us to combine foreign-born mothers in different ethnic groups. Secondly, because we cannot compare the health of children born to immigrant mothers to that of children born to mothers who do not migrate (in order to assess the degree of selective migration among immigrant families), any immigrant advantage or disadvantage we observe should be interpreted as an upper and lower bound. Third, the large number of differences in population composition and policy across the U.S. and U.K. limits our ability to attribute cross-national variation to a particular source. At the same time, without extending our analytic consideration to the U.K., it would not be possible to assess whether the immigrant advantage is limited to the United States. These limitations notwithstanding, our findings provide evidence that the immigrant advantage in child health is not equally strong across all skill groups, and that it is observed for some, but not all, markers of children’s physical and mental health. Indeed, in some cases there is evidence of an immigrant disadvantage. Initial inspection reveals that, in both countries, there is an immigrant advantage in asthma, no nativity patterning to overweight/obesity, and an immigrant disadvantage in internalizing behaviors. In the U.S., there is an immigrant advantage in externalizing behaviors, while in the U.K. there is no meaningful pattern of externalizing behaviors across nativity groups. Further examination reveals that low-skill families drive immigrant-native differences in child health. The immigrant advantage in child asthma in both countries is strongest in low-skill families, consistent with the original identification of the paradox. In the U.S., a similar pattern
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is observed for externalizing behaviors. In these cases, children of low-skill immigrants have healthier outcomes than children of low-skill natives, and the size of the immigrant health advantage is larger among low-skill than high-skill families. In the case of internalizing behaviors, the immigrant disadvantage is also driven by children in low-skill families, who (in the U.K.) experience the greatest disadvantage relative to their peers in similarly-skilled nativeborn families. That we observe largely similar patterns across the U.S. and U.K. in most of the outcomes we examine is striking. Important differences in U.S. and U.K. immigrants’ regional origins and reasons for migration, and in the policy structure of each country, led us to expect some differences in patterns across the two countries. Examining immigrant-native differences in the two countries provides a needed extension of the analytic lens beyond the United States, which has informed much of our understanding about child development in the context of immigration. These findings suggest that caution is warranted when characterizing the health outcomes of children in immigrant families as favorable. It is not the case that the children of immigrants are uniformly “paradoxically” better off than their peers. Instead, there is heterogeneity across physical and mental health outcomes and evidence for both advantage and disadvantage in immigrant families, which in both cases is most pronounced among low-skill families. There are a number of possible explanations for the low-skill immigrant advantage in children’s asthma, with the two primary explanations focusing on a) cultural variation between immigrants and natives and b) selection processes influencing who migrates. Cultural explanations for the immigrant paradox among low-resource families often center around these families’ lack of “unhealthy acculturation” toward undesirable host-country behavioral norms (e.g., AbraidoLanza et al. 1999). Families may alter their health behaviors over time (Akresh 2007; Hawkins
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et al. 2008) because of shifts in kin networks and non-kin networks in neighborhoods and in parents’ workplace. These changes may be tied to socioeconomic status in some cases—foreignborn families living in advantaged conditions may even adapt their behaviors more quickly than families who are relatively more disadvantaged but who live among a dense network of ethnic peers (Gordon-Larsen et al. 2003; Pickett et al. 2009). Selection processes are equally plausible as an explanation for the immigrant paradox in physical health. Foreign-born mothers, for example, may comprise the members of their native population with the healthiest lifestyles, given recent evidence of socioeconomic gradients in smoking and obesity among women in countries with previously inverse relationships between