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THE HEALTH CONSEQUENCES OF ASIAN IMMIGRANT INTEGRATION

Annie Eun Young Ro

A dissertation submitted in partial fulfillment of the requirements for the degree of

Doctor of Philosophy (Health Behavior and Health Education)

in The University of Michigan 2011

Doctoral Committee

Professor Arline T. Geronimus, Chair Professor John Bound Assistant Professor Derek Griffith Associate Professor Gilbert Gee, University of California, Los Angeles

UMI Number: 3493122

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ACKNOWLEDGEMENTS

I am indebted to a number of people who have provided intellectual, social and

emotional support during my dissertation writing and throughout my time here at

Michigan. Truly, this dissertation is the product of a group effort.

My dissertation committee chair, Dr. Arline Geronimus, has guided this project

from its infancy. Her commitment to use rigorous scholarship to highlight structural

inequities has been the bedrock of my training and will continue to inspire me as I leave

Michigan. I am also grateful to her for the opportunity to work at the Population Studies

Center, which has been one of the highlights of my graduate training.

Dr. Gilbert Gee has been a gracious mentor throughout my graduate career. His

scholarly insight and advice have always provided encouragement and clarity. I look

forward to working with him during my postdoctoral fellowship.

Dr. John Bound has provided invaluable advice on the methodology of this

project. His analytical input has greatly strengthened my dissertation and I feel

incredibly fortunate to have had him on my committee.

Dr. Derek Griffith has consistently provided helpful feedback to develop my

theoretical arguments and I have appreciated his thorough and discerning comments.

My colleagues at the University of Michigan School of Public Health and

Population Studies Center have unselfishly shared their expertise and time through the

years. Kurt Christensen, Nancy Fleischer, Maggie Hicken, Danya Keene, Erin

Linnenbringer and Akilah Wise read the earliest and roughest drafts, pored over Stata

output with me and sat many hours over coffee, offering moral support as only they

could. They are wonderful friends and have made my time at Michigan especially

memorable.

I have received generous financial support from various sources. I would like to

acknowledge the Population Studies Center pre-doctoral traineeship from the National

Institutes of Aging and the Rackham Merit Fellowship from the Horace H. Rackham

School of Graduate Studies for their multiple years of funding. I would also like to thank

Drs. Arline Geronimus and John Bound for providing summer funding.

My family, Sung Hyon and Okey Ro, Michael Connolly and Christina Ro-

Connolly, have been enthusiastic cheerleaders and my strongest supporters. This

dissertation is for them.

Finally, my husband Fernando Rodriguez - my best friend and partner in every

sense of the word. I could not have done it without him.

i n

TABLE OF CONTENTS

Acknowledgements ii List of Tables v List of Figures vii List of Appendices viii

Chapter 1 1 References 11

Chapter 2 Critical Literature Review 13 Introduction 13 Asian Immigrant Health Trajectories 14 Acculturation and Health Trajectories 20 New Framework for Understanding Asian Immigrant Integration 27 Different Integration Experiences 52 Conclusion 72 References 74

Chapter 3 - Empirical Paper 1 85 Introduction 85 Aims and Hypotheses 92 Methods 94 Results 104 Discussion 108 References 120

Chapter 4 -Empirical Paper 2 124 Introduction 124 Aims and Hypotheses 128 Methods 129 Results 134 Discussion 141 References 160

Chapter 5 - Discussion 162

Appendix A 165 Appendix B 177 Appendix C 184 Appendix D 187 Appendix E 194

LIST OF TABLES

Table 2-1. Contexts of Reception and Influences on Integration Processes 53

Table 3-1. Historical Cohorts and Corresponding Year of Entry Cohorts 98

Table 3-2. Weighting Example for NHIS Survey Year 2002, 5-9 years of U.S. Residence 101

Table 3-3. Asian Sample Sizes, by Year of Entry Cohort and Survey Years 114

Table 3-4. Sample Characteristics by Cohort 115

Table 3-5. Prevalence of Health Outcomes for Cohort/Duration Groups, Matched by Age and Gender to US Born Asians 116

Table 3-6. Cohort Differences in Sociodemographic Characteristics 117

Table 3-7. Cohort Differences and Duration Differences in Physical Health Outcomes 118

Table 3-8. Duration Effects within Cohorts 119

Table 4-1. Sample Characteristics 147

Table 4-2. Mean Prevalence of Disability by Wage/Salary and Duration, Age

Standardized 149

Table 4-3. Regression Results for Aggregated Asian Sample 151

Table A-l. Cohort Weighting for NHIS Survey Year 1995 166

Table A-2. Cohort Weighting for NHIS Survey Year 1996 167

Table A-3. Cohort Weighting for NHIS Survey Year 1997 168

Table A-4. Cohort Weighting for NHIS Survey Year 1998 169

Table A-5. Cohort Weighting for NHIS Survey Year 1999 170

Table A-6. Cohort Weighting for NHIS Survey Year 2000 171

Table A-7. Cohort Weighting for NHIS Survey Year 2001 172

Table A-8. Cohort Weighting for NHIS Survey Year 2002 173

Table A-9. Cohort Weighting for NHIS Survey Year 2003 174

Table A-10. Cohort Weighting for NHIS Survey Year 2004 175

Table A-l 1. Cohort Weighting for NHIS Survey Year 2005 176

Table B-1. Cohort Differences in Sociodemographic Characteristics, Fully Adjusted Model 178

Table B-2. Cohort and Duration Differences in Physical Health Outcomes, Fully

Adjusted Model 180

Table B-3. Duration Effects within Cohorts, Fully Adjusted Model 181

Table C-1. Mean Prevalence of Disability by Per Capita HH Inc and Duration, Age

Standardized 185

Table E-1. Regression Results for Aggregated Asian Sample, Fully Adjusted Models 195

Table E-2. Chinese Regression Results, Fully Adjusted Models 197

Table E-3. Japanese Regression Results, Fully Adjusted Models 199

Table E-4. Filipino Regression Results, Fully Adjusted Models 201

Table E-5. Asian Indian Regression Results, Fully Adjusted Models 203

Table E-6. Korean Regression Results, Fully Adjusted Models 205

Table E-7. Vietnamese Regression Results Fully Adjusted Models 207

LIST OF FIGURES

Figure 4-1. Aggregated Asians Wage/Salary and Duration Interaction 152

Figure 4-2. Aggregated Asians Per Capita Household Income and Duration Interaction 153

Figure 4-3. Filipino Wage/Salary and Duration Interaction 154

Figure 4-4. Asian Indian Wage/Salary and Duration Interaction 155

Figure 4-5. Chinese Per Capita Household Income and Duration Interaction 156

Figure 4-6. Filipino Per Capita Household Income and Duration Interaction 157

Figure 4-7. Asian Indian Per Capita Household Income and Duration Interaction 158

Figure 4-8. Vietnamese Per Capita Household Income and Duration Interaction 159

Figure D-l Chinese Economic Measures and Disability by Duration 188

Figure D-2. Japanese Economic Measures and Disability by Duration 189

Figure D-3. Filipino Economic Measures and Disability by Duration 190

Figure D-4. Asian Indian Economic Measures and Disability by Duration 191

Figure D-5. Korean Economic Measures and Disability by Duration 192

Figure D-6. Vietnamese Economic Measures and Disability by Duration 193

LIST OF APPENDICES

Appendix A 165

NHIS Cohort Weighting Scheme for Chapter 3

Appendix B 177

Full Regression Models for Chapter 3

Appendix C 184

Age Standardized Disability Tables by Per Capital Household Income for Chapter 4

Appendix D 187

Graphs of Predicted Disability Prevalence and Economic Measures by Asian Ethnicity for Chapter 4

Appendix E 194

Full Regression Models for Chapter 4

CHAPTER 1

Introduction

The Asian immigrant population in the United States has grown considerably

within the past fifty years. Between 1970 and 2000, the number of immigrants from Asia

increased on average 4% per year. This steady immigrant flow has fueled the growth of

the overall Asian American population; between 2000 and 2010, Asians were the fastest

growing racial/ethnic group in the United States with a 43.3% percentage increase that

outpaced even Hispanics (Humes, Jones, & Ramirez, 2011).

As the Asian American population composes a more substantial segment of

American society, the importance of identifying forces driving their overall health

patterns becomes more significant as well. At first glance, the health status of Asians

appear very positive, as their health outcomes are very similar, or even superior to,

native-born Whites. Compared to other racial groups, Asians have lower prevalence of

chronic diseases, the longest life expectancy and favorable maternal and child outcomes

(NCHS, 2008; OMH, 2009). Their positive health patterns are statistically accounted for

by behavioral factors, such as a lower likelihood of smoking and drinking, or higher

economic resources (Rogers, Hummer, & Nam, 2000). Behaviors and resources may

empirically explain the Asian health advantage, but their prominence in the public health

literature obscures a full account of health influences arising from contextual and

environment factors.

A favorable health profile does not preclude Asian Americans from the negative

health consequences of a socially stratified society. As with other racial groups, Asians

have undergone social classifications that are predicated on the racial hierarchy that

creates and enforces social order. Racial categorization is a marker of the inequalities in

power and status, as American society has historically organized access to goods and

resources along racial lines (Smedley & Smedley, 2005). The eventual health impacts of

racialization can operate through racial residential segregation, experiences of racial

discrimination or inequitable medical access and care. These stressors and barriers can

erode health advantages as Asian immigrants interact with American society.

Asian Americans occupy a unique space within the racial hierarchy. One on

hand, they have long experienced negative social consequences of racialization. The

earliest Asian immigrants in the late 19th century were subject to segregation, racial

violence and eventual legal exclusion from the United States. The historical nadir of

their marginalization was the internment of Japanese Americans during World War II.

Current views of Asian Americans are less overtly negative, but are still informed by

stereotypes that depict Asians as un-American, foreign and untrustworthy. These views

are further fueled by national anxiety over the economic rise of Asian countries, first

Japan, then China and India.

On the other hand, Asians have access to educational and material resources that

are similar to those of the White American majority. The college graduation rates for

many Asian ethnic groups are well above the national average, as are the median

household incomes and percent in professional occupations (Census, 2011; Crissey,

2009). This duality forces us to acknowledge that the health impacts of racial

classification cannot be approximated by socioeconomic (SES) measures. Instead, we

must explicitly consider how the social, economic and political forces that have

determined a group's content, importance and meaning (Omi & Winant, 1994), uniquely

impact health.

Migration and integration are the central pieces by which we understand Asian

Americans' place in the American social hierarchy. Migration has established their

favorable population-level SES characteristics, but has also formed their status as

outsiders. Salient forces of migration and integration include immigration policy, labor

market conditions and coethnic communities. These forces create the context in which

Asian immigrants must operate in the United States, as well as underlie the population's

characteristics. For example, immigration policy plays an important role in

understanding the current demographic and socioeconomic features of Asian Americans,

as it establishes definitive criteria for who can enter the United States (Park & Park,

2005). Accordingly, different eras of immigration policy have affected the characteristics

of the Asian population by setting various occupational or educational requirements.

Likewise, the occupational opportunities immigrants encounter in the labor market can

impact their subsequent socioeconomic status and available resources. Such a structural

analysis can expand our understanding of health production to include larger contextual

factors.

In this dissertation, I examine the roles of migration and integration in

influencing the health trajectories of Asian immigrants. Health trajectories refer to the

changing health status of Asian immigrants as they spend more time in the United States.

They are of particular interest to public health researchers, as they provide insight into the

larger experiences of Asian immigrants in the United States and how they may affect

health. Currently, health trajectories are interpreted though a lifestyle and behavioral

framework that has shaped the majority of Asian American health literature. When we

apply a structural perspective, it widens our interpretive lens to create a more complex

picture of integration that considers several dimensions across which Asian immigrants

are being incorporated into American society. Specifically, I identify and test social

determinants of Asian immigrant health that originate from the historical and structural

forces that have surrounded their economic, social and cultural integration into the United

States.

My dissertation is arranged by the following chapters. Chapter 2 is a critical

review of the literature on health trajectories among Asian immigrants. Chapters 3 and 4

are my two empirical papers in which I test two aspects of health trajectories.

In Chapter 2,1 review the current knowledge of health trajectories among Asian

immigrants. I then discuss acculturation theory, which is the most prevalent interpretation

of health trajectories. Acculturation theory assumes that as immigrants spend more time

in the United States, they adopt Western behaviors while simultaneously shedding their

ethnic lifestyles; worsening health is a consequence of poor diets and other harmful

lifestyle changes. I argue that the lifestyle and behavioral assumptions inherent in the

acculturation theory exclude explicit consideration of contextual factors that shape the

larger experiences of Asian immigrants in the United States.

I then present a model of understanding health trajectories that incorporates social

determinants of health that arise from structural forces. This model, called Contexts of

Disease, begins with a discussion of several ways in which Asian immigrants are being

incorporated into American society: economic, social and cultural. Economic integration

involves their employment and occupational trajectories. Social integration is

immigrants' incorporation into American social structure that is racially stratified.

Cultural integration involves immigrants' changing cultural identity, which is expressed

in one's cultural practices, values and identification. These aspects of integration

produce health-related stressors and coping mechanisms that impact health outcomes.

For example, economic integration can offer material resources that offer better access to

medical care, social integration can produce stressful experiences of racial discrimination

and cultural integration can develop co-ethnic social networks.

These processes can interact in a number of ways, but I detail two examples of

contexts of disease: one is the intersection of economic and social integration and the

other is the intersection of social and cultural integration. I end my paper with a

discussion of how economic, social and cultural integration processes and their related

health outcomes can vary across different groups of Asian immigrants. I discuss

potential differences among different entry cohorts, Asian ethnicities, and gender.

The following two chapters empirically test aspects of my framework. Chapter 3

examines how groups of Asian immigrants entering the United States in different cohorts

may have unique health trajectories. I use Portes and Zhou's segmented assimilation

theory as the theoretical framework for this paper. They suggest that an immigrant's

integration depends largely on the circumstances that surround migration: pre-migration

characteristics and features of the receiving country, such as domestic policies, societal

reception and co-ethnic communities. Likewise, the health resources and detriments that

immigrants accrue from the various dimensions of integration will vary according to such

contexts of reception.

Between 1965 and 2000, Asian immigration was marked by distinct periods that

were impacted by certain immigration policies and had specific societal reception and

varying levels of co-ethnic support. I hypothesize that cohorts entering under different

periods would have demographic and health profiles that reflect the circumstances of

entry. For example, more recent cohorts would have better educational status and

baseline health because of restrictive immigration policies that favored the highly-skilled.

This selectivity could extend to health, as high educational attainment and migration

involves fitter and healthier individuals. I further hypothesize that immigrants entering

under separate periods would have unique health trajectories, in other words, that the

effect of duration would vary across cohorts.

I use the 1995-2005 waves of the National Health Interview Survey as the

primary analytic dataset for this paper. The NHIS is a repeated cross-sectional survey

with a nationally representative sample; this design enables me to create cohorts and

follow them through the survey waves. This quasi-cohort analysis provides a unique way

to examine both cohort and duration effects simultaneously in the same sample. My

analysis includes three physical health outcomes: disability, fair/poor self rated health and

obesity based on BMI.

Chapter 4 examines one of the contexts of disease examples I detail in my critical

literature review, the intersection of economic and social integration. Economics

research has found that immigrants earn more with increasing duration in the United

States. Economic assumptions about SES as a Fundamental Cause of Disease would

suggest that these rising material resources would translate into improving health

trajectories for longer-term immigrants, as high socioeconomic status (SES) can provide

better health care access, reduce one's exposure to health risks or facilitate one's

residence into a better neighborhood. This viewpoint does not consider potential

stressors that emerge from Asian immigrants' social integration, such as racial

discrimination or barriers to upward mobility, such the glass ceiling. When we consider

social integration alongside economic integration, health trajectories are better

understood within a socio-ecological stress and coping framework, in which the stressors

and related resources arise from these dimensions of integration. While Asian

immigrants may be earning higher incomes with longer residence, they are also exposed

to stressors that originate from their marginalized status as non-White, foreign born. I

hypothesize that because of regular and continued engagement in the stress and coping

process, longer term immigrants will display the weakest relationship between income

and physical health measures. I also hypothesize that this pattern will differ across Asian

ethnicities, as the unique immigration histories and co-ethnic resources will differentially

impact the stress and coping process.

I use the 2005-2007 waves of the American Community Survey (ACS) to

conduct my analyses. This survey only includes one measure of physical health,

disability status. This measure assesses one's sensory, physical, cognitive, self-care,

mobility and work limitations.

Instead of focusing on a single disease outcome in my empirical papers, I used

measures of general physical health. These measures align with the World Health

Organization (WHO) definition of health as a "state of complete physical, emotional and

social well-being, and not merely the absence of disease or infirmity," (WHO, 1946).

Because I suggest that structural factors impact the entire health profile of Asian

immigrants, my measures are accordingly broad enough to include a range of possible

illnesses that can reflect the overall state of population health. I propose three measures to

assess general physical health: self-rated health, disability, and body mass index (BMI).

Self-rated health - This is commonly a single-item measure that asks respondents

to rate their overall health as excellent, very good, good, fair or poor. The measure

assesses health across a broad range of illnesses and is understood as "a summary

statement about the way in which numerous aspects of health, both subjective and

objective, are combined within the perceptual framework of the individual respondent,"

(Tissue, 1972). Self-rated health has been found to be a predictor of mortality, health

utilization behaviors, and disability (Benyamini & Idler, 1999; Ferraro, Farmer, &

Wybraniec, 1997; Idler & Benyamini, 1997; Idler & Kasl, 1995).

Disability - This outcome refers to limitations in tasks and roles that are caused by

one or more health conditions (Pope & Tarlov, 1991). It is a useful measure of overall

health because it encompasses specific health problems (disease or condition, a missing

extremity or organ, or any type of impairment), as well as disorders not always thought of

as health-related problems (i.e., alcoholism, drug dependency or reaction, senility,

depression, retardation) (IHIS, 2010). Disability is detrimental to one's quality of life

and is predictive of mortality (Scott, Macera, Cornman, & Sharpe, 1997).

Obesity - This is a measure of body composition that is a strong risk factor for

chronic diseases, including Type II diabetes, gallbladder disease, high blood pressure and

osteoarthritis (Must et al., 1999). While the accuracy of self-reported height and weight

varies by sociodemographic characteristics (namely, age, ethnicity and gender)

(Engstrom, Paterson, Doherty, Trabulsi, & Speer, 2003), the limited work on Asian

Americans suggests that this will not impact their BMI classification (Brunner Huber,

2007). Including BMI will also provide a useful counter point to current interpretations

of health trajectories. Overweight/obesity or increasing BMI are the most-often studied

health outcomes in relation to a duration effect, most likely because of the close

connection to diet and exercise, two central factors in the lifestyle and behavior

framework. If my findings lend support to the role of contextual factors, I can offer

alternative interpretations of changing BMI.

Together, my three dissertation papers narrate a story about the structural

influences on Asian immigrant health trajectories. In doing so, I hope to demonstrate

how health can be produced from historical and contextual factors that are not typically

associated with physical health outcomes. This will expand our understanding of health

as a state of well-being, as well as the interconnected roles of policy, community and

individuals in shaping it.

References

Benyamini, Y., & Idler, E. L. (1999). Community studies reporting association between self-rated health and mortality - Additional studies, 1995 to 1998. Research on Aging, 21(3), 392-401.

Brunner Huber, L. R. (2007). Validity of self-reported height and weight in women of reproductive age. Maternal and Child Health, 11, 137-144.

Census. (2011). Money Income of Households—Median Income by Race and Hispanic Origin in Current and Constant (2008) Dollars. National Statistical Abstract: Current Population Survey, Census Bureau

Crissey, S. R. (2009). Educational Attainment in the United States: 2007. Washington, DC: Census Bureau.

Engstrom, J. L., Paterson, S. A., Doherty, A., Trabulsi, M., & Speer, K. L. (2003). Accuracy of self-reported height and weight in women: an integrative review of the literature. Journal of Midwifery & Women's Health, 48(5), 338-345.

Ferraro, K. F., Farmer, M. M., & Wybraniec, J. A. (1997). Health trajectories: Long-term dynamics among Black and White adults. Journal of Health and Social Behavior, 38(1), 38-54.

Humes, K. R., Jones, N. A., & Ramirez, R. R. (2011). Overview of Race and Hispanic Origin: 2010. Washington DC: Census Bureau.

Idler, E. L., & Benyamini, Y. (1997). Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior, 38(\), 21-37.

Idler, E. L., & Kasl, S. V. (1995). Self-Ratings of Health - Do They Also Predict Change in Functional Ability. Journals of Gerontology Series B-Psychological Sciences and Social Sciences, 50(6), S344-S353.

IHIS. (2010). FLGOOUT: How difficult to go out to events without special equipment. NHIS Codebook, 2010, from http://www.ihis.us/ihis-action/variables/FLGOOUT

Must, A., Spadano, J., Coakley, E. H., Field, A. E., Colditz, G., & Dietz, W. H. (1999). The Disease Burden Associated With Overweight and Obesity. JAMA, 282(16), 1523-1529.

NCHS. (2008). Health, United States, 2008. Hyattsville, MD: National Center for Health Statistics.

OMH. (2009). Asian American/Pacific Islander Profile. Retrieved October 16, 2009, from http://www.omhrc.gov/tcmplates/browse.aspx?lvl=2&lvlid=53

Omi, M., & Winant, H. (1994). Racial Formation in the United States from the 1960s to the 1990s. New York: Routledge.

Pope, A. M. D., & Tarlov, A. (1991). Disability in America: Towards a National Agenda for Prevention. Washington, DC: National Academies Press.

Rogers, R. G., Hummer, R. A., & Nam, C. (2000). Living and Dying in the USA: Behavioral, Health, and Social Differentials of Adult Mortality. San Diego, CA: Harcourt Press.

http://www.ihis.us/ihis-action/variables/FLGOOUT

http://www.omhrc.gov/tcmplates/browse.aspx?lvl=2&lvlid=53

Scott, W. K., Macera, C. A., Cornman, C. B., & Sharpe, P. A. (1997). Functional health status as a predictor of mortality in men and women over 65. Journal of Clinical Epidemiology, 50(3), 291-296.

Smedley, A., & Smedley, B. D. (2005). Race as biology is. fiction, racism as a social problem is real - Anthropological and historical perspectives on the social construction of race. American Psychologist, 60(\), 16-26.

Tissue, T. (1972). Another Look At Self-rated Health Among the Elderly. Journal of Gerontology, 27(1), 91-94.

WHO. (1946). Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

CHAPTER 2 CRITICAL LITERATURE REVIEW

Introduction

Immigration has historically been one of the main political and social issues in the

United States. Within the past 40 years, however, the country has seen a dramatic

increase in immigration that is unlike any previous era. Accordingly, there is a growing

body of literature on the health status and health needs of these contemporary immigrants

(Kandula, Kersey, & Lurie, 2004). Of particular interest to public health researchers are

immigrants' health trajectories once they have settled in the United States, as these

patterns represent the health consequences of integration processes. Acculturation has

dominated the public health literature as the primary influence on health trajectories. The

health impacts of acculturative processes have been largely conceptualized through

individual-level behavioral changes that represent the extent to which immigrants adopt

unhealthy "Western" lifestyles and shed ethnic resources that are thought to be health-

protective, such as social networks and ethnic diets (Abraido-Lanza, Armbrister, Florez,

& Aguirre, 2006; Salant & Lauderdale, 2003).

The emphasis on individual-level change can diminish the significance of other

dimensions of integration. Immigrants are not only changing their behavior, but are

becoming incorporated into American society across many levels. Social, economic and

cultural aspects of integration have been examined in other disciplines, but their health

impacts have not been widely explored. These forms of integration may also contribute

to a more complete understanding of immigrant health patterns, as they better incorporate

structural factors that influence all aspects of incorporation into the United States.

For Asian Americans, factors that influence immigrant health are critical to

understanding overall population-level health patterns, as the population is primarily

foreign-born. In this critical literature review, I will review our current knowledge on

Asian immigrant health trajectories and discuss their popular interpretations. I will then

present new framework for understanding population-level Asian immigrant health

trajectories called Contexts of Disease that is guided by principles of social determinants

of health. A social determinants perspective considers key determinants of health status

to be cultural, social and economic factors, over such individual-level factors such as

medical care inputs or utilization (Dunn & Dyck, 2000). This framework augments our

understanding by casting a wider net for identifying health influences to include

economic, social and cultural dimensions of integration processes that have not

previously been considered in health trajectories. My discussion of the framework ends

with a consideration of how contexts of disease can vary across groups with different

contexts of reception into the United States.

Asian Immigrant Health Trajectories

Much of our current knowledge on immigrant health trajectories comes from the

body of literature that examines the relationship between duration of residence in the

United States and health. This literature provides a descriptive overview of Asian

immigrants' health patterns as they spend more time in the United States. Duration

represents processes of integration that progress with longer residence in the United

States. There are several kinds of health trajectories we can expect: immigrant health

profiles can improve with increased residence in the United States, such that those with

longer duration have lower disease prevalence than more recent immigrants; they can

worsen such that those with longer duration have higher disease prevalence than recent

immigrants; or they can remain relatively stable, controlling for other factors.

This section examines 43 quantitative studies of Asian immigrants that assess the

effect of years in the United States on health outcomes. The studies were located through

a key word search using "Asian", "immigrant", "duration" and "health" on Pubmed and

Google Scholar journal databases. Additional studies were identified through a citation

search of frequently cited papers duration and health among Asians (Cho & Hummer,

2001; Frisbie, Cho, & Hummer, 2001).

Findings from the Current Literature

Notably, there is some evidence for changing health status with increased

residence in some health outcomes, but not others. There is little evidence that mental

health, as measured by symptoms of psychological distress, depressive symptoms, or

mood or anxiety disorders, worsens with longer U.S. residence (Dey & Wilson Lucas,

2006; Diwan, Jonnalagadda, & Gupta, 2004; W. H. Kuo, 1976; Marshall, Schell, Elliott,

Berthold, & Chun, 2005; Mossakowski, 2007; Zhang & Ta, 2009).

On the other hand, physical health outcomes, such as BMI, number of chronic

conditions, self-rated health and disability, appear to show some evidence of a duration

effect in aggregated Asian populations, such that there is a higher likelihood of worsening

health across these measures with longer US residence (de Castro, Gee, & Takeuchi,

2008b; Dey & Wilson Lucas, 2006; Frisbie et al., 2001; Goel, McCarthy, Phillips, &

Wee, 2004; Lauderdale & Rathouz, 2000; Y. Park, Neckerman, Quinn, Weiss, & Rundle,

2008; Roshania, Venkat Narayan, & Oza-Frank, 2008; Sanchez-Vaznaugh, Kawachi,

Subramanian, Sanchez, & Acevedo-Garcia, 2008; Singh & Miller, 2004; Singh &

Siahpush, 2002; Zhang & Ta, 2009). Even within a single physical health outcome,

however, support for the trend varies across different measures. For example, in studies

of disability in nationally-representative samples of aggregated Asians, the negative

duration effect is seen in bed days and work disability (Dey & Wilson Lucas, 2006;

Frisbie et al., 2001; Ro & Gee, 2009; Singh & Siahpush, 2002), but not consistently in

mobility, activity and self-care limitations (Frisbie et al., 2001; Mutchler, Prakash, &

Burr, 2007; Ro & Gee, 2009; Singh & Miller, 2004). The majority of these studies were

conducted with large-scale, nationally representative samples, suggesting that the

heterogeneity is not due to sampling biases or methodological differences, but because of

underlying variation in the duration effect. While this variation does not itself cast doubt

on acculturation, the inconsistencies suggest complexity within duration's health effect.

Even within the relatively robust physical health patterns, health trajectories

appear to vary by sample and sociodemographic characteristics. While the majority of

physical health studies were conducted on nationally-representative samples of the

aggregated Asian population, some studies used non-random community-based samples

of specific Asian ethnicities and did not find evidence of worsening health with increased

time in the United States. For example, poorer self-rated health was associated with

longer duration in a nationally-representative sample of aggregated Asians (Frisbie et al.,

2001), yet this relationship was not present among a sample of Korean older adults

affiliated with Florida-area churches and senior centers (Jang, Kim, & Chiriboga, 2005).

The differences across populations can arise from the weaker methodology of the smaller

non-random samples, but can also be suggestive of heterogeneity in integration

experiences across Asian ethnicity, ages, age at migration and gender.

Age and gender are two such characteristics that have been shown to moderate

health trajectories in nationally-representative datasets. Lauderdale & Rathouz (2000)

found that the effect of duration on the odds of obesity and overweight differed across

men and women; women had higher odds for more substantial weight gain. Increasing

years in the United States was associated with a higher odds for overweight among men

and obesity among women. Two studies found a moderating effect of current age on the

relationship between duration and disability status; a relationship between longer duration

and poorer disability outcomes was more pronounced among younger immigrants (Ro &

Gee, 2009), but did not exist among elderly Asian immigrants (Mutchler et al., 2007).

Current age may mitigate the differences in health between elderly short-term and longer-

term immigrants, as the natural aging process may overtake any health benefit of a

shorter duration.

Years in the United States provide a broad view of health trajectories, yet they do

not offer insight into actual health risks or health-related processes that are occurring with

increased residence. Health behaviors are one potential mechanism that can lead to

changing health with duration, but they have not been widely researched. Fewer studies

still consider these changing health patterns with a health outcome. The few available

studies suggest longer term-immigrants consume fewer vegetables, yet exercise more and

smoke more or less, depending on gender. The methodological limitations of these

studies weaken their conclusions; the majority of these studies used non-random samples

with small, unique populations (Misra, Patel, Davies, & Russo, 2000; Parikh, Fahs,

Shelley, & Yemeni, 2009; Taylor et al., 2007). For example, one study sampled

respondents from a member directory of a national organization of Punjabi Indians.

However, the few studies that have used nationally-representative datasets confirm some

of the findings from smaller studies (Kandula & Lauderdale, 2005). The health behaviors

that appear to be related to increased duration (i.e., more exercise, yet unhealthier diet)

oppose one another, leaving little clarity about the nature of the actual health outcomes

that can be predicated on these behaviors.

Implications of Findings

Patterns in the published literature expose the many gaps in our understanding of

health trajectories and health-related integration processes among Asian immigrants. Our

comprehension of the nature of health trajectories may be sparse, but this review also

points to future directions.

First, health trajectory patterns vary across health outcomes. While there does not

appear to be a significant relationship between mental health and duration, duration is

most robustly associated with physical health outcomes in the empirical literature,

particularly BMI, chronic conditions and self-rated health. Although there were

differences across these general physical health outcomes in the preliminary data

analyses, they may still be a more useful starting point for investigating a new framework

over specific disease outcomes, as health behavior mechanisms or other more proximal

health risk factors have not yet been convincingly identified. There some is evidence of

changing health behaviors with increased years of U.S. residence, yet these studies have

some methodological limitations and interpretation weaknesses.

Further, there is no one clear health trajectory pattern, as the relationship between

duration and health varies widely in different analytic scenarios across health outcomes,

groups and diverse demographic characteristics. If we understand years in the United

States to represent processes of integration that impact health trajectories, it seems that

Asian immigrants have a complex picture of integration. If acculturation was indeed the

chief process, we would expect to see negative relationship, whereby increasing duration

is associated with worsening health. Instead, the literature implies that duration can

represent other processes that may have different health impacts. Ascribing duration-

associated health variation to acculturation alone overlooks these potentially important

processes. Future research should consider the role of these alternative pathways and

better elucidate their role in immigrant integration and subsequent health patterns.

Finally, there is heterogeneity in the duration effect within the population of

Asian immigrants. In the empirical literature, age and gender appear to moderate the

effect. Younger immigrants and men display a more positive relationship between

duration and health outcomes compared to older immigrants and women. Another

important source of heterogeneity is across Asian ethnic groups. While the absence of an

obvious duration pattern among the different Asian ethnic groups could be due to smaller

sample sizes that reduce statistical power, it is also possible that ethnic differences

encompass influential differences in immigration history, diet, regional concentration,

labor market patterns and sociodeomographic characteristics. Future research should

consider whether such can factors impact health trajectories.

Acculturation and Health Trajectories

Acculturation is the most prevalent explanation for changing health trajectories

associated with integration, yet it falls short in elucidating the complexity we see in the

literature. First, it assumes that all groups experience the same advancement towards

Anglo-conformity and does not consider variations from this integration process.

Secondly, pathways between acculturation and health outcomes have been limited to

individual-level behaviors. Finally, its definition and measurement throughout the

literature have been vague, leaving few clear health-related mechanisms. In this section,

I review the literature on acculturation and health and offer critiques of acculturation

theory that underscore the need for a more comprehensive understanding of Asian

immigrant integration and subsequent health outcomes.

Acculturation is formally defined as a process of change that two societies and

their respective individuals undergo when they come into contact (Moyerman & Forman,

1992). Early definitions considered dynamic changes in both immigrants and the

receiving society. Robert Park (1928) was among the first social scientists to suggest that

migration was inevitably accompanied by social change. The migrant would be

"emancipated" from the social norms of his home society and eventually would "learn to

look upon the world in which he was born and bred with something of the detachment of

a stranger". With this new enlightenment, migrants would break down historical and

traditional bonds of their new countries and expedite a new social order. Out of this

conceptualization came one of the classic definitions of acculturation from Redfield,

Linton, and Herskovits (1936) who said it was a "phenomena which result when

individuals having different cultures come into first-hand continuous contact, with

subsequent changes in the original culture patterns of either or both groups".

Park's protegee, Milton Gordon (1964), identified three potential assimilation

outcomes: Anglo-Conformity, The Melting Pot and Cultural Pluralism. While Gordon

initially conceived a variety of possible outcomes, he came to assume that acculturation

primarily involved Anglo-Conformity, or change on the part of an immigrant group in the

direction of middle-class Anglo culture (Alba & Nee, 1997). His viewpoint heavily

influenced subsequent scholarship and Anglo-Conformity has become the prevalent

framework for acculturation as it is studied in social sciences today (Salant & Lauderdale,

2003).

Marmot and Syme (1976) were among the first to consider the health effects of

this process. They examined the role of acculturative factors in predicting rates of

coronary and heart disease (CHD) among Japanese Americans living in California. Their

work was preceded by a series of articles from the Ni-Hon-San Studies, a collaborative

study in Japan, Hawaii and California that documented a gradient of coronary heart

disease among Japanese men; men in Japan had the lowest rates, Japanese in Hawaii had

intermediate rates and Japanese in California had the highest. This gradient was not fully

explained by differences in behavioral risk factors, such as diet or smoking (Marmot et

al., 1975; Worth, Kato, Rhoads, Kagan, & Syme, 1975). Marmot and Syme hypothesized

that this gradient could be explained by the loss of protective Japanese cultural features

due to increasing acculturation.

In their sample of Japanese-American men, they measured acculturation in three

ways: culture of upbringing, cultural assimilation and social assimilation. They found

that each of the acculturation measures was associated with increasing prevalence of

CHD, net of dietary preferences, smoking and other CHD risk factors. Out of the

acculturative measures, culture of upbringing had the strongest effect on CHD; those

respondents reporting a more Japanese upbringing had lower odds for CHD. They

concluded that social and cultural factors play an important role on the etiology of CHD

and that the retention of non-Western cultural values may be protective.

Marmot and Syme's analysis was novel in its emphasis on the influence of social

and cultural factors, over and above typical physiological risk factors associated with

CHD (serum cholesterol levels, blood pressure, body weight). However, subsequent

scholarship has not expanded upon these early findings to improve our understanding of

the relationship between acculturation and health. As a result, many of the limitations of

this landmark study have become emblematic of the shortcomings of the larger field.

One limitation was their placement of Japanese and Western culture at two ends

of a continuum with immigrants invariably becoming more Westernized at the expense of

their Japanese cultural orientation. The complexity in the health trajectory empirical

literature casts doubt on this linear progression. Even within Marmot and Syme's study,

we see evidence of a complex picture of integration and health outcomes. They created

an acculturation typology by crossing culture of upbringing by social assimilation,

resulting in three categories: 1) traditional (traditional upbringing/no social assimilation),

2) intermediate (traditional upbringing/social assimilation, Western upbringing/no social

assimilation) and 3) non-traditional (Western upbringing/social assimilation) groups.

They found a gradient of CHD prevalence that progressively increased from traditional,

intermediate and non-traditional. However, their definition of acculturation may be

better exemplified by the intermediate group, as they experienced the highest degree of

cultural change as they moved from a traditional upbringing to social assimilation. The

prevalence of CHD for the intermediate group was lower than the non-traditional group,

however.

A related limitation was their assumption that much of the health impacts

emerged from behaviors that reflected immigrants' changing lifestyles. This lifestyle and

behavioral interpretation has become the standard way by which to understand

acculturation's health effects. A commonly cited definition in public health research

describes acculturation as "process whereby immigrant change their behavior and

attitudes towards those of the host society," (Rogler, Cortes, & Malgady, 1991). While

behaviors are certainly immediate health influences, this narrow view of acculturation is

problematic because it disregards contextual factors that shape the social and political

landscape that determine the kind of lifestyle and subsequent behaviors immigrants will

adopt.

Gordon's conceptualization of immigration was essentially an optimistic one; he

believed that immigrants would naturally progress through stages that would eventually

lead to assimilation. This suggests that acculturation is progressive; an individual begins

with cultural acculturation and ends with complete assimilation, the latter characterized

by the "absence of value and power conflict" with the host society (Hazuda, Stern, &

Haffner, 1988). There are some historical precedents to his theory, such as German,

Italian, and Irish immigrants who migrated to the United States in the late 19th century

and have become interwoven in American society (Alba & Nee, 1997). There is no

mention, however, of structural or social barriers that might impede this progression,

leading one to assume that as individuals adopt "American" ways of life and

understanding, they will seamlessly integrated into mainstream society.

Waters (1999) denies such a benign view of the social landscape and suggests that

immigrants are thrust into a racial hierarchy that has been forged through historical

struggle and maintained by enduring discrimination. In other words, we cannot separate

the immigrant experience from issues of race and power that dominate social hierarchies.

Likewise, Bhatia and Ram (2001) argue that unless we consider the existing class and

racial structures of the host society when considering acculturation, "we undervalue the

asymmetrical relations of power and the inequities and injustices faced by certain

immigrant groups as a result of their nationality, race or gender." Their arguments were

preceded by Shibutani and Kwan (1965), who argue that how a person is treated in a

society depends "not on what he is" but on the "manner in which he defined". In their

view, immigrant cultural change, as conceptualized by increasing acculturation, is

impeded by limitations that originate from the fundamental color line between Whites

and non-Whites.

As public health researchers move towards ecological understandings of health

that highlight the dynamic interplay between individuals and their social and physical

environments, the lifestyle and behavior framework that assumes progression towards

Anglo norms appears incomplete. Conflating health trajectories with acculturation

bolsters two assumptions about Asian immigration integration that promote Gordon's

simplistic acculturation process. First is the inevitability and linearity of acculturation.

This process is thought to operate at a linear pace that can be approximated in year

intervals and advances in a similar fashion across different Asian sub groups, ages and

genders. The second assumption is that Asian immigrant health (and any associated

changes) is largely a product of individual behaviors and cultural beliefs, keeping much

of the discussion of immigrant health at this level of understanding.

The field has grown considerably since Marmot and Syme's study was first

published. Hunt et al. (2004) document over a six-fold increase in the acculturation

literature on Medline in the thirty-year period between 1970 and 2000. The upsurge in

the literature has not demonstrated a convincing pattern between acculturation and health

or a common explanation of why it would affect health (Salant & Lauderdale, 2003).

The messiness of the acculturation and health literature can stem from the

ambiguity of the acculturation concept itself. While the concept has been part of the

national lexicon for nearly as long as the history of American immigration itself (Glazer,

1993), it remains notoriously vague and dynamic. The concept is rarely articulated

clearly in empirical work and is presumed to be implicitly and commonly understood. As

Hunt et al. (2004, p. 974) state in their critical review of acculturation in Hispanic health

research, "Fuller delineation of the concept is left to a presumed understanding of what

constitutes a culture, which traits should be ascribed to the 'mainstream' versus the ethnic

culture, and what adapting to a new cultural system might entail". Similar critiques have

been leveled at the construct in Asian immigrant health research (Salant & Lauderdale,

2003).

The wide range of proxy measures for acculturation reflects the field's lack of

definitional convergence; the concept has been measured as language proficiency, social

contacts or relationships, nativity, duration of residence in new country, cultural

participation and "western lifestyle" (Salant & Lauderdale, 2003). Each of these

measures is assumed to be a mechanism by which acculturation affects health, but the

array of measures suggests that there are a host of mechanisms that acculturation initiates,

some of which have contradictory hypotheses on health outcomes. On one hand,

increased acculturation is thought to lead to better health outcomes, as immigrants

consume healthier foods, exercise more and experience fewer barriers to care with

increased familiarity of the United States. Conversely, acculturation is also hypothesized

to lead to worse health outcomes, as immigrants experience more social or health

disadvantages with greater integration into the United States. Further, with increasing

acculturation, they also adopt unhealthy habits and lifestyles that are associated with poor

health in American society (Abraido-Lanza et al., 2006; Takeuchi, Hong, Gile, &

Alegria, 2007). The range of measures and potential theoretical pathways produce

different results, leaving few robust theories about the relationship of acculturation on

health.

Assuming that acculturation drives Asian immigrant health trajectories without

considering the drawbacks in the acculturation literature obscures our identification of the

specific integration processes that impact immigrant health. Given the variety of

acculturation measures, we do not gain any specific knowledge of specific health-related

processes when we simply attribute any changes in immigrant health to "acculturation" or

"changing lifestyles". It is unclear whether more years in the United States assumes that

respondents have changed their diets, acquired better language skills, achieved social

mobility, shed ethnic identity or adopted other "westernized" lifestyle changes. In this

way, we perpetuate the pervasiveness of acculturation without adding any specific

knowledge of heath-risks or resources immigrants accrue.

New Framework for Understanding Asian Immigrant Integration

In light of the shortcomings of the extant literature, I develop a new social

determinants of health framework of understanding Asian immigrant health trajectories

that stands in contrast to popular lifestyle and behavioral frameworks that are closely tied

to acculturation theory. This new framework, called Contexts of Disease, assumes that

Asian immigrants' health trajectories are produced within the structural constraints of

their place in the new American society, their interactions with non-immigrants, their

labor experiences and their developing ethnic identity. These forces manufacture health

risks, buffers and resources that are jointly experienced by Asian immigrants to impact

their overall health patterns.

The framework begins with the identification of several dimensions across which

Asian immigrants experience integration. The idea that integration can occur across

several dimensions is not new; Gordon (1964) identified seven dimensions of

assimilation: cultural/behavioral, structural, marital, identificational, attitude receptional,

behavior receptional, and civic. While his original typology has fallen out of favor (Alba

& Nee, 1997), identifying multiple components of integration considers specific health-

related resources and risks across multiple aspects of the immigrant experience. I

identify three dimensions of integration that may be related to health outcomes among

Asian immigrants: economic, social and cultural. Economic integration involves their

employment and occupational trajectories. Social integration is immigrants'

incorporation into American social structure that is racially stratified. Cultural

integration involves immigrants' changing cultural identity, which is expressed in one's

cultural practices, values and identification.

I explore the health consequences of these processes through a concept called

Contexts of Disease, which are formed from the intersecting resources and stressors from

each form of integration. These contexts of disease arise from social-ecological theories

of health, which suggest that proximal health influences arise from individual's

adaptation to their surroundings. I also use stress and coping theories to explain how

resources and barriers from integration processes can produce health outcomes. I provide

two examples for Asian immigrants and discuss their potential health outcomes.

I end my framework with a discussion of how integration experiences can differ

across groups of immigrants with alternative characteristics. I use Portes and Zhou's

segmented assimilation as a guiding theory to explain why different groups experience

alternate integration. This theory suggests that contexts of reception, such as policies of

the host government, the values and prejudices of the receiving society, and the

characteristics of the coethnic community, determine the kinds of integration experiences

immigrants will have. For Asian immigrants, this might be best illustrated in different

year of entry cohorts, as these cohorts entered under unique U.S. immigration policy eras,

geopolitical circumstances and societal receptions. Other potentially salient group

differences are Asian ethnicity and gender.

Dimensions of Integration

Economic Integration

The economic integration of immigrants considers their economic and work

trajectories as they spend more time in the United States. The economic integration of

immigrants has been considerably researched in the economics literature. Among the

first researchers to consider immigrants' wage earnings over time was Barry Chiswick

(1978). Using the 1970 Census, he found that the foreign-born appeared to have a

particular pattern of wage earnings with increasing duration in the United States. While

they experienced an initial decline in wage earnings in the first five years after

immigrating, over time, their wages increased, eventually surpassing the native born in

11 or 12 years.

Chiswick's work combined all immigrants to the U.S., but his patterns have been

replicated in studies of individual Asian ethnic groups as well. Zhou and Kamo used the

1980 Census to examine wage assimilation, analyzing the Chinese and Japanese groups

only. They found that Chinese immigrants had similar wage assimilation patterns as

Chiswick's model, but the Japanese immigrants did not. The explained the difference by

employment circumstances; many Japanese immigrants were for Japanese companies

abroad, making their wages high upon entry to the United States. The Chinese, in the

other hand, represented a common model of wage assimilation found among immigrants

(Zhou & Kamo, 1994). More recently, Akresh found support for Chiswick's model of

wage assimilation among all immigrants in the baseline survey of the New Immigrant

Survey (NIS), but did not stratify Asian immigrants (2007).

Some have called Chiswick's analysis and others that have used similar methods

into question, primarily due to their use of cross-sectional data to infer a time-related

pattern. Borjas, in particular, questioned Chiswick's findings after using a quasi-cohort

analysis to examine earnings patterns over time. Using the 1970 and 1980 censuses,

Borjas argued that the higher wages that longer-term immigrants enjoyed was due to

changes in the human capital and occupational skills between newer and older

immigrants (Borjas, 1985). In particular, newer immigrants (those entering the U.S. after

1970) did not experience the same levels of wage assimilation compared to their older

counterparts. Borjas suggested this was due to the declining "quality" of newer

immigrants.

Despite the heated debate, Borjas' quasi-cohort model still suggests wage increase

among immigrants, although not at the same speed as Chiswick's models. This was

especially the case for Asian immigrants, who still displayed substantial within-cohort

increases of up to 20% between the 1970 and 1980 censuses (Borjas, 1985). While

Borjas' analysis does not suggest complete wage assimilation with native-Whites, the

within-cohort increases that were commensurate with more years in the United States still

suggest an underlying process whereby immigrants increase their earnings with duration.

Others have adopted Borjas' quasi-cohort analysis and have found similar within-

cohort increases for Asian immigrants. Lalonde and Topel (1991) replicated his findings

in the 1980 Census and found that Asian immigrants experienced higher wages with

increasing duration in the United States, but did not reach convergence with native-born

Whites because of their substantial disadvantage immediately post-migration. Scheoni

(1997) found that a combined sample of Chinese, Korean and Japanese immigrants from

the 1970, 1980 and 1990 Censuses experienced substantial wage increases with duration,

eventually surpassing the wages of native-born Whites. Filipino also experienced wage

increases, but did not converge with native-born Whites. Central to this debate is

whether the foreign-born reach the same wage levels as Whites; what does not appear to

be in dispute is the increase in earnings over time.

One of the most commonly accepted explanations for wage assimilation is the

human capital argument (Akresh, 2007; Borjas, 1985; Chiswick, 1986). Human capital is

the set of intangible resources embedded within individuals that influence their future

income (Becker, 1962). Examples of human capital include education or on-the-job

training. According to this theory, the initial depression in earnings is due to a period of

resource-intensive investment in human capital that commences upon arrival to the

United States (Chiswick, 1986). During this period, immigrants are learning job skills

that are specific to the U.S. labor rnarket, such as English language skills, US-specific

professional skills, and professional contacts. Because of selective migration (such that

talented economic migrants are motivated to migrate for better occupational rewards in

the United State vis-a-vis their home countries) these immigrants possess an advantage in

the acquisition and application of human capital. As a result, immigrants can readily

transfer their newly acquired human capital characteristics towards securing better

occupational opportunities, which can be seen in their improved employment status,

occupation and wage.

Social Integration

The social integration of Asian immigrants involves their integration into a

racialized social hierarchy and the experiences and encounters associated therein. This

dimension of integration can range from immigrants' growing understanding of the

American social hierarchy (Waters, 1999), to their personal encounters and relationships

with members of the host society (Massey, 1981). Consistent across this range is the

role of national understandings of citizenship and migrants' rights in determining the

nature of these interactions (Ager & Strang, 2008). In this way, the social integration of

Asian immigrants must consider how the racial formation of Asians, that is, the "Asian

race", has developed into a salient social construct (Omi & Winant, 1994). Such

racialization constructs a distinct group that is attributed with certain value-laden

characteristics and stereotypes (Griffith, Johnson, Ellis, & Schulz, 2010).

As immigrants enter a new society, their identity as foreigners quickly intersects

with the social and racial hierarchy (Waters, 1999). Throughout history, immigrants have

been targets of hostility and suspicion, particularly during periods of economic hardship

or war. Immigrants from southern and Eastern Europe in the early 1900's were heavily

ostracized upon entering the United States (Alba & Nee, 2003). While obvious hostility

may not be as evident today, recent policies, such as Arizona's racial profiling law,

English-only statutes, limitations to immigrants' education and social services, and other

anti-immigrant policies, are underwritten by individuals and organizations with strong

nativist sentiments (Hing, 1997).

This racial hierarchy is complicated by the centrality of the immigrant story in

America's narrative of national history. The United States is routinely referred to as a

country of immigrants; this representation has given rise to enduring notions about the

nature of the United States. Geronimus and Thompson identify one such ideology, the

"American Creed", which proposes that success is available to individuals who are

committed to hard work and have the determination to succeed (2004). This 'American

Creed' ideology props up notions of personal responsibility and hard work, which are

underscored by the assumption of equality for those who try hard. Immigrants fully

embrace America as a land of opportunity (Espiritu, 1994), which motivates them

towards sacrifice and hard work.

For Asian immigrants, the juxtaposition of the American Creed ideal and the

racialized social hierarchy have been defining features in their racialization process; that

is, the creation of the Asian race as a salient construct with value-laden characteristics

that are used to classify and arrange social relationships. On the one hand, their

educational and occupational achievement is held as proof of the validity of the American

Creed. This 'model minority' stereotype is a widely-held view of Asian Americans that

emphasizes the role of cultural values in their perceived economic and academic success

(Suzuki, 1977). Although this stereotype can lead to favorable judgment by the White in-

group, it is simultaneously linked to ostracism by both Whites and non-Whites.

This phenomenon, called "racial triangulation", situates Asians between Whites

and non-Whites in the racial landscape. On one hand, Asians are viewed as competent

and hard-working, but their citizenship is continually in question. The continual use of

the "model minority" label maintains a degree of differentiation of Asians from Whites,

despite their similar educational and occupational achievements (Chang, Tugade, &

Asakawa, 2006). Further, Whites' valorization of Asians as a successful minority

relative to other racial groups fosters fractious inter-racial relationships, perpetuating a

zero-sum mentality whereby only a single racial group can operate successfully within

the American racial landscape (C. J. Kim, 1999). Asians are lauded for their dutiful

commitment, yet they are concurrently viewed as having few or no barriers to their

success, controlling too much economic power and working too hard to succeed. This

has resulted in inaccurate interpretations of Asian American "culture" (i.e., deferential,

authoritarian) and increased frictions among other racial groups who are simultaneously

vilified for their poor work ethic (C. J. Kim, 1999; Lee, 2000).

Research on attitudes towards Asian Americans provides a glimpse into the

complex racial landscape in which Asian immigrants must operate. While the model

minority trope implies that Asians have few experiences of discrimination and barriers to

integration, empirical work on Americans' views of Asians suggest otherwise. Lin and

colleagues found that Asians were viewed as having high competence but low sociability.

Among their sample, low sociability was the driving factor behind rejection of Asian

Americans, as measured by high scores on an anti-Asian stereotypes scale and social and

cultural avoidance of Asians (Lin, Kwan, Cheung, & Fiske, 2005). In the 2000 General

Social Surveys, Asians consistently had the most social distance with other racial groups.

Among White respondents, only 6% expressed compatibility with Asian groups,

compared to 15% for Blacks and 13% for Hispanics. Thirty-two percent of Whites

considered Asians the group they had the least in common with, the highest out of all

racial groups (Smith, 2001). Similarly, a Los Angeles Times poll found that over half of

Black and Latino respondents and over forty percent of Whites considered Asians

"inscrutable". Asians are not viewed as facing any racial discrimination; less than 20%

of all respondents in the Los Angeles Times poll thought that Asians faced any barriers to

equal opportunities. White respondents believed Asians had fewer barriers than did their

own fellow whites. In fact, White, Black and Latino respondents reported that Asians

held too much economic power and worked the hardest to succeed- even more than

Whites (Lee, 2000).

One outcome of Asian immigrants' social integration is experiences of racial

discrimination. Contrary to beliefs that Asians do not experience discrimination, reports

of discrimination suggest that it is a common experience in their interpersonal exchanges.

In a Commonwealth Foundation survey, 18% of Asians believed that they would have

received medical better care had they been of a different race or ethnic group. The

National Latino and Asian American Survey (NLAAS), the first national psychiatric

epidemiological study that solely surveyed Latinos and Asians, found that over ten

percent of the Asian sample reported frequently feeling that they are treated with less

courtesy than others. Nearly 18% of the Asian sample reported that they are sometimes

or often disliked because of their race. The rates vary among the different ethnicities,

with certain groups like the Filipinos, having higher discrimination prevalence than

others. Over 20% of the total Asian sample in the California Health Interview Survey

(CHIS) reported experiencing poor treatment because of their race in a medical setting

sometimes or often (Gee & Ro, 2009).

Cultural Integration

This form of integration concerns cultural identity development, which focuses on

the individual-level experiences of immigrants and considers their adaptation of personal

values and beliefs as they interact with American society. Expressions of cultural

identity can include cultural practices, values and identification (Schwartz, Unger,

Zamboanga, & Szapocznik, 2010). Cultural practices are the lifestyle choices and

behaviors such as language use, media preferences, social affiliations, and cultural

customs and traditions. Cultural identification is the attachment to a cultural group and

the positive esteem derived from it. This aspect has been explored in other concepts as

ethnic identity, which is generally seen as having self-identification, feelings of

belongingness and connection to a group, a sense of shared values and attitudes towards

one's ethnic group (Phinney, Horenczyk, Liebkind, & Vedder, 2001).

As immigrants first enter the United States, they encounter a new environment

with distinctive characteristics that order routines of daily living, such as language use or

communication patterns. Qualitative works and literature have aptly chronicled the

loneliness, fear and alienation that often accompany immigration (Constantine,

Kindaichi, Okazaki, Gainor, & Baden, 2005; Yoon, Lee, Koo, & Yoo, 2010). Kim

describes the feelings this way:

Some of the surprises may awaken or shaken strangers previously taken-for-granted self-concepts and collective ethnic identity and bring the anxiety of temporary rootlessness. Strangers in a new environment are confronted with situations in which their mental and behavioral habits are called into question, and they are forced to suspend or even abandon their identification with the cultural patterns that have symbolized who they are and what they are. (2001, p. 50)

Early researchers coined the phrase "culture shock" (Oberg, 1960), which has

become a popular term to describe social difficulties and psychological reactions to

unfamiliar cultural environments. In her model of cross-cultural adaptation, Kim (2001)

uses tenants of ecological systems theory to suggest that these factors create

environmental fluctuation to which immigrants must respond in order to achieve an

overall "fit" between the individual and the environment. She goes on to propose that as

immigrants confront environmental challenges and adapt to their immediate

surroundings, they in turn develop their cultural identities. This process encompasses a

dynamic negotiation between one's original cultural orientations and the demands of the

new environment.

Several psychological models of cultural identity development that have been

applied to Asian Americans detail this process further (Uba, 1994, Phinney 1989). For

example, Uba applies the Minority Identity model to Asian Americans and identifies five

stages of ethnic identity development: Conformity; Dissonance; Resistance and

Immersion; Introspection; and Synergetic Articulation and Awareness (Uba, 1994). This

and similar models were developed primarily for heuristic use in clinical settings and are

not meant to classify individuals by personality sub-types. Instead, they view ethnic

identity as a positive resource that is achieved after serious consideration of one's

affiliation with a marginalized group.

Contexts of Disease

While I have articulated economic, cultural and social integration separately,

these processes do not occur in isolation from one another. Some researchers have

suggested that different dimensions of integration occur chronologically, most often with

economic integration preceding social and cultural integration (Bean & Stevens, 2003).

It is possible that economic integration may facilitate certain social and cultural

experiences, but a temporal ordering is difficult to establish. Instead, immigrants are

simultaneously undergoing occupational-related development while interacting with

American society and developing their cultural identities.

Likewise, the respective health resources and risks from each dimension of

integration are simultaneously experienced. In this way, the physical health effects of

integration may best be understood in the interactive or cumulative effects of economic,

social and cultural integration. The processes of integration create contexts of disease

which are the collective health-related resources and barriers that result from the

economic, social and cultural integration. For example, economic integration can

produce material resources, such as residence in wealthier neighborhoods or access to

better medical care. Social integration can produce social mobility resources, such as

social capital, or stressors, such as experiences of racial discrimination. Cultural

integration can provide such resources as co-ethnic identity.

Contexts of disease can be understood through the combination of two

interpretive frameworks: social-ecological theories of health and stress and coping

theories. Social-ecological theories of health have their roots in ecology, which asserts

that living organisms continually adapt to meet the changing demands of their

environments. Social-ecological theories integrate social and biological reasoning to

explain how individuals "embody" historically and politically-produced environments in

their health behaviors and well-being (Krieger, 2001a, 2001b). The social and physical

environment can serve as a symbolic stimulus, leading individuals to alter their

behaviors, norms and problem-solving actions to avoid any potential harm.

Stress and coping theories also rely on this dynamic relationship and assert that

the environment can be a source of harmful contaminants or stressors (Moos, 1979).

These stressors produce health outcomes by impacting health directly or initiate coping

behaviors that have eventual health impacts.

Stressors can directly impact health by activating a physiological 'flight or fight'

response that releases hormones, which in turn raise heart rate and blood pressure,

suppress the immune system and alter brain activity (McEwen & Seeman, 1999). When

such responses are perpetually maintained or accumulate over the lifecourse, they create

'wear and tear' on the body and have a greater negative health impact (McEwen &

Seeman, 1999). Measures such as allostatic load, an array of biomarkers that are

associated with a prolonged stress response, have been associated with increased risk for

decreased mental and physical functioning and cardiovascular disease (Seeman, Singer,

Rowe, Horwitz, & McEwen, 1997).

Coping responses are behavioral, emotional and social responses to stressors that

manage or alter the source of the stress and regulate stressful emotions (Folkman &

Lazarus, 1980). Coping strategies can directly harm health, such as through drug or

alcohol use (Chae, Takeuchi, Barbeau, Bennett, Lindsey, & Krieger, 2008; Chae,

Takeuchi, Barbeau, Bennett, Lindsey, Stoddard et al., 2008; Jackson & Knight, 2006).

Coping strategies can also indirectly lessen the effect of the stressor and its eventual

health impact. Syme first articulated this concept in relation to the contextual factors that

surround Black Americans and play a role in their higher prevalence of hypertensions

vis-a-vis Whites: "Those with hypertension seem to be faced with demanding social

situations in which aspirations are blocked, in which meaningful human intercourse is

restricted, and in which the outcome of important events in uncertain," (1979, p. 96).

He suggested some that individuals in demanding situations must employ prolonged and

high-effort coping responses to attempt to control their environment.

This framework is inspired by Geronimus, James, Walters and Peasron, who have

adapted socioecological stress and coping models to take into account how communities

of color contend with stressors that arise from larger structural barriers. Geronimus'

weathering hypotheses considers how social inequity and racialized ideologies result in

African Americans' disproportionate exposure to stress (Geronimus & Thompson, 2004).

James identifies John Henryism (JH) as a high-effort coping strategy that some African

Americans utilize when confronted with stressors. It is an outgrowth of larger ideology

that took hold of African Americans after Emancipation, where freed slaves adopted high

effort coping in order to create a new American identity, express core American values of

"hard work", "self-reliance" and "freedom", and resist new forms of oppression (James,

1994). The JH hypothesis states that continuous, high-effort coping with demanding

psychosocial stressors could compromise health among those with lower SES, as

environmental demands will exceed personal coping resources. Walters and Simoni's

indigenist model of Native women's health situates the stress-coping paradigm within the

larger context of Native women's status as a colonized people. This unequal distribution

of power leads to large-scale instances of discrimination, which empirical evidence

indicates impacts Native women's health trajectories (Walters & Simoni, 2002).

Pearson's (2008) Shine Sociocultural and Structural Framework of Race/Ethnicity and

Health identifies several health valences across a variety of domains, including

ethnoracial assignment, ethnic identity, high-effort coping and social and economic

resources. He suggests that the combination of these positive or negative health valences

produce overall health status across different populations.

There has been some empirical exploration of these hypotheses among immigrant

populations (Haritatos, Mahalingam, & James, 2007; Wildsmith, 2002), yet the specific

barriers and resources that surround Asian immigrants require a unique model. While

these studies were novel in their attempts to expand the immigrants' stress process to

incorporate the larger context, these hypotheses were developed for specific populations

with their unique histories in mind. For example, a high level of John Henryism is

hypothesized to lead to worse cardiovascular outcomes for Black Americans with fewer

material resources. For immigrants, however, the coupling of John Henryism and

material resources may propel immigrants to better health outcomes. Indeed, Haritatos

and colleagues (2007) found that John Henryism was predictive of better reports of self-

rated health, somatic symptoms and physical health functioning among Chinese and

Asian Indian immigrants. They found that high levels of JH mediated perceived stress

that was associated with worse outcomes for their three health measures. While

weathering, John Henryism and the indigenist models may not be fully applicable to

Asian immigrants, we can draw inspiration from their emphasis on the contextual to

develop a stress and coping process that is more directly related to the Asian immigrant

experience.

The health outcomes of varying context of disease are best illustrated in

examples that demonstrate the interconnected nature of economic, social and cultural

forms of integration. For the remainder of the section, I will detail several examples and

hypothesize how health outcomes may emerge.

Economic and Social Integration

The intersection between economic and social integration raises doubts whether

material resources from increasing economic means will confer benefits to groups that

have been historically marginalized. The resources that are assumed to accompany

higher SES may not have the same benefit for some groups if, for example, their social

position limits their access to certain goods or services or if the path to upward social

mobility takes such a toll on their health that it counteracts any resource-related benefits

(Pearson, 2008).

As previously discussed, immigrants' earnings have been shown to increase as

they spend more time in the United States. The human capital theory attributes this

increase to improving job skills that are readily applied to occupational situations. Those

who consider SES a Fundamental Cause of Disease connect this process to better health

outcomes; increasing SES is beneficial for health, as higher SES can create resources that

protect health and promote salubrious behaviors (Link & Phelan, 1995). Higher SES can

provide opportunities to settle in neighborhoods that have better access to health-

promoting resources, including safe neighborhoods, nutritious foods, health services, and

leisure. Higher-income neighborhoods also do not have the toxins and other pollutants

that are direct health risks.

This sequence of events relies heavily on economistic assumptions. Geronimus

and Thompson (2000) describe economism as a deeply entrenched American ideology

that emphasizes the role of personal agency in placing individuals within social

hierarchies that lead to differential material outcomes. According to this view,

"individuals choose to invest in their human capital to best position themselves to engage

the market and fulfill their personal responsibilities" (2000, p. 252). Thus, economic

forces are the primary vehicle by which health is formed and material resources are the

most significant health influences.

When we consider the social integration of Asian immigrants alongside their

economic integration, we see that the road to upward economic status contains barriers

that are unforeseen in the economism narrative. Their high educational and occupational

achievement does not always translate into upward social mobility and proportionate

financial compensation. First, there appears to be a limit to how high Asians can advance

through employee ranks. While a large percentage of the male API workforce is

professional (23%), a substantially smaller percentage was in executive-managerial

positions (14%). White male Americans, however, have fewer professionals (14%) but

more of them advance to become executives or managers (17%) (Woo, 1994). In the

National Institutes of Health, Asian scientists make up 21.5% of the tenure-track

researchers, yet only 9.2% are senior investigators (tenured researchers) (Mervis, 2005).

Further, Asians do not appear to be compensated commensurate with their

education. While Asians as a whole have median incomes that are equivalent to White

Americans, their financial standing does not reflect their higher educational attainment.

Asians are often overeducated compared to Whites in the same occupational position

(Barringer, Takeuchi, & Xenos, 1990). Finally, Asians earn less over their lifetime

compared to White employees with the same educational attainment (with the exception

of advanced degrees) (Day & Newburger, 2002). Nativity may factor into the earnings

differential; Iceland found that foreign-born Asian men are disadvantaged relative to

native-born non-Hispanic white men, although the finding vary by nation of origin

(Iceland, 1999). Further delineating this point, Zhen and Xie found that foreign-born

men who were educated in Asia had the highest wage penalty, suggesting a devaluing of

Asian education (2004).

Many of these occupational barriers can be traced back to their social integration.

One contributing factor to blocked occupational mobility are perceptions that Asian

workers are passive and unsuitable for managerial positions (Fernandez, 1998) or better

equipped for technical rather than people-oriented work (Woo, 1994). Friedman and

Krackhardt (1997) suggest that social capital is the mechanism that transforms human

capital into workplace gains; the combination of discrimination, preference for other co-

ethnic workers and language factors exclude Asian immigrants from informal networks

that can boost their career mobility.

As Asian immigrants experience barriers in the workplace, they also continue to

encounter discrimination in other areas that can counteract the benefit of material

resources. For example, better health care access is thought to be a benefit of higher

SES, but clinical settings are not escapes from racial profiling and differential treatment.

On average, Asian patients wait longer for transplants and are given fewer analgesics and

they consistently report being less satisfied with their care (Ezenwa, Ameringer, Ward, &

Serlin, 2006; Klassen, Klassen, Ron, Frank, & Marconi, 1998; Lauderdale, Wen, Jacobs,

& Kandula, 2006). Higher income is also thought to provide access to better residential

neighborhoods without harmful environment exposures. Asian immigrants may not have

the same access to these areas, however, as there is evidence to suggest that they

encounter discrimination when trying to purchase a home (Turner, Ross, Bednarz,

Harbig, & Lee, 2003). Further, living racially heterogeneous neighborhoods may also

invite more experiences of interpersonal discrimination.

The positive SES-health relationship is considered one of the most robust in

health, but the pervasiveness of such barriers questions whether increasing

socioeconomic status can produce health-promoting resources for Asian immigrants in

the same way they have been shown to do among non-Hispanic Whites. The SES-health

relationship is modest or non-existent for Asian immigrants in BMI (Lauderdale &

Rathouz, 2000; Sanchez-Vaznaugh et al., 2008) and fair or poor self-rated health

(Acevedo-Garcia, Bates, Osypuk, & McArdle, 2010; Kimbro, Bzostek, Goldman, &

Rodriguez, 2008) compared to non-Hispanic Whites. These findings are often attributed

to cultural characteristics serve as protective factors across the socioeconomic spectrum,

but an alternative interpretation is that stressors and discrimination can counteract health

resources among the wealthier and higher educated.

Increasing wages in the face of constant barriers suggests that Asians may employ

high-effort coping over extended periods of time to reach their wage levels. A unique

stressor that may applicable to Asian immigrants' economic and social integration is

goal-striving stress, which is related to unfulfilled aspirations (W. Kuo, 1976). This

concept is similar to the frustrated expectations model that Vega, Kolody and Valle

(1987, p. 516) apply to depression among Mexican women. They define frustrated

expectations as a stress that arises from circumstances in which "goals of material

success are collectively valued and endorsed, but where the institutional means of

attainment is reduced or unavailable to some people".

Kuo suggests that as immigrants become more upwardly mobile, they experience

higher degrees of goal-striving stress. As they have higher levels of aspirations due to

socialization experiences in a new society, they are simultaneously unable to overcome

the consequences of discrimination (1976). He measured goal-striving stress as the

discrepancy between an individual's aspirations and their actual socioeconomic

achievements and found it to be a significant predictor of depression among Chinese

Americans.

Since Kuo, there have been few explorations of similar topics among Asian

immigrants. Some researchers have tested the health effects of alternative forms of

aspiration and achievement discrepancy, such as underemployment or economic

opportunity. Underemployment and unemployment have been shown to be positively

associated with depressive disorder (Beiser & Hou, 2001). Shin et al measured the

degree of change in occupational prestige as the result of migration and did not find any

relationship between it and depression in their sample of Korean immigrants (Shin, Han,

& Kim, 2007). In the National Latino and Asian American Study (NLAAS), economic

opportunity was measured by one item, "How do you feel about the economic

opportunity you have had in the U.S.?" de Castro, Gee and Takeuchi (2008a) found that

respondents who reported favorable economic opportunity had significantly higher odds

for better self-rated health, lower odds of smoking and lower BMI.

Social and Cultural Integration

Another context of disease example is the intersection between social and cultural

integration. Social integration considers how immigrants are incorporated into a

racialized social hierarchy and cultural integration considers how immigrants internalize

their experiences in a new country to form new identities. Social-ecological theories

would suggest that the social integration serves as a context to stimulate certain forms of

cultural integration. Nagel describes their relationship this way:

"While an individual can choose from among a set of ethnic identities, that set is generally limited to socially and politically defined ethnic categories with varying degrees of stigma or advantage attached to them." (1994, p. 156)

There are several well-known social constructionist approaches to cultural or

ethnic identity development, such as selective assimilation and reactive ethnicity (Portes

& Zhou, 1993), that acknowledge the interplay between social classification and self-

determined identity. These ideas share the view that, "ethnic boundaries, identities, and

cultures are negotiated, defined and produced through social interaction inside and

outside ethnic communities" (Nagel, 1994, p. 152).

For Asian immigrants, this means making sense of racialized stereotypes related

to the model minority myth and perpetual foreignness. Asian immigrants also encounter

previously unknown classifications, such as a pan-Asian identity or racial minority.

These group distinctions are externally applied to Asian immigrants and contain political

and social implications.

There are several potential outcomes to the social construction of cultural identity.

The first is that immigrants form alternative subgroups that arise from repeated

encounters with discrimination. Pearson's (2008) ethno-racial assignment and ethno-

racial identity exemplify this view. Ethno-racial assignment involves the external

attribution of characteristics and classifications and their economic, political and social

significance. Ethno-racial identity consists of individually-established beliefs, values and

practices that represent a counter-cultural orientation from external assignment.

According to this model, individuals use ethnic resources to resist and offset the

constraints imposed by racial assignment.

Another outcome is identity rejection, in which immigrants create distance

between their external categorization and personal affiliations with them. One key force

in this process is internalized racism, which is the subtle processes by which racial

inequality shapes the way that the oppressed think of themselves and other members of

their group (Pyke & Dang, 2003). Shwalbe and colleagues try to supersede the potential

victim-blaming mentality that internalized racism can provoke by conceptualize it as an

adaptive strategy (Schwalbe et al., 2000). By disassociating with their ethnic identities,

individuals can protect themselves against the negative stereotypes and create a positive

self-identity (Pyke & Dang, 2003).

A final potential outcome is a bicultural identity. Portes and Zhou use the term

"selective assimilation" to describe the outcome by which immigrants choose certain

aspects of their ethnic identity that will provide the best opportunities to build resources

and reflect one's connections to both American and Asian ethnic identities (Schwartz et

al., 2010). This process is based on traits they perceive to be adaptive and conducive to

social mobility. Bean suggests that selective assimilation occurs among immigrants of

higher socioeconomic status, as they have access to co-ethnic networks that provide

social and economic resources that are not available in other non-ethnic networks (Bean

& Stevens, 2003).

The health effects of this process emerge from the intersection between stressors

that arise from social integration and coping resources from cultural identity

development. One of the primary stressors from social integration is experiences of

racial discrimination. Racial discrimination has been repeatedly demonstrated to be

associated with poorer health outcomes among Asian immigrant populations. Nearly all

of the 59 studies identified in a recent review paper on reported discrimination and

mental health outcomes among Asian Americans found a negative relationship between

the two; the more discrimination respondents report, the higher their risk for poor mental

health outcomes (Gee, Ro, Shariff-Marco, & Chae, 2009). Discrimination seemed to

have a similar pattern in physical health outcomes, although some studies did not have

significant findings, particularly when birth weight and blood pressure were the outcomes

in question (Brown, 2006; Shiono, Rauh, Park, Lederman, & Zuskar, 1997). Poorer

health behaviors, such as decreased medical utilization, smoking, alcohol use, high-risk

sexual activity, have been shown to associated with higher reports of discrimination

(Chae, Takeuchi, Barbeau, Bennett, Lindsey, & Krieger, 2008; Chae, Takeuchi, Barbeau,

Bennett, Lindsey, Stoddard et al., 2008; Chae & Yoshikawa, 2008).

The resources that emerge from cultural integration can moderate discrimination's

health effects on Asian immigrants. There is some evidence to suggest that a strong

ethnic identity is directly related to better mental health outcomes (Phinney et al., 2001;

H.C. Yoo & Lee, 2005), but it and other related psychosocial resources arising from

cultural identities may have a more profound health impact by acting as buffers from the

stressors that arise from social integration.

A strong ethnic identity can provide a buffer against racism-related stressors by

reinforcing positive associations with one's ethnic group after an experience of racial

discrimination. Conversely, individuals with low ethnic identity may not have the

psychological resources (i.e., clarity, knowledge, and pride of their ethnic group) to deal

with recurring instances of racial discrimination. On the other hand, a strong ethnic

identity can heighten the negative impact of racism, as it may invoke a stronger reaction

among those with a very salient ethnic identity. Individuals with high ethnic identity may

be more rejection-sensitive than individuals with low ethnic identity because they are

more likely to identify and invest in that particular group affiliation.

Among Asians, there is empirical evidence to support both the positive and

negative buffering effects of ethnic identity. Strong ethnic identity significantly

decreased the relationship between perceived racial discrimination and depression

(Cassidy, O'Connor, Howe, & Warden, 2004; Mossakowski, 2003; Noh, Beiser, Kaspar,

Hou, & Rummens, 1999) and between racial discrimination and adverse coping

behaviors, such as smoking and drinking (Chae, Takeuchi, Barbeau, Bennett, Lindsey, &

Krieger, 2008; Chae, Takeuchi, Barbeau, Bennett, Lindsey, Stoddard et al., 2008). In

contrast, Asians with higher levels of ethnic identity reported more negative affect after

imagining racially discriminatory scenarios than those with lower ethnic identity (H. C.

Yoo & Lee, 2008).

Another important moderator emerging from cultural integration is social

networks and resultant social support. Group affiliation is a key factor underlying

cultural identity and individuals with a strong cultural identity may be more active in co-

ethnic networks that can provide important social resources. Strong social networks can

impact health in three ways: 1) by influencing health-related behaviors; 2) influencing

access to services and amenities; and 3) affecting psychosocial processes. These

influences appear to be protective of health; there are positive associations between social

networks and all-cause mortality, stroke and infectious diseases (Kawachi & Berkman,

2000).

Another outcome of social networks is social support. Empirical evidence

suggests that social support buffers the effects of stress among Asian immigrants. Social

support has been shown to enhance the well-being of immigrants, especially when they

perceive high levels of discrimination in their new country (Jasinskaja-Lahti, Liekind,

Jaakkola, & Reuter, 2006). Social support, in the form of emotional support, appeared

to buffer the effect of discriminatory stressors among Filipinos (Gee et al., 2006). Ethnic

support has been shown to have an interactive effect between perceived stress on

depressive symptomatology for Koreans living in Canada (Noh & Avison, 1996).

Strong social support may also produce certain types of coping that counteract the

negative effects of discrimination. In Asian immigrants; problem-based coping was more

effective in reducing the mental health impacts of perceived discrimination, but only

among those with strong social support (Noh & Kaspar, 2003).

Different Integration Experiences

As demonstrated in the empirical literature, much of the complexity surrounding

health trajectories is due to variation across groups with different socioeconomic, ethnic

or demographic characteristics. One possible explanation for this heterogeneity is that

groups can differ in their experiences of integration, resulting in discrete health

trajectories. Portes and Zhou's segmented assimilation theory (1993) posits that

contemporary immigrants can experience different integration paths by virtue of varying

contexts of reception. Some important contextual factors that determine such patterns are

government policies, conditions of the host labor market, social context (including

immigrants' assigned racial attributes, geographical concentration and social mobility

ladders) and co-ethnic communities. These determine where immigrants will find

themselves in the social hierarchy and the subsequent environment in which they will

assimilate towards. Different contexts of reception also avail resources that can hinder or

facilitate certain integration outcomes. The table below provides examples of how three

influential modes of incorporation, governmental policies, societal reception and co-

ethnic communities, may impact immigrants' economic, cultural and social integration.

Table 2-1. Contexts of Reception and Influences on Integration Processes

Dimensions of Integration

Economic Integration

Social Integration

Cultural Integration

Contexts of Reception Governmental

Policies

Determines human capital characteristics

Reinforces or reflects larger public

sentiment towards immigrants

Prohibits certain cultural practices

Societal Reception

Facilitates or hinders occupational

mobility

Experiences of racial discrimination

Reactive cultural identity development

Co-ethnic communities

Provides alternative employment

opportunities outside the primary labor

market

Buffers against hostile experiences

Promotes cultural identity development

Government policies represent federal immigration policy, visa regulations,

government assistance or state-level policies that address undocumented immigration.

Immigration policy can impact economic integration by determining who can enter the

United States and the characteristics they should have. For example, employee-

sponsored (H-IB) visas are issued to employers in certain industries and can lead to high

concentrations of foreign-born workers in such fields as high-tech or engineering. Social

integration can be affected by anti-immigrant policies that attempt to curtail social

services for immigrants or criminalize undocumented immigrants. These policies both

validate and encourage larger public sentiments regarding immigration and foster an anti-

immigrant climate. Policies can also directly impact the cultural integration of

immigrants by prohibiting or stigmatizing certain cultural behaviors. For example,

English-only policies can curtail immigrants' use of native languages.

Societal reception represents the values and prejudices of the receiving society.

Some groups have been exempted from the traditional prejudice aimed at the foreign-

born; Portes and Zhou cite Cuban refugees during 1960 and 1980 as one such group

(Portes & Zhou, 1993). For Asian immigrants, societal reception can impact economic

integration by producing occupational barriers, such as discriminatory hiring practices or

block upward mobility. It can impact social integration by fostering experiences of racial

discrimination. Finally, societal reception can impact cultural integration by encouraging

immigrants to form their cultural identities as they are mindful of what may or may not

be acceptable. Light and Rosenstein (1995) have termed this "reactive ethnicity", which

is a response to their involuntary designation as outsider, lower-status groups; they seek

to preserve the group's endangered collective self-esteem by enhancing solidarity.

Co-ethnic communities provide resources that immigrants utilize as they progress

through economic, social and cultural integration. Immigrants who join well-established

and diversified ethnic groups have access to invaluable moral and material resources.

Strong co-ethnic communities with economic diversity can open up immigrants'

occupational options by providing opportunities away from primary labor market. They

can also impact immigrants' social integration by shielding immigrants from racial

discrimination by limiting social and professional contacts to those within the co-ethnic

community. They can also provide tangible means for immigrants to retain their cultural

identity through larger social networks of co-ethnics, access to ethnic foods and

organized cultural activities.

Modes of incorporation are dynamic and can vary across periods of time and

groups of Asian immigrants. I discuss three factors that can alter integration experiences:

entry cohorts, Asian ethnicity and gender. Each of factors not only produce separate

groups that are compositionally varied, but have symbolic meanings that can alter

integration processes by virtue of the kinds of resources that individuals in certain groups

derive from the various modes of incorporation.

Cohorts

Year of entry cohorts signify unique periods of Asian immigrant integration that

differ in the types of people immigrating, countries of origin, pre-migration

characteristics, circumstances of entry and the social and cultural community that await

them. One influential factor in the creation of separate cohorts is immigration policy.

Immigration policy has influenced much of the Asian immigrant population's

demographic and socioeconomic features, as immigration policy establishes hard-line

criteria for who can enter the United States (Hing, 1993; E. Park & Park, 2005).

Immigration policy can vary in response to the political climate, suggesting that it may be

a distal contributor to health differences across segments of the Asian population by

altering the distribution of pre-migration characteristics that can shape subsequent

integration.

While the Asian health literature has long called for disaggregating by Asian

ethnicity to account for the wide variation in cultural and socioeconomic characteristics

within the population (Lin-Fu, 1988), year of entry cohorts not only encompass

differences in these characteristics, but also identifies immigration policy and contexts of

reception as sources of such variation. Furthermore, the different ethnicities are likely

clustered within certain cohorts, as certain periods of immigration were more amenable to

particular countries of origin.

Immigration policy in the early 19th century played an obvious role in controlling

the characteristics of the Asian immigration population by restricting the entry of Asian

women or immigrants from certain countries completely. More contemporary

immigration policy works less obviously, but can still create distinct groups across time.

I identify five post-1965 Asian immigrant cohorts: the First Professional Wave (1966-

1976); the First Family Reunification Wave (1978-1991); the Refugee Wave (1976-

1988); the Second Professional Wave (1992-2005); and the Second Family Reunification

Wave (1998-2005).

First Professional Wave (1966-1976)

The first contemporary wave of Asian immigrants entered the United States

immediately following the enactment of the 1965 Immigration Act that dissolved national

preferences. A defining feature of this cohort is their high educational and occupational

achievement, as required by the newly-established immigration statutes. Asian

immigrants quickly became the largest group to enter under the third preference category

for professionals. Eighty-six percent of Indian immigrants and 74% of Filipino

immigrants who entered in the United States between 1965 and 1975 held professional

occupations prior to immigration. In contrast, the total percent of Americans in a

professional occupation during the same time period was between 25 and 29% percent.

The Asian professional immigrants were predominantly health workers, principally

doctors and nurses; 67% of Indians and Filipino and 75% of Korean professional

immigrants were in the health field (Liu, 1992). High-tech personnel, mainly engineers

were also highly represented, among the Chinese-speaking countries in particular (Liu,

1992).

These immigrants entered during a receptive government era and non-prejudiced

social context. The passage of the Immigration Act of 1965 was widely hailed as an

achievement on par with the Civil Rights Act (Zolberg, 2006, pg. 332). The legislation

was thought to better represent American values of equality than the previous national

quotas which favored White European immigrants. Further, the marginal presence of

immigrants contained large-scale anti-immigrant hostility; 1965, the foreign-born

represented only 5% of the population, the lowest level since the 191 century.

As the first substantial cohort of Asian immigrants, the coethnic communities for

these immigrants were weak. The existing Asian American communities were primarily

Japanese and Chinese immigrant stock who had first come to the United States in the

early part of the 19* century. The majority of these professionals arrived in the United

States with their immediately families, however. Immigrants coming in as family

families tend to further minimize dependency upon pre-existing social networks (Liu,

Ong, & Rosenstein, 1991).

First Family Reunification Wave (1978-1991)

The second cohort represented the first visible immigration boom after the 1965

Act and was composed of the immediate and extended families of the First Professional

Wave members. As naturalized citizens, members of the first cohort could now sponsor

their family members for family reunification visas, as stipulated in the 1965

Amendments. The family reunification visas facilitated the "chain migration" that drove

the exponential increase in Asian immigrants during this period. Between 1961 and

1970, there were 427,000 Asian immigrants admitted to the United States. From 1971 to

1980, the admitted Asian immigrant population jumped to over 1.5 million, a 250%

increase (INS). While family reunification was also a widely-used entry route in the

previous cohort, the sheer size increase of Asian immigrants during this period made the

family reunification contingent substantially larger.

While most of this cohort still had higher levels of educational and occupational

attainment than the U.S. average, their human capital resources were considerably lower

compared to the First Professional Wave. The percent of Asian Indian immigrants who

held a professional occupation prior to immigration between 1980 and 1984 was 50%,

compared to 86% in 1970-1974. Filipinos also saw a drop from 74% to 30% in this same

time period. Less than 20% of Koreans held professional occupations, the lowest percent

in the 35-year span between 1965 and 2000. Some of the drop may be attributed to

government-imposed restrictions on employment visas enacted just prior to this period

(Min, 2006a). Further, the family reunification visas did not hold any economic or

occupational stipulations, enabling more heterogeneity in human capital characteristics.

The government and societal context was decidedly less favorable during this

period. An economic downturn in the early 1970's precipitated two amendments in 1976

that introduced restrictions on employment preference visas. The Eilberg Act required

immigrants to have a solid job offers before receiving visas and required employers to

demonstrate that the certification of a foreign worker had no adverse effects on

Americans workers (Liu, 1992). The Health Professions Educational Assistance Act

required foreign medical professionals to get job offers from American companies, take

the TEOFL and get U.S. medical licenses. These policies represented the growing

perception that the ever-increasing immigration population threatened American jobs.

The rise of Japanese manufacturing and automobile industries in the face of American

decline further antagonized Asian immigrants, who were perceived to embody the Asian

economic threat. In 1982, Vincent Chin was murdered outside of Detroit by two

unemployed autoworkers who yelled racial slurs while they pummeled him to death.

Despite the rising hostility, Asian immigration continued to expand and co-ethnic

communities strengthened as the population grew and concentrated in certain

metropolitan area. There was a marked increase in immigrant population in along the

coasts, such as in Los Angeles and New York (Min, 2006b). These co-ethnic

communities became important sources of social support, as well as economic-related

resources, as they provided employment opportunities through networks or the ethnic

economy.

Refugee Wave (1976-1988)

After the Vietnamese Civil War, millions of Southeast Asian refugees were

displaced in camps throughout Southeast Asia. The U.S. involvement in the war and

other geopolitical activities in the surrounding region including Cambodia and Laos,

ultimately facilitated the entry of millions of Vietnamese, Vietnamese-Chinese, Laotian,

Cambodian and Hmong refugees into the United States. In 1976, 14,000 Southeast Asian

refugees entered the United States and the numbers grew steady with each passing year,

reaching 167,000 at its peak in 1980. 1.4 million refugees were ultimately resettled in the

United States (Haines, 2001).

The earliest refugees came directly into the United States and represented more

educated populations from Vietnam, as they were in positions of influence in the former

pro-Western governments. The later and more numerous refugees, however, were war

exiles from Cambodia, and ethnic Lao and Hmong fleeing government persecution in

Laos and Thailand. Most of these refugees escaped in boats to neighboring countries,

coining the term "boat people". The group had lower levels of formal education and

suffered from higher levels of post-traumatic stress and had other low levels of human

capital. Immigrants who entered in this cohort continue to have the highest levels of

poverty compared to other Asian ethnic groups.

This cohort received strong government support. As the Vietnam War ended and

the American-supported governments in Cambodia, Laos and Vietnam fell, Congress

acted quickly to ensure that former allies could resettle directly into the United States.

Early acts were passed in 1975, 1977 and 1978 that facilitated easier U.S. entry and

subsequent naturalization for refugees and established domestic resettlement programs.

The policies culminated in the comprehensive 1980 Refugee Act, which removed

refugees from the worldwide numerical restrictions and brought the United States refugee

law in accord with international standards (Haines, 2001). The social reception was

mixed, however. Within policy circles, the refugees were viewed as strong allies against

communism in the Cold War. The general public was less supportive; public opinions

polls showed that over half of surveyed Americans opposed Asian resettlement to the

United States, fearing loss of jobs and increased public spending (Bolin, 2005).

The coethnic community for these refugees was weak; resettlement policies

explicitly dispersed the refugees throughout the country to avoid the formation of ethnic

enclaves and to lessen the impact of large numbers of refugees in one geographic area.

The actual resettlement efforts were conducted by voluntary agencies (volags), such as

the United States Catholic Conference, the International Rescue Committee, and Church

World Service, who arranged sponsorships for the refugees and took care of their initial

needs upon arriving in the United States. These volags sought to provide support and

material support for the incoming refugees and incorporate them into the communities in

which they were brought.

Second Professional Wave (1992-2005)

This wave was influenced by an overhaul in immigration policy in 1990 that

expanded employment-based immigration. The Immigration Act of 1990 tripled the

number of employment-based visas from 54,000 to 140,000 and increased the

employment-based preferences from two categories to five. The act also created 195,000

temporary work visas (H visas), which proved to be a popular avenue by which to adjust

to permanent resident status. For example, 58% of Indian Hl-B workers adjusted their

status between 2000 and 2003. Not surprisingly, the proportion Asian immigrants who

held professional positions in their home countries increased from the previous cohort,

reaching 46% in 2001-2005 (Min, 2006a).

Asian Indians comprised a large percent of this cohort. Strides in Indian

education, particularly technical training institutes, prepared many Indian computer

programmers, computer technologists and engineers to immigrate under the new H l - B

visas. This cohort saw a moderate decline of immigration from South Korea, Taiwan and

Hong Kong, as significant economic and social improvements in these countries reduced

the motivation for educated, middle-class citizen to emigrate (Min, 2006a). This period

also saw a spike in Chinese status adjusters after Tiananmen Square, as President George

Bush issued an executive order to facilitate the adjustment of Chinese foreign students to

permanent residency between 1993 and 1994.

The human characteristics of this sample are similar to the first professional wave.

Instead of health professionals, however, this wave shifted to more scientific and

technical professionals (Sana, 2010).

The government policies and societal context that surrounded this cohort were

increasingly hostile. At the federal level, two 1996 laws sought to enhance punitive

measures against non-resident immigrants and reduce immigrants' eligibility for social

programs. The 1996 Illegal Immigration Reform and Immigrant Responsibility Act

(IIRIRA) and increased the number of aliens subject to mandatory detention and

increased the crimes for which non-citizens could be deported. The 1996 Personal Work

and Responsibility Act (PWRORA) barred new legal immigrants from federally funded

assistance programs for their first five years in the U. S. State policy was markedly more

severe. California's Proposition 187 in 1994 proposed ending education, nonemergency

health care, and other public services for undocumented immigrants and required police

and government workers to report suspected undocumented immigrants. While the new

laws were meant to address illegal immigration, they effectively blurred the lines

between "legal" and "illegal" immigrants and reflected the public's resentment towards

immigrants at large.

Second Family Reunification Wave (1998-2005)

This wave reflects the chain migration that followed the refugee wave. Refugees

were eligible to naturalize two years after their arrival, enabling their sponsorship of

family members. Refugee visas declined since 1994, but the numbers of Vietnamese,

Cambodian and Laotian immigrants grew through family reunification (Haines, 2001).

The human capital characteristics of this cohort are unclear. While the refugee

wave was characterized by low levels of human capital, and the subsequent family

reunification cohorts may have similar characteristics if they were also coming from

displacement camps outside their countries of origin. The government and societal

context of this cohort were similar to those experienced by the concurrent Second

Professional Wave.

The coethnic community surrounding these immigrants is strong. While refugees

were initially settled in disparate parts of the country, a significant amount of secondary

migration occurred within a few months, mainly to California and Texas, the two states

that now have the largest Southeast Asian populations. The geographic concentration of

this cohort to these states suggests that they migrate to areas with established co-ethnic

communities.

Integration Differences across Cohorts

While these cohorts have been identified from a historical and policy perspective,

I have not located empirical data that investigates their potential integration differences.

Some work in the economic literature has investigated differences in economic outcomes

across visa status. Jasso and colleagues (1998) examined whether changes in immigration

policy between 1972 and 1995 affected the numbers of employment visas versus spousal

visas and the skill levels of entering immigrants. Using a panel data set constructed from

immigration records obtained from the Immigration and Naturalization Service (INS)

between 1972 and 1995, they found that rising immigrant skill during this period was due

in part to the increase of employment visas and changing immigration policies.

Other research has not considered policy directly, but has examined the impact of

visa status on economic outcomes, such as wage or occupation. Immigrants from the

Eastern Hemisphere (the majority of whom were from Asian counties) who entered under

employment visas had higher wages immediately following immigration compared to

family reunification immigrants. However, with increased time in the United States, this

differential shrinks (Jasso & Rosenzweig, 1995). A similar pattern holds for refugees;

Cortes (2004) found that while refugees had lower wages and work fewer hours in 1980

than other immigrants, this differential disappeared in 1990. Combined, these studies

suggest that immigrants who enter under different policy regimes have varied

socioeconomic patterns of integration. None of these studies explicitly examined Asian

immigrants however, so the question of whether Asian immigrant cohorts that have been

shaped by separate policy eras are different in their socioeconomic and health profiles

remains an empirical one.

In general, the role of immigration policy is not widely considered as a factor in

Asian immigrant health trajectories. There is even less discussion of the potential effect

of the most recent changes to immigration policy in the 1990s. Any mention of

immigration law and practice on health outcomes is only discussed in terms of its effect

on Asian Americans' trust in governmental institutions and the potential ramifications on

Census participation and health-related data (Srinivasan & Guillermo, 2000). Part of the

reason for this absence of research is due to the lack of information on visa status in

datasets with health outcomes. Large, representative datasets such as the Decennial

Census, American Community Survey, the National Latino and Asian American Survey,

the National Health Interview Survey and the California Health Interview Survey do not

include visa information.

While cohort differences have not been explicitly explored, some research has

considered how refugees differ from the rest of Asian immigrants, drawing particular

attention to the poorer socioeconomic status and worse health profile of Laotians, Hmong

and Cambodians. In the 2000 Census, these groups had over three times the odds for a

physical disability and over six times the odds for mental disability compared to the

Japanese (Ro & Gee, 2009). Many studies have documented their higher-than-U.S.

average rates of depression, trauma and other mental disorders (Hsu, Davies, & Hansen,

2004; Kinzie et al., 1990; Kroll et al., 1989). Laotians have median incomes levels

around $10,000, far below other groups such as the Japanese. Sixty-three percent of

Hmong live in poverty compared to 6% of Filipinos (Srinivasan & Guillermo, 2000).

Little work has been done to distinguish the family and work visa cohorts in this regard,

however. Further, this work tends to highlight health disparities within the Asian

population over the historical role of immigration policy. While some researchers have

attributed the socioeconomic and health profiles of these groups to their refugee status

(Hsu et al., 2004; Lin-Fu, 1988), they do not expand their explanation to consider how

immigration policies may have influenced the potentially favorable characteristics of

other Asian groups as well.

Gender

The different integration experiences between men and women lie in the separate

social and cultural ideals of gender that organize opportunities and shape life chances

(Hondagneu-Sotelo, 1994). Much like other social categories such as race or ethnicity,

gender classifies individuals within a historically and socially determined unequal power

structure (Llacer, Zunzunegui, del Amo, Mazarrasa, & Bolumar, 2007). Gender is an

important source of differences in overall health patterns among Asian immigrants; men

and women have different prevalence of chronic disease, health care utilization and diets

(Choe, 2009; Park Tanjasiri & Nguyen, 2009). For immigrants, however, gender may

play an even more unique role in their integration processes and subsequent health

outcomes as immigrant men and women experience shifting social roles both within the

household and in their new society.

The earliest and most influential immigration studies, developed separately from

gender issues; researchers often viewed the migrant as male or gender-less (Pessar,

1999). More recent work has amended this early omission and has demonstrated that

experiences of migration and gender are closely intertwined. First, women have initiated

and composed the bulk of post-1965 Asian migration. Between 1975-1980, when Asian

immigration was growing most rapidly, working-age women outnumbered men in

immigrants from China, the Philippines, Taiwan, Korean, Burma, Indonesia, Japan and

Thailand (Salazar Parrenas, 2003). This created a chain effect whereby women who had

already secured U.S. residence, such as Korean military brides and Filipina nurses, often

served as visa sponsors for their extended families, making the maternal family more

prominent in the United States (K. Park, 1997).

Secondly, the act of migration modifies gender roles within the family and

domestic sphere. In her study of Korean immigrant business owners, Park (1997) finds

that traditional Korean gender roles are first disrupted in the migration process itself, as

the majority of immigration is female-initiated and maintained. This has shifted the

hierarchies of traditional Korean families, which typically revolve around the husband's

relatives. Having more maternal relatives enables Korean women to utilize family

resources to share the burden of cooking, childcare and housework. The traditional

arrangement is further upended in business ownership, as women must also participate in

the business and work alongside their husbands. Labor participation provides a stronger

sense of independence and satisfaction among the female Korean immigrants. In Korea,

women are not expected to work after child-bearing age, leaving them financially

dependent on their husbands or other male family members. Park concludes that the

employment factor has been revolutionary for Korean immigrant women and has

established new gender consciousness that manifests itself in growing self-esteem,

autonomy, freedom and equality.

More recent research has examined how gendered roles permeate all aspects of

the daily operations of immigrant integration, such as patterns of labor incorporation,

ethnic enclaves, citizenship, sexuality, and ethnic identity (Hondagneu-Sotelo, 2000). In

matters related to economic integration, the labor market has been segmented by gender,

with certain occupations characterized as feminine and masculine. The informal service

sector, such as paid domestic work, child care, garment and electronic assembly has

relied heavily on female employees, particularly immigrant women of color (Espiritu,

1999).

Within their social integration, immigrant women may have experiences of

gender discrimination on top of racial discrimination. The relationship between health,

race and gender discrimination is a complex one, as women simultaneously experience

their racial and gender identities and the two forms of discrimination may not be fully

disentangled from one another (Moradi & Subich, 2003). These dual roles can

compound stressors and their negative health effects. Further, immigrant men's

experiences with racial discrimination and marginalization may introduce additional

stressors within marriage, even culminating in domestic abuse (Dasgupta, 2000). Min

recounted a story of marital discord arising from a husband's social status concerns:

"Five years ago, he left home after a little argument with me and came back two weeks later. He wanted to get respect from me. But a real source of the problem was not me but his frustration over low status."

Women are also more likely to utilize their networks within their co-ethnic

communities than are men (Billings & Moos, 1981). These social relationships not only

provide material resources but are also forms of social support to cope with immigration-

related difficulties.

These differences are borne out in the different health trajectories between men

and women. Smoking and drinking have been one of the most studied health outcomes

when examining gender differences, likely because they represent changing ideas about

gender norms. While smoking and drinking prevalence is lower among Asian immigrant

women than men, duration appears to have a more positive effect on smoking and

drinking among Asian immigrant women (Choi, Rankin, Stewart, & Oka, 2008;

Maxwell, Bernaards, & McCarthy, 2005). Duration is associated with more substantial

weight gain among women compared to men (Lauderdale & Rathouz, 2000).

Asian Ethnicity

Ethnicity is a social construct that encompasses personal identity and group

affiliation. It is distinct from racial classifications, which have been developed

historically through systems of social stratification and are often externally applied (Ford

& Harawa, 2010). Different Asian ethnic groups may experience alternative integration

processes on account of their distinct social and lifestyle characteristics, such as common

geographic origins, family patterns, language, values, cultural norms, religious traditions,

literature, music, dietary preferences and employment patterns (Williams, 1997). These

factors may be more proximal to health outcomes, as they are influential on attitudes

towards medical services, diet and health-risk behaviors (i.e., violence, substance use,

smoking).

Health differences among Asian ethnic groups have been well-documented.

Filipinos have the highest rates of hypertension among the Asian ethnic groups, even

surpassing the rate for White Americans. Koreans have the highest levels of current

smoking status, smoking at a rate comparable to White Americans (Islam, Trinh-Shevrin,

& Rey, 2009). Rates of cervical cancer incidence among Vietnamese women are more

than two and a half times higher than rates for women of any other racial or ethnic group

(Parker, Davis, Wingo, Ries, & Heath, 1998).

A common refrain within public health research on Asian Americans has been to

disaggregate the population into separate Asian ethnicities when conducting quantitative

analysis to account for such heterogeneity (Srinivasan & Guillermo, 2000). Researchers

have suggested a bimodal distribution of socioeconomic and health characteristics within

the Asian population (Lin-Fu, 1988). Classifying Asians into a single group in statistical

analyses masks such heterogeneity and biases results to the null. Further, when Asians

are combined into a single pan-ethnic group, it suggests similar characteristics and

lifestyles among the Asian respondents. Ultimately, culture is dynamic and what

constitutes broad understandings of the Asian "culture" are continually in flux (Pfeffer,

1998). Outside of the shared racialized experience, there are few common "cultural"

characteristics, such as language, social networks, or diet across Asian ethnicities.

Disaggregating by Asian ethnicity may also account for separate immigration

histories. While year-of-entry cohorts most clearly delineate the contexts of immigration

history for subsequent integration and health patterns, ethnicity can also be proxy for this,

as populations from different countries of origin entered in the United within certain time

periods. For example, the Japanese have one of the longest histories of immigration to

the United States, but their immigration peaked in the 1970's and has declined the

decades since. As a result, this population has low linguistic isolation and is

predominantly American-born (Hing, 1993). This is in contrast to the Vietnamese, many

of whom entered as refugees in the 1970's and 1980's, during political unrest in

Southeast Asia. Their incorporation into the United States was heavily governed by

refugee resettlement policies, which determined where they could live and the type of

government support available to them (Hing, 1993). For datasets that lack information

that cannot easily classify by year of entry cohorts, ethnicity or country of origin may

provide a reasonable substitute.

Finally, ethnicity has a strong bearing on the development of a cultural identity, as

Asians tend to self-identify more with their ethnic identity than a pan-ethnic one. In the

debate between using "Latino" or "Hispanic", Yankauer suggests that the ideal solution is

to ask the members themselves (1987). A similar argument can be made for Asians; self-

identification is important because socially constructed categories are largely applied

externally. Self-identification gauges the extent to which an individual has internalized a

label and consequently acquires the resources and drawbacks associated therein. While a

nationally-representative survey has yet to be conducted, Lien and colleagues surveyed

1218 Asian immigrants residing in the metropolitan areas of Los Angeles, New York,

Honolulu, San Francisco and Chicago (Lien, Conway, & Wong, 2003). They found that

when Asian immigrants are given the choice of identifying as ethnic-specific or pan-

ethnic, they tend to identify foremost with their ethnicity. This is not surprising;

throughout the history of Asian immigration, groups from different Asian countries went

through lengths to distinguish themselves from one another, most often when one group

was the target of discriminatory policies (Takaki, 1993).

Conclusion

This review provides an overview of our current knowledge of Asian immigrant

health trajectories and develops a new framework that identifies new economic, social

and cultural influences on health patterns. The framework expands upon popular lifestyle

and behavior explanations for Asian immigrant health patterns in three ways. First, it

incorporates structural influences on health. Second, it identifies specific aspects of

integration that are not typically associated with health and produces health-related

pathways. Third, it attempts to identify sources of group variation in integration

experiences and subsequent health trajectories.

Aspects of the framework have been carefully studied in economics, demography,

sociology and psychology, but it has yet to be considered in public health. The validity

of the framework can be securely established with empirical work that demonstrates the

significance of economic, social and cultural factors on Asian immigrant health

trajectories.

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CHAPTER 3 - EMPIRICAL PAPER 1

Cohort Differences in Health Trajectories

Introduction

Scholarship on immigrant integration into the United States has long been

influenced by classic definitions of assimilation that assume a unidirectional progression

towards American lifestyles. Gordon's early work on Anglo-Conformity (1961)

describes change on the part of an immigrant group in the direction of middle-class

Anglo culture. This assumes that as immigrants interact more with American host

society, they will shed their ethnic origins and conform in language, culture and identity

towards an Anglo-Protestant core culture. Anglo-Conformity shaped subsequent

scholarship and became the prevalent framework for understanding integration in the

social sciences (Alba & Nee, 2003). This viewpoint has also been applied to studying the

health consequences of integration. Changes in immigrant health over duration are

believed to be the result of lifestyle and behavior changes that reflect the progression

towards dominant American culture (Salant & Lauderdale, 2003).

Other work, however, has proposed a more complex picture of integration that

acknowledges heterogeneity across experiences in the United States. Most recognizable

among these is segmented assimilation theory, which suggests that the circumstances

surrounding migration, the resources that immigrants bring with them and the conditions

of the host country can shape the social standing of immigrants. Consequently,

immigrants proceed along integration paths that reflect their social standing; they may

display progression towards the White middle class, or they can display "downward

assimilation" patterns that mirror those of marginalized groups (Portes & Rumbaut, 1990;

Portes & Zhou, 1993).

There have been other similar arguments for complex integration experiences that

depend on how an immigrant is received and the resources available to them as they

adjust to American society (Alba & Nee, 2003; Nee, Sanders, & Sernau, 1994; Waters,

1999). Common across these views is the emphasis on structural constraints and

contextual influences on the nature of immigrant integration. More specifically, they

identify aspects of the circumstances of migration and contexts of reception that set

immigrants on an integration path that reflects the stratified nature of American society.

As the scholarship on immigrant integration develops, public health research has

also demonstrated heterogeneity in immigrants' physical health trajectories. Some

groups have displayed worsening physical health with duration, while others do not show

any duration effect or only display effects among certain outcomes (Cho & Hummer,

2001; Lauderdale & Rathouz, 2000; Mutchler, Prakash, & Burr, 2007). The inconsistent

relationship between duration and physical health outcomes aligns well with emerging

work that argues for divergent integration experiences. Bridging these strands of

research, it would appear that disparate health trajectories arise from separate integration

experiences.

The pathways by which integration impacts health trajectories can be understood

through the stress and coping framework. Migration and subsequent integration are

inherently stressful experiences that encompass both major life events and daily hassles.

Several scholars have identified unique migration-related stressors that impact

immigrants in addition to general life stressors, such as racial discrimination, language

difficulties, cultural adjustment and goal-striving stress (Kuo, 1976; Noh & Avison,

1996; Takeuchi et al., 2007). The physical effects of stress exposure have been well-

documented (McEwen & Seeman, 1999; Seeman, Singer, Rowe, Horwitz, & McEwen,

1997). Certain factors can mitigate or exacerbate the impact of stress among immigrants,

such as co-ethnic social support, material resources or cultural identity (Chae et al., 2008;

Noh, Beiser, Kaspar, Hou, & Rummens, 1999; Noh & Kaspar, 2003). Throughout their

integration processes, immigrants must encounter and cope with stressors; health

trajectories represent the accumulation of this process.

Divergent integration experiences can create differential stress and coping

processes. I argue that two underlying factors that drive separate integration paths,

circumstances of migration and contexts of reception, can impact the stress and coping

process in two ways. First, changing circumstances of migration can determine the

resources immigrants bring with them and their baseline health upon entry to the United

States. This is primarily seen through changing immigration policy and geopolitical

circumstances. Immigration policy sets criteria for who can enter the United States; as

the stipulations of immigration policy change, so can the characteristics of incoming

immigrants (Gee & Ford, 2011). Immigration policies that favor the highly-skilled

ensure that immigrants enter the United States with high human capital resources, such as

education and professional skills. Such policies may also be indirectly preferencing

healthier migrants, as high educational and occupational achievement is conditional on

health. Further, geopolitical changes in the sending countries in areas such as access to

medicine, better nutrition, or the presence or absence of widespread conflict, can alter

population-level health patterns (Jasso, Massey, Rosenzweig, & Smith, 2004). Incoming

migrants' health can reflect such shifts. Selective migration has been well-studied in

immigration health, but it has not been considered as a factor in health trajectories.

Second, contexts of reception can alter the types of integration-related stressors

immigrants encounter and resources available to them. Some important contexts of

reception in this regard are the societal reception of immigrants, domestic policies of the

host country, labor market conditions and co-ethnic communities (Portes & Rumbaut,

1990). Contexts of reception reflect the host country's larger views towards immigrants

and can determine immigrants' interpersonal interactions, as well as the nature of

domestic policies and labor market conditions (Ager & Strang, 2008). If immigrants are

negatively received, this may result in discriminatory hiring or similarly closed labor

markets and compel restrictive domestic policies that limit immigrants' resources.

Taken together, selective migration and the disparate stress and coping process

can produce unique health trajectories among different groups of immigrants. For

example, positively health-selected immigrants who enter the United States with a

favorable societal reception and a robust labor market may have an easier time securing

financial stability and experience higher upward social mobility. If immigrants can

utilize such material and social resources to improve medical access and avoid certain

health risks, they can experience improving health trajectories. Conversely, positively

health-selected immigrants who enter the United States under negative societal reception

and closed labor markets may have more difficulty securing upwards social mobility and

the associated resources that can translate to better health outcomes. The strength to

overcome such barriers may exact a physical toll on their health, ultimately resulting in

worsening trajectories. While these immigrants may have better physical health at

baseline, the cumulative assaults on health will not enable the same health gains over

time as immigrants entering under more favorable contexts of reception.

Cohorts

One useful way to study the health impacts of divergent integration paths is

through separate year of entry cohorts. Cohorts encompass historical changes in

migration circumstances as well as changing contexts of reception. Asian immigrants

may be a particularly useful group to study in this regard, as there are several distinct

cohorts who have entered after the 1965 Immigrant Act. I identify four cohorts of Asian

immigration during this modern era of immigration. Each is briefly described below.

First Professional Wave (1966-1976)

The 1965 Immigration Act dissolved national preferences and ushered in a new

wave of Asian immigration. A defining feature of these immigrants is their high

educational and occupational achievement, as required by the newly-established

immigration statutes. This was particularly seen among Asian Indian and Filipino

immigrants; 86% of Indian immigrants and 74% of Filipino immigrants who entered in

the United States between 1965 and 1975 held professional occupations prior to

immigration (Liu, 1992). These immigrants entered during a receptive government and

social context. The passage of the Immigration Act of 1965 was widely hailed as an

achievement on par with the Civil Rights Act. The legislation was thought to better

represent American values of equality than the previous national quotas which favored

White European immigrants. Further, the marginal presence of immigrants contained

large-scale anti-immigrant hostility; in 1965, the foreign-born represented only 5% of the

population, the lowest level since the 19th century (Zolberg, 2006).

Family Reunification Wave (1978-1991)

This was the first visible immigration boom and was composed of the immediate

and extended families of the immigrants of the First Professional Wave. This cohort

gained entry through family reunification visas, which were not subject to worldwide

quotas. While most incoming migrants still had higher levels of educational and

occupational attainment than the U.S. average, their human capital resources were

considerably lower compared to their predecessors (Min, 2006).

The government and social context was decidedly less favorable during this

period. An economic downturn in the early 1970's precipitated two amendments in 1976

that introduced restrictions on employment preference visas, the Eilberg Act and the

Health Professions Educational Assistance Act (Liu, 1992). These policies represented

the growing perception that the increasing immigration population threatened American

jobs.

Southeast Asian Refugees (1976-1988)

The U.S. involvement in the Vietnamese Civil war and other geopolitical

activities in the surrounding region ultimately facilitated the entry of millions of

Vietnamese, Vietnamese-Chinese, Laotian, Cambodian and Hmong refugees into the

United States during this wave. The earliest refugees came directly into the United States

and represented more educated populations from Vietnam, as they were in positions of

influence in the former pro-Western governments. The later and more numerous

refugees, however, were war exiles and had lower levels of formal education and suffered

from higher levels of post-traumatic stress and other disorders (Nicholson, 1997).

Refugees received strong government support. The 1980 Refugee Act removed

refugees from the worldwide numerical restrictions and brought the United States refugee

law in accord with international standards (Haines, 2001). The social reception was

mixed, however. Public opinions polls showed that over half of surveyed Americans

opposed Asian resettlement to the United States, fearing loss of jobs and increased public

spending (Bolin, 2005).

Second Professional Wave (1992-2005)

The Immigration Act of 1990 represented an overhaul in immigration policy

whose aim was to encourage more high-skill migrants; the act tripled the number of

employment-based visas, increased the employment-based preferences, and created the

temporary work visas (H visas) (Jasso, Rosenzweig, & Smith, 2000). The H-visa proved

to be a popular avenue by which Asian immigrants adjusted to permanent resident status,

Asian Indian workers in particular. Strides in Indian education, particularly technical

training institutes, prepared many Indian computer programmers, computer technologists

and engineers to immigrate under the new Hl-B visas. Conversely, there was a moderate

decline of immigration from South Korea, Taiwan and Hong Kong, as significant

economic and social improvements in these countries reduced the motivation for

educated, middle-class citizen to emigrate (Min, 2006).

The contexts of reception during this era were increasingly hostile. At the federal

level, two 1996 laws sought to enhance punitive measures against non-resident

immigrants and reduce immigrants' eligibility for social programs, the Illegal

Immigration Reform and Immigrant Responsibility Act and the Personal Work and

Responsibility Act (PWRORA) (Fix & Passel, 2002). State policy was markedly more

severe. California's Proposition 187 in 1994 proposed ending education, nonemergency

health care, and other public services for undocumented immigrants and required police

and government workers to report suspected undocumented immigrants (Hing, 1997).

While the new laws were meant to address illegal immigration, they reflected the public's

resentment towards immigrants at large.

Aims and Hypotheses

I assume that health trajectories are driven by the stress and coping process and

that the relationship between duration and health exposes the health impacts of this

process. Changing circumstances of migration and contexts of reception can alter the

stress and coping process across different cohorts of immigrants. The aim of this paper is

to explore the health impact of divergent integration experiences among separate cohorts

of Asian immigrants.

Hypothesis 1. The First and Second Professional Waves will have higher levels

of education and lower levels of self-employment compared to other cohorts