Immigrants and the use of preventive care in the United States

The Impact of Limited English Proficiency on Healthcare Access and Outcomes in the U.S.: A Scoping Review

A majority of individuals with limited English proficiency (LEP) in the U.S. are foreign-born, creating a complex intersection of language, socio-economic, and policy barriers to healthcare access and achieving good outcomes. Mapping the research literature is key to addressing how LEP intersects with healthcare. This scoping review followed PRISMA-ScR guidelines and included PubMed/MEDLINE, CINAHL, Sociological Abstracts, EconLit, and Academic Search Premier. Study selection included quantitative studies since 2000 with outcomes specified for adults with LEP residing in the U.S. related to healthcare service access or defined health outcomes, including healthcare costs. A total of 137 articles met the inclusion criteria. Major outcomes included ambulatory care, hospitalization, screening, specific conditions, and general health. Overall, the literature identified differential access to and utilization of healthcare across multiple modalities with poorer outcomes among LEP populations compared with English-proficient populations. Current research includes inconsistent definitions for LEP populations, primarily cross-sectional studies, small sample sizes, and homogeneous language and regional samples. Current regulations and practices are insufficient to address the barriers that LEP individuals face to healthcare access and outcomes. Changes to EMRs and other data collection to consistently include LEP status and more methodologically rigorous studies are needed to address healthcare disparities for LEP individuals.

Inequities in routine preventive care utilization among persons with overweight/obesity in the United States: An analysis of nativity, racial and ethnic identity, and socioeconomic status

Extant literature documented various health disparities among immigrants and racial and ethnically marginalized individuals in the United States. However, health disparities in the intersection of nativity and race are generally less visited. This cross-sectional study assessed utilization of routine preventive care among adults with overweight/obesity at the junction of their nativity, racial/ethnic identity, and socioeconomic status (i.e., income and education). Pooling data on 120,184 adults with overweight/obesity from the 2013-2018 waves of the National Health Interview Survey (NHIS), we estimated modified Poisson regressions with robust standard errors to obtain adjusted prevalence rates of preventive care visit, receiving flu shot, and having blood pressure, cholesterol and blood glucose screened. We found that immigrant adults with overweight/obesity had lower rates of utilization of all five preventive care services. However, these patterns varied by racial and ethnic sub-populations. While White immigrants had comparable rates of cholesterol and blood glucose screening, they had 2.7%, 2.9%, and 14.5% lower rates of preventive care visit, blood pressure screening, and getting a flu shot respectively, compared to native-born Whites. These patterns were similar for Asian immigrants as well. Black immigrants, on the other hand, had comparable rates of getting a flu shot and blood glucose screening, and had 5.2%, 4.9%, and 4.9% lower rates of preventive care visit, blood pressure screening, and cholesterol screening respectively. Lastly, the rates of utilization among Hispanic immigrants were significantly lower (ranging from 9.2% to 20%) than those of their native-born counterparts for all five preventive care services. These rates further varied by education, income, and length of stay in the US, within the racial and ethnic subgroups. Our findings thus suggest a complex relationship between nativity and racial/ethnic identity in relation to preventive care utilization among adults with overweight/obesity.

Differences in use of high- and low-value health care between immigrant and US-born adults

OBJECTIVE

To examine differences in the use of high- and low-value health care between immigrant and US-born adults.

DATA SOURCE

The 2007-2019 Medical Expenditure Panel Survey.

STUDY DESIGN

We split the sample into younger (ages 18-64 years) and older adults (ages 65 years and over). Our outcome measures included the use of high-value care (eight services) and low-value care (seven services). Our key independent variable was immigration status. For each outcome, we ran regressions with and without individual-level characteristics.

DATA COLLECTION/EXTRACTION METHODS

N/A.

PRINCIPAL FINDINGS

Before accounting for individual-level characteristics, the use of high- and low-value care was lower among immigrant adults than US-born adults. After accounting for individual-level characteristics, this difference decreased in both groups of younger and older adults. For high-value care, significant differences were observed in five services and the direction of the differences was mixed. The use of breast cancer screening was lower among immigrant than US-born younger and older adults (-5.7 [95% CI: -7.4 to -3.9] and -2.9 percentage points [95% CI: -5.6 to -0.2]) while the use of colorectal cancer screening was higher among immigrant than US-born younger and older adults (2.6 [95% CI: 0.5 to 4.8] and 3.6 [95% CI: 0.2 to 7.0] percentage points). For low-value care, we did not identify significant differences except for antibiotics for acute upper respiratory infection among younger adults and opioids for back pain among older adults (-3.5 [95% CI: -5.5 to -1.5] and -3.8[95% CI: -7.3 to -0.2] percentage points). Particularly, differences in socioeconomic status, health insurance, and care access between immigrant and US-born adults played a key role in accounting for differences in the use of high- and low-value health care. The use of high-value care among immigrant and US-born adults increased over time, but the use of low-value care did not decrease.

CONCLUSION

Differential use of high- and low-value care between immigrant and US-born adults may be partly attributable to differences in individual-level characteristics, especially socioeconomic status, health insurance, and access to care.

Pap Smear and Mammogram Screening Rates in a Refugee and General OB/GYN Clinic: A Retrospective Review

Although multiple studies have shown that resettled refugee women are less likely to receive preventative cancer screenings like pap smears and mammograms, a small number have demonstrated the opposite. This retrospective chart review, conducted between January 2017 and October 2018, compares pap smear and mammogram rates of patients seen in a refugee-specific OB/GYN clinic with patients from the general OB/GYN clinic at the same institution. Data from 298 patients (149 refugee and 149 general clinic patients matched by age and date-of-visit) were analyzed. Pap smear screening rates were 90.60% in the refugee group and 73.83% in the general group [p < 0.009, aOR 3.46 (1.36-8.81)], while mammogram screening rates were 36.84% and 38.60%, respectively (p = 0.46). The provision of holistic services meeting refugee women's unique needs can effectively increase pap smear screening rates.

Gains in insurance coverage following the affordable care act and change in preventive services use among non-elderly US immigrants

Immigrants have lower and disproportionate use of preventive care. We use longitudinal panel data to examine how the 2014 full implementation of the ACA mandates affected change in preventive services (PS) use among immigrants that gained insurance. We used data on Foreign-Born (FB) and US-Born (USB) adults, ages 26-64 years, from the 2013/16 Medical Expenditures Panel Survey longitudinal files to examine within-person change in yearly utilization of age/sex specific United States Preventive Services Task Force (USPSTF) recommended services. We included five primary care (e.g., influenza immunization), three behavioral (e.g., diet), and seven cancer screening (e.g., mammography) measures. We used generalized estimating equations and difference-in-differences tests to assess the effects of insurance gain on: (1) change in PS utilization, and (2) reduction in utilization disparities between USB and FB adults, adjusting for predisposing, health enabling, and health needs factors. Our results showed that newly-insured FB adults substantially increased their use of all primary care checks, and exercise and diet advice. We also found improvements in use of endoscopies, two modalities of colon cancer screening, and prostate cancer screening, but not in receipt of mammography and clinical breast exams. Newly-insured FB PS use remained lower than use among continuously-insured USB adults, but some of the differences were explained by adjustment to enabling and health needs factors. Briefly, health insurance gains among immigrants translated into substantial improvements in use of recommended PS. Still, notable disparities persist among the newly-insured FB, and more so among the 1 in 5 that remain continuously uninsured.

Barriers to Prostate Cancer Screening Among Indo-Guyanese

Prostate cancer is one of the most common types of cancer in many industrialized countries and is among the leading causes of death. Ranking among one of the top three forms of cancer, it is unfortunate that prostate cancer screening is not routinely recommended. This study attempts to explore the barriers to prostate cancer screening among Indo-Guyanese men. We conducted in-depth, one on one interviews among 20 Indo-Guyanese men between the ages of 45 and 75 years old, residing in the New York City neighborhood of Queens. Qualitative analysis was performed using multiple coders. Detailed analysis of the data found four major themes to be the culprit associated with a decrease in prostate cancer screening in this population: (1) lack of knowledge about the disease, (2) fear of diagnosis, (3) embarrassment and, (4) personal reservations with the rectal exam. The findings of this research suggest that Indo-Guyanese immigrants are lacking the basic understanding of prostate cancer and the importance of screening. It is possible that this deficiency is also applicable to many other disease states. By collaborating with healthcare providers and other stakeholders, such as community leaders and elected officials, we can develop culturally appropriate services specific to this population, to address these barriers to healthcare services.