socioeconomic status and health behavior (Buttenheim et al. 2009). If foreign-born families represent the healthiest of their sending populations, and if this process of selection is strongest among low skill immigrants, then the degree of difference between immigrant and native-born families and children may appear larger than it would otherwise (Jasso et al. 2004). Factors related to migration—who migrants are and how representative they are of their sending population—should therefore be considered as possible explanations alongside cultural variation. In future research it will be important to consider the ways in which both cultural and selection processes influence the health of children with migration backgrounds and the degree of immigrant-native differences in health. In the case of asthma, for example, the fact that children of immigrant mothers are less likely to be exposed to secondhand smoke points to the importance of behavioral factors that are independent of socioeconomic resources. Supplementary analyses of mothers’ smoking behavior confirm that, across both countries and all ethnic groups—with the exception of foreign-born whites in the U.K.—immigrant mothers are less likely to smoke than natives, perhaps suggesting a behavior imported from their country
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of origin that is beneficial for children, despite low resources. In contrast, the lack of immigrantnative differences observed for children’s weight suggests that immigrant parents’ behaviors do not confer the same protective benefit for low-resource children. In the same vein, for aspects of mental health that are closely tied to parenting behavior, children of low-skill mothers may be less likely to be exposed to behaviors that the host society perceives as important for healthy psychological development. Indeed, supplementary analyses of warm and harsh parenting behavior show patterns consistent with the internalizing and externalizing behaviors examined here. This also suggests that immigrant-native differences in children’s mental health do not simply reflect cultural variation in the interpretation of questions about children’s behavior. It is worth nothing that the findings for mental health are reversed when comparing across skill groups within the foreign-born—children of low-skill immigrant mothers are at a disadvantage compared to children of high-skill immigrants with respect to internalizing behavior. This finding will be important to investigate in future research, as it suggests that for some outcomes, immigrant children may experience a “double jeopardy” that comes from the combination of migrant status and socioeconomic disadvantage (Conley and Bennett 2001; Pampel and Rodgers 2004). Taken as a whole, our findings suggest that the development of children in immigrant families is neither strictly (and paradoxically) favorable, nor uniformly unfavorable. Accordingly, future research should compare children in immigrant and nativeborn families in ways that are theoretically informed about how parental resources condition the extent to which immigrant status is beneficial or detrimental to children’s healthy development.
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21
Table 1 Weighted Characteristics of U.S. FFS and U.K. MCS Samples U.S. FFS
Variable Nativity
Children of For. Born (N=844) 25
U.K. MCS
Children of Native Born (N=2,598)
Total Sample (N=3,442)
75
100
Race/Ethnicity Hispanic
63
21
32
Black
8
27
23
NHW
8
49
37
Other
23
3
8
Maternal Skill Mother Low Education
70
55
59
Child Development Physical Health Asthma Overweight/Obese Mental Health Mean Internalizing ZScore Mean Externalizing ZScore
Variable
Children of For. Born (N=1,637)
Children of Native Born (N=14,171)
Total Sample (N=15,808)
Nativity
10
90
100
Race/Ethnicity Black African or Caribbean South Asian (Ind., Pak., Bang.)
12
2
3
33
2
5
Other
13
1
2
White
42
95
90
47
49
48
Maternal Skill Mother Low Education Child Development Physical Health
9
15
13
Asthma
11
14
14
33
22
24
Overweight/Obese
20
21
20
Mental Health 0.202
-0.039
0
Mean Internalizing Z-Score
0.121
-0.068
0
-0.198
-0.002
0
Mean Externalizing Z-Score
-0.083
-0.054
0
Note: Cells show percentages, unless otherwise indicated
22
Table 2 Regression of Nativity and Ethnic Differences in Child Physical and Mental Health, Age 5 Physical Health U.S. Foreign-Born Mother Low Education Intercept
Asthma
Overweight
Externalizing Z-Score
Internalizing Z-Score
-0.579**
0.124
-0.237**
0.120†
(0.14)
(0.17)
(0.06)
(0.06)
0.0591
0.128
0.215**
0.279**
(0.09)
(0.11)
(0.04)
(0.04)
**
**
**
0.194*
-1.906
U.K. Foreign-Born Mother Low Education Intercept Model Type N Note: † p
