Cohort profile: the Health of Philippine Emigrants Study (HoPES) to examine the health impacts of international migration from the Philippines to the USA

Leading causes of death in Vietnamese Americans: An ecological study based on national death records from 2005-2020

BACKGROUND

Disaggregated data is a cornerstone of precision health. Vietnamese Americans (VietAms) are the fourth-largest Asian subgroup in the United States (US), and demonstrate a unique burden of disease and mortality. However, most prior studies have aggregated VietAms under the broader Asian American category for analytic purposes. This study examined the leading causes of death among VietAms compared to aggregated Asian Americans and non-Hispanic Whites (NHWs) during the period 2005-2020.

METHODS

Decedent data, including underlying cause of death, were obtained from the National Center for Health Statistics national mortality file from 2005 to 2020. Population denominator estimates were obtained from the American Community Survey one-year population estimates. Outcome measures included proportional mortality, age-adjusted mortality rates per 100,000 (AMR), and annual percent change (APC) in mortality over time. Data were stratified by sex and nativity status. Due to large differences in age structure, we report native- and foreign-born VietAms separately.

FINDINGS

We identified 74,524 VietAm decedents over the study period (71,305 foreign-born, 3,219 native-born). Among foreign-born VietAms, the three leading causes of death were cancer (26.6%), heart disease (18.0%), and cerebrovascular disease (9.0%). Among native-born VietAms the three leading causes were accidents (19.0%), self-harm (12.0%), and cancer (10.4%). For every leading cause of death, VietAms exhibited lower mortality compared to both aggregated Asians and NHWs. Over the course of the study period, VietAms witnessed an increase in mortality in every leading cause. This effect was mostly driven by foreign-born, male VietAms.

CONCLUSIONS AND RELEVANCE

While VietAms have lower overall mortality from leading causes of death compared to aggregated Asians and NHWs, these advantages have eroded markedly between 2005 and 2020. These data emphasize the importance of racial disaggregation in the reporting of public health measures.

The association between local area immigrant fraction and prevalence of cardiovascular diseases in the United States: an observational study

Background

Local area immigrant fraction is strongly and positively correlated with local life expectancy in the United States. The aim of the study was to determine the relationship between local area immigrant fraction and local prevalence of coronary heart disease (CHD) and stroke.

Methods

Cross-sectional study design, with ZIP code as the unit of observation. Demographic data was obtained from the American Community Survey, and linked to indicators of health access (e.g., insurance, annual check-ups, cholesterol screening), obesity, behavior (smoking, exercise), and cardiovascular outcomes data from the 2020 Population Level Analysis and Community Estimates. Multivariable regression and path analyses were used to assess both direct and indirect relationships among variables.

Findings

CHD prevalence was lower in the second (3.9% relative difference, 95% CI: 3.1-4.5%), third (6.5%, 95% CI: 5.8-7.1%), and fourth (14.8%, 95% CI: 14.1-15.8%) quartiles of immigrant fraction compared to the lowest (p-trend <0.001). These effects remained robust in multivariable analysis following adjustment for indicators of access, obesity, and behavioral variables (p-trend <0.0001). For stroke, only the highest quartile demonstrated a significant difference in prevalence (2.1%, 95% CI: 1.2-3.0% with full adjustment). In CHD path analysis, ∼45% of the association of immigrant fraction was direct, and ∼55% was mediated through lower prevalence of deleterious behaviors (e.g., smoking). In stroke path analysis, the effect was entirely mediated through indirect effects.

Interpretation

In the United States, ZIP codes with higher immigrant fractions have lower prevalence of cardiovascular diseases. These associations are partially mediated through differences in health behaviors at the community level.

Funding

NIH (K08CA252635, P30AG0059304, K24HL150476), Stanford University, Rutgers University.

Visa type and financial strain on depressive symptoms among Filipino migrants to the United States

Migrants have been theorized to be healthier than their non-migrant counterparts; however, there is limited examination of health selection using binational data and how selection occurs, particularly for mental health outcomes. This study examines the role of visa status and financial strain as critical factors for mental health selection among Filipino migrants to the U.S. and non-migrants who remain in the Philippines. We used the baseline data from the Health of Philippine Emigrants Study (HoPES; n = 1631) to compare depressive symptoms between non-migrants and migrants who were both surveyed prior to their departure to the U.S. We assessed depressive symptoms using linear regression by migration status, financial strain, and by visa categories including fiancée/marriage, unlimited family reunification, limited family reunification, and employment. Overall, all migrants reported lower depressive symptoms than non-migrants; however, depressive symptoms varied by visa type. Fiancée/marriage migrants had lower depressive symptoms than compared to limited family reunification migrants. Additionally, those who reported financial strain had higher depressive symptoms than those without any financial strain. We find that migrants were positively selected for mental health using a unique sample of Filipino migrants before they left for the U.S.

Health selection on self-rated health and the healthy migrant effect: Baseline and 1-year results from the health of Philippine Emigrants Study

Studies of migration and health focus on a "healthy migrant effect" whereby migrants are healthier than individuals not migrating. Health selection remains the popular explanation of this phenomenon. However, studies are mixed on whether selection occurs and typically examine migrants post-departure. This study used a novel pre-migration dataset to identify which health and social domains differ between migrants and their non-migrant counterparts and their contribution to explaining variance in self-rated health by migrant status at pre-migration and 1-year later. Data were used from the baseline and 1-year follow-up of the Health of Philippine Emigrants Study (HoPES). We used multivariable ordinary least squares regression to examine differences in self-rated health between migrants to the U.S. and a comparable group of non-migrants at baseline (premigration) and one year later, accounting for seven domains: physical health, mental health, health behavior, demographics, socioeconomic factors and healthcare utilization, psychosocial factors, and social desirability. A migrant advantage was present for self-rated health at baseline and 1-year. Accounting for all domains, migrants reported better self-rated health compared to non-migrants both at baseline (β = 0.32; 95% CI = 0.22, 0.43) and at 1-year (β = 0.28; 95% CI = 0.10, 0.46). Migrant status, health behavior, and mental health accounted for most of the variance in self-rated health both at baseline and 1-year follow-up. This analysis provides evidence of migrant health selection and nuanced understanding to what is being captured by self-rated health in studies of migrant health that should be considered in future research.

Type 2 Diabetes Among Filipino American Adults in the Multiethnic Cohort

INTRODUCTION

Several Asian racial and ethnic groups, including individuals of Filipino ancestry, are at higher risk of developing type 2 diabetes than White individuals, despite their lower body mass index (BMI). This study examined determinants of type 2 diabetes among Filipino American adults in the Multiethnic Cohort Study.

METHODS

Participants in Hawaii and Los Angeles completed questionnaires on demographics, diet, and anthropometrics. Generational status was determined according to birthplace of participants and their parents. Based on self-reported data and data on medications, type 2 diabetes status was classified as no, prevalent, or incident. We used polytomous logistic regression, while adjusting for confounders, to obtain odds ratios.

RESULTS

Among 10,681 Multiethnic Cohort Study participants reporting any Filipino ancestry, 57% were 1st-, 17% were 2nd-, and 25% were 3rd-generation Filipino Americans. Overall, 13% and 17% of participants had a prevalent or incident type 2 diabetes diagnosis. Overweight and obesity and the presence of other risk factors increased from the 1st to subsequent generations. First-generation immigrants were less likely to report type 2 diabetes at cohort entry than immigrants of subsequent generations who were born in the US or whose parents were born in the US; only the prevalence of type 2 diabetes was significantly elevated in the 2nd generation compared with the 1st generation.

CONCLUSION

The results support the hypothesis that Filipino migrants adopt lifestyle factors of the host country and subsequent generations experience higher type 2 diabetes rates due to changes in risk factor patterns.

Strategies to Enhance Retention in a Cohort Study Among Adults of Turkish Descent Living in Berlin

Retention is important for statistical power and external validity in long-term cohort studies. The aims of our study were to evaluate different retention strategies within a cohort study of adults of Turkish descent in Berlin, Germany, and to compare participants and non-participants. In 2011–2012, a population-based study was conducted among adults of Turkish descent to primarily examine recruitment strategies. 6 years later, the participants were re-contacted and invited to complete a self-report questionnaire regarding their health status, health care utilization, and satisfaction with medical services. The retention strategy comprised letters in both German and Turkish, phone calls, and home visits (by bilingual staff). We calculated the response rate and retention rate, using definitions of the American Association for Public Opinion Research, as well as the relative retention rate for each level of contact. Associations of baseline recruitment strategy, sociodemographic, migration-related and health-related factors with retention were investigated by logistic regression analysis. Of 557 persons contacted, 249 (44.7%) completed the questionnaire. This was 50.1% of those whose contact information was available. The relative retention rate was lowest for phone calls (8.9%) and highest for home visits (18.4%). Participants were more often non-smokers and German citizens than non-participants. For all remaining factors, no association with retention was found. In this study, among adults of Turkish descent, the retention rate increased considerably with every additional level of contact. Implementation of comprehensive retention strategies provided by culturally matched study personnel may lead to higher validity and statistical power in studies on migrant health issues.

Heterogeneity in Migrant Health Selection: The Role of Immigrant Visas

This study proposes that visa status is an important construct that is central to understanding how health selection occurs among immigrants. We used the 2017 baseline survey data of the Health of Philippine Emigrants Study (n = 1,632) to compare the health of nonmigrants remaining in the Philippines and migrants surveyed prior to migration to the United States. Furthermore, we compared migrant health by visa type: limited family reunification, unlimited family reunification, fiancé(e)/marriage, and employment. Migrants reported fewer health conditions than nonmigrants overall. However, health varied among migrants by visa type. Migrants with fiancé(e)/marriage visas were the healthiest, reporting significantly fewer health conditions than the other groups. Limited family reunification migrants reported more health conditions than nonmigrants and unlimited family reunification migrants. We discuss how the immigration visa process reflects broader forms of social and political stratification that cause heterogeneity in immigrant health selection.