Disparities in Access to Health Care Among US-Born and Foreign-Born US Adults by Mental Health Status, 2013-2016

Objectives. To compare access to care between US-born and foreign-born US adults by mental health status. Methods. We analyzed data on nonelderly adults (n = 100 428) from the 2013-2016 National Health Interview Survey. We used prevalence estimates and multivariable logistic regression models to compare issues of affordability and accessibility between US-born and foreign-born individuals. Results. Approximately 22.2% of US-born adults and 18.1% of foreign-born adults had symptoms of moderate to severe psychological distress. Compared with US-born adults with no psychological distress, and after adjustment for sociodemographic characteristics, US-born and foreign-born adults with psychological distress were much more likely to report multiple emergency room visits and unmet medical care, mental health care, and prescription medications because of cost. Conclusions. Our study found that adults with moderate to severe psychological distress, regardless of their immigration status, were at greater risk for reporting issues of affordability when accessing health care compared with US-born adults with no psychological distress. Public Health Implications. Health care and mental health reforms should focus on reducing health care costs and establishing innovative efforts to broaden access to care to diverse populations.

Barriers and Facilitators to Breast and Cervical Cancer Screening Among Immigrants in the United States

To summarize the literature on barriers and facilitators to breast and cervical cancer screening among immigrants to the US. A literature review was conducted for studies on breast and cervical cancer screening among immigrant populations. A thematic analysis of 180 studies identified a variety of barriers and facilitators to screening at the personal and system levels. Personal barriers included lack of knowledge and insurance coverage, high cost of care, and immigration status. System barriers included poor access to services, lack of interpreter services, and insensitivity to patient needs. Facilitators to screening included knowledge of disease, access to information sources, physician recommendation, and social networks. Cultural norms and resource availability at the individual and system levels influence screening among immigrants. Health insurance coverage was found to be an important predictor of preventative screening use. Future research should seek to identify the best way to address this and other barriers to cancer screening among immigrants groups.

Migration and cognitive function: a conceptual framework for Global Health Research

BACKGROUND

Migration is a fundamental demographic process that has been observed globally. It is suggested that migration is an issue of global health importance that can have an immediate and lasting impact on an individual's health and well-being. There is now an increasing body of evidence linking migration with cognitive function in older adults. In this paper, we synthesized the current evidence to develop a general conceptual framework to understand the factors contributing to the association between migration and cognitive function.

METHODS

A comprehensive review of the literature was conducted on the associations between migration and cognition among middle-aged and older adults.

RESULTS

Five potential mechanisms were identified from the literature: 1) socioeconomic status-including education, occupation, and income; 2) psychosocial factors-including social networks, social support, social stressors, and discrimination; 3) behavioral factors-including smoking, drinking, and health service utilization; 4) physical and psychological health status-including chronic conditions, physical function, and depression; and 5) environmental factors-including both physical and social environment. Several underlying factors were also identified-including early-life conditions, gender, and genetic factors.

CONCLUSIONS

The factors linking migration and cognitive function are multidimensional and complex. This conceptual framework highlights potential implications for global health policies and planning on healthy aging and migrant health. Additional studies are needed to further examine these mechanisms to extend and refine our general conceptual framework.

Cardiovascular Disease Screening Among Immigrants from Eight World Regions

Inequalities between native-born and foreign-born individuals in screening rates for a variety of conditions have been well-documented in literature on immigrant health. A preponderance of this research focuses on the Latin American case and on cancer-specific screening. This study seeks to expand knowledge of such preventative-health screening differences by analyzing screening rates for blood sugar, blood pressure, and serum cholesterol among nine groups overall and (for immigrants) at various stages of US residency. Using nationally representative data from the National Health Interview Survey, we find that immigrants from eight geographic regions receive preventative care at lower rates than US-born Whites and that preventative screening is generally higher after 15 years than during the first 4 years of residency in the United States. Importantly, our data also show that screening patterns and trends vary based on region of origin and outcome. These findings improve our understanding of immigrant health and health care use in the United States.

Vaccination Coverage Disparities Between Foreign-Born and U.S.-Born Children Aged 19-35 Months, United States, 2010-2012

Healthy People 2020 targets high vaccination coverage among children. Although reductions in coverage disparities by race/ethnicity have been described, data by nativity are limited. The National Immunization Survey is a random-digit-dialed telephone survey that estimates vaccination coverage among U.S. children aged 19-35 months. We assessed coverage among 52,441 children from pooled 2010-2012 data for individual vaccines and the combined 4:3:1:3*:3:1:4 series (which includes ≥4 doses of diphtheria, tetanus, and acellular pertussis vaccine/diphtheria and tetanus toxoids vaccine/diphtheria, tetanus toxoids, and pertussis vaccine, ≥3 doses of poliovirus vaccine, ≥1 dose of measles-containing vaccine, ≥3 or ≥4 doses of Haemophilus influenzae type b vaccine (depending on product type of vaccine; denoted as 3* in the series name), ≥3 doses of hepatitis B vaccine, ≥1 dose of varicella vaccine, and ≥4 doses of pneumococcal conjugate vaccine). Coverage estimates controlling for sociodemographic factors and multivariable logistic regression modeling for 4:3:1:3*:3:1:4 series completion are presented. Significantly lower coverage among foreign-born children was detected for DTaP, hepatitis A, hepatitis B, Hib, pneumococcal conjugate, and rotavirus vaccines, and for the combined series. Series completion disparities persisted after control for demographic, access-to-care, poverty, and language effects. Substantial and potentially widening disparities in vaccination coverage exist among foreign-born children. Improved immunization strategies targeting this population and continued vaccination coverage monitoring by nativity are needed.

Emergency department services use among immigrant and non-immigrant groups in the United States

Immigrants have disproportionate lack of access to healthcare and insurance. Emergency departments could serve as a healthcare substitute and increased demand can negatively affect the US emergency services system. Medical Expenditures Panel Survey (2000-2008) data was modeled to compare emergency departments (ED) use between non-citizens, foreign-born (naturalized), and US-born citizens. Group differences were assessed using non-linear decomposition techniques. Non-citizens were less likely to use ED services (8.7 %) compared to naturalized immigrants (10.6 %) and US-born Americans (14.7 %). Differences in ED use persisted after adjusting for the Behavioral Model covariates. Healthcare need and insurance partially explained the differences in ED use between the groups. Between 2000 and 2008 non-citizen immigrants used markedly less ED services compared to US citizens, regardless of their nation of origin. We also found that demographic and healthcare need profiles contributed to the divergence in use patterns between groups. A less restrictive healthcare policy environment can potentially contribute to lower population disease burden and greater efficiencies in the US health care system.

Barriers to HIV Testing in Black Immigrants to the U.S

BACKGROUND

Late HIV testing is common among immigrants from sub Saharan Africa and the Caribbean. Since 2010, HIV testing is no longer a required component of immigrant screening examinations or mandatory for immigrants seeking long term residence in the US. Thus, barriers to HIV testing must be addressed.

METHODS

Five hundred and fifty-five (555) immigrants completed a barriers-to-HIV testing scale. Univariate and multivariate linear regression were performed to examine predictors of barriers.

RESULTS

In multivariate analysis, primary language other than English (β=2.9, p=.04), lower education (β=5.8, p=.03), low income [= below $20K/year] (β=4.6, p=.01), no regular provider (β=5.2, p=.002) and recent immigration (β=5.7, p=.0008) were independently associated with greater barriers. Barriers due to health care access, privacy, fatalism, and anticipated stigma were greater for recent versus longer term immigrants.

DISCUSSION

Immigrants from sub-Saharan Africa and the Caribbean face significant barriers to HIV testing. Interventions to improve access and timely entry into care are needed.

Disparities in preventive health services among Somali immigrants and refugees

African immigrants and refugees-almost half of them from Somalia-account for one of the fastest-growing groups in the United States. There is reason to suspect that Somali-Americans may be at risk for low completion of recommended preventive health services. This study's aim was to quantify disparities in preventive health services among Somali patients compared with non-Somali patients in an academic primary care practice in Rochester, Minn. It also examined the effect of medical interpreters, emergency department visits, and primary care visits on the completion of preventive services. Rates of pap smears, vaccinations (influenza, pneumococcus, and tetanus), lipid screening, colorectal cancer screening, and mammography were assessed in Somali and non-Somali patients during the second quarter of 2008. Data were collected regarding the utilization of medical interpreters, emergency services, and primary care services among Somali patients. Results were reported using standard descriptive statistics. Of the 91,557 patients identified in the database, 810 were Somali. Somali patients had significantly lower completion rates of colorectal cancer screening, mammography, pap smears, and influenza vaccination than non-Somali patients. Use of medical interpreters and primary care services were generally associated with higher completion rates of preventive services. There are significant discrepancies in the provision of preventive health services to Somali patients compared with that of non-Somali patients. These findings suggest the need to identify the root causes of these discrepancies so that interventions may be crafted to close the gap.

Preventive services for adults: how have differences across subgroups changed over the past decade?

BACKGROUND

A large literature documents cross-sectional differences in adult preventive services across population subgroups. Less is known, however, about how these differences have changed over time.

OBJECTIVES

This study tracks changes over time in the distribution of preventive services use across groups defined by poverty status, race/ethnicity, insurance coverage, Census region, and urbanicity.

METHODS

Data from the 1996-2008 Medical Expenditure Panel Survey are used to examine 5 preventive services: general checkups, blood pressure screening, blood cholesterol screening, Pap smears, and mammograms. Multivariate logistic regression models of preventive services use are used to compute adjusted utilization for each subgroup of adults aged 19-64 in 1996/1998, 2002/2003, and 2007/2008. We then examine the extent to which percentage point gaps in utilization rates across subgroups have changed between 1996/1998 and 2007/2008.

RESULTS

Our analysis of utilization rates across subgroups and over time identified only rare cases in which subgroup differences narrowed or widened between 1996/1998 and 2007/2008. Rather, differences across subgroups tended to persist over time. Some of the largest (adjusted) gaps are between adults with and without coverage, and only for blood cholesterol screening do we observe significant narrowing of the gap between the uninsured and the privately insured. Regional differences persisted or widened over the study period.

CONCLUSIONS

On the eve of health reform implementation, a key challenge facing the Affordable Care Act will be to address persistent differences in preventive services use within the US population.

Immigrants' mortality patterns in the short- and long-term point toward origin-related diversities: the Israeli experience

Immigrant mortality studies reveal conflicting results that were attributed to diversity in immigrant definition, different classifications, and lack of appropriate comparisons. This work studied mortality patterns of the immigrations absorbed in Israel. Short-term mortality was evaluated by comparing the Standardized Mortality Rate (SMR) of the first year after immigration to the SMR of the second to fifth years. Long-term mortality was evaluated by comparing recent immigrant cohorts to cohorts of immigrants who have been residents 5 and 10 years. Stratification was made by source country classification and gender. Data were derived from the Israel National Population Registry and were analyzed anonymously. Immigrants from developed and developing countries had the highest SMR in the first year, which considerably decreased in both short and long term. Immigrants from mid-developed countries had stable SMR in the short term followed by only a modest decrease in the long term. Ethiopian immigrants exhibited exceptionally low SMR in the first year, following which it increased but remained relatively low. Mortality patterns of different immigrant groups differ even under similar definitions, conditions, and period. Only immigrants of developed and developing countries presented the expected pattern of excessive short-term mortality, which consistently decreased with time. Unique mortality patterns were discovered among two groups: Immigrants from mid-developed countries presented stable mortality attributable to isolation and delayed adaptation, and Ethiopian low mortality attributable to pre-migration natural selection.

Health care access and utilization among US-born and foreign-born Asian Americans

Despite efforts to eliminate inequality in health and health care, disparities in health care access and utilization persist in the United States. The purpose of this study was to compare the access to care and use of health care services of US-born and foreign-born Asian Americans. We used aggregated data from the National Health Interview Survey (NHIS) from 2003 to 2005, including 2,500 participants who identified themselves as Asian. Associations between country of birth and reported access and utilization of care in the previous 12 months were examined. After controlling for covariates, being foreign-born was negatively related to indicators of access to care, including health insurance (OR = 0.29, 95%CI = 0.18-0.48), routine care access (OR = 0.52, 95%CI = 0.36-0.75), and sick care access [OR = 0.67, 95%CI = 0.47-0.96)]. Being foreign-born was also negatively related to all indicators of health care utilization (office visit: OR = 0.58, 95%CI = 0.41-0.81; seen/talked to a general doctor: OR = 0.69, 95%CI = 0.52-0.90; seen/talked to a specialist: OR = 0.42, 95%CI = 0.28-0.63) but ER visit (OR = 0.84, 95%CI = 0.59-1.20). There are substantial differences by country of birth in health care access and utilization among Asian Americans. Our findings emphasize the need for developing culturally sensitive health services and intervention programs for Asian communities.

Comparing and decomposing differences in preventive and hospital care: USA versus Taiwan

As the USA expands health insurance coverage, comparing utilization of healthcare services with countries like Taiwan that already have universal coverage can highlight problematic areas of each system. The universal coverage plan of Taiwan is the newest among developed countries, and it is known for readily providing access to care at low costs. However, Taiwan experiences problems on the supply side, such as inadequate compensation for providers, especially in the area of preventive care. We compare the use of preventive, hospital, and emergency care between the USA and Taiwan. The rate of preventive care use is much higher in the USA than in Taiwan, whereas the use of hospital and emergency care is about the same. Results of our decomposition analysis suggest that higher levels of education and income, along with inferior health status in the USA, are significant factors, each explaining between 7% and 15% of the gap in preventive care use. Our analysis suggests that, in addition to universal coverage, proper remuneration schemes, education levels, and cultural attitudes towards health care are important factors that influence the use of preventive care.

Health care practices of the foreign born Asian Indians in the United States. A community based survey

Although successful utilization of medical and preventive care by members of the non-US born communities is an important public health concern, our knowledge regarding health practices of different ethnic subgroups is limited. In the present study, participants of the health fairs organized during South Asian cultural and religions events were asked anonymously to complete the South Asian Total Health Initiative (SATHI) health survey questionnaire to evaluate their health-related practices, self-health perception, and satisfaction with medical care. Among 1,250 surveyed, 1,016 foreign born Asian Indians adults that represented the fastest growing subgroups of the South Asian born nationals in the US were included in the analysis. We found that the majority reported healthy behavior (exercise activities and abstinence from alcohol or tobacco), high self-health perception, satisfaction with medical care, and compliance with annual routine medical examinations that was directly associated with the annual house income. Approximately 40% of women complied with breast and cervical cancer screenings and less than 20% of men complied with prostate cancer screening guidelines. Presence of chronic conditions (mostly cardiovascular pathology and/or diabetes) that were reported by approximately half of the participants negatively impacted their self-health perception. In conclusion, positive self-reported health perception and compliance with routine health examinations of the surveyed foreign born Asian Indians was reported along with an increased rate of chronic morbidity and underutilization of specific preventive services. Observed discrepancy between self-health perception and health status highlights the need to enhance utilization of preventive services among the non-US born Asian Indian community.

Effects of length of stay and language proficiency on health care experiences among immigrants in Canada and the United States

This study sought to examine the influence of length of stay and language proficiency on immigrants' access to and utilization of care in Canada and the United States (U.S,). Data came from the 2007-2008 Canadian Community Health Survey and the National Health Interview Survey. Analyses were limited to foreign-born, non-elderly adults in each country (n = 12,870 in Canada and n = 7440 in the U.S.). Health care indicators included having a usual source of care; annual consultation with a health professional, dentist, and eye doctor; flu shot in the past year; and Pap test in the past 3 years. Logistic regression models were employed to estimate the relative odds of access or use of care, adjusting for need, demographic factors, socioeconomic status, and insurance coverage. In general, rates of health care access and utilization were higher in Canada than the U.S. among all immigrant groups. In both countries, adjusted analyses indicated that immigrants with shorter length of stay (less than 10 years) and limited language proficiency generally had lower rates of access/use compared with those with longer length of stay (10 years or more) and proficiency in each country's official language(s), respectively. There was one exception to this pattern in the U.S.: immigrants with limited English had higher odds of having a recent Pap test relative to English-proficient immigrants. The persistence of disparities in health care experiences based on length of stay and language proficiency in Canada suggests that universal health insurance coverage may not be sufficient for ensuring access to and utilization of primary and preventive care for this population.

BMI differences in 1st and 2nd generation immigrants of Asian and European origin to Australia

We estimate assimilation of immigrants' body mass index (BMI) to the host population of Australia over one generation, conducting separate analyses for immigrants from 7 regions of Europe and Asia. We use quantile regressions to allow for differing impact of generational status across 19 quantiles of BMI from under-weight to morbidly obese individuals. We find that 1st generation South European immigrants have higher, and South and East Asian immigrants have lower BMI than Australians, but have assimilated to the BMI of their hosts in the 2nd generation. There are no or only small BMI differences between Australians and 1st and 2nd generation immigrants from East Europe, North-West Europe, Middle East and Pacific regions. We conclude that both upward and downward assimilation in some immigrant groups is most likely caused by factors which can change over one generation (such as acculturation), and not factors which would take longer to change (such as genetics). Our results suggest that public health policies targeting the lifestyles of well educated Asian immigrants may be effective in preventing BMI increase in this subgroup.

Migrants and emerging public health issues in a globalized world: threats, risks and challenges, an evidence-based framework

International population mobility is an underlying factor in the emergence of public health threats and risks that must be managed globally. These risks are often related, but not limited, to transmissible pathogens. Mobile populations can link zones of disease emergence to lowprevalence or nonendemic areas through rapid or high-volume international movements, or both. Against this background of human movement, other global processes such as economics, trade, transportation, environment and climate change, as well as civil security influence the health impacts of disease emergence. Concurrently, global information systems, together with regulatory frameworks for disease surveillance and reporting, affect organizational and public awareness of events of potential public health significance. International regulations directed at disease mitigation and control have not kept pace with the growing challenges associated with the volume, speed, diversity, and disparity of modern patterns of human movement. The thesis that human population mobility is itself a major determinant of global public health is supported in this article by review of the published literature from the perspective of determinants of health (such as genetics/biology, behavior, environment, and socioeconomics), population-based disease prevalence differences, existing national and international health policies and regulations, as well as inter-regional shifts in population demographics and health outcomes. This paper highlights some of the emerging threats and risks to public health, identifies gaps in existing frameworks to manage health issues associated with migration, and suggests changes in approach to population mobility, globalization, and public health. The proposed integrated approach includes a broad spectrum of stakeholders ranging from individual health-care providers to policy makers and international organizations that are primarily involved in global health management, or are influenced by global health events.

Lifestyles, demographics, dietary behavior, and obesity: a switching regression analysis

OBJECTIVES; To investigate the effects of lifestyles, demographics, and dietary behavior on overweight and obesity.

DATA SOURCE

Continuing Survey of Food Intakes by Individuals 1994-1996, U.S. Department of Agriculture.

STUDY DESIGN

We developed a three-regime switching regression model to examine the effects of lifestyle, dietary behavior, and sociodemographic factors on body mass index (BMI) by weight category and accommodating endogeneity of exercise and food intake to avoid simultaneous equation bias. Marginal effects are calculated to assess the impacts of explanatory variables on the probabilities of weight categories and BMI levels.

PRINCIPAL FINDINGS

Weight categories and exercise are found to be endogenous. Lifestyle, dietary behavior, social status, and other sociodemographic factors affect BMI differently across weight categories. Education, employment, and income have strong impacts on the likelihood of overweight and obesity. Exercise reduces the probabilities of being overweight and obese and the level of BMI among overweight individuals.

CONCLUSION

Health education programs can be targeted at individuals susceptible to overweight and obesity. Social status variables, along with genetic and geographic factors, such as region, urbanization, age, and race, can be used to pinpoint these individuals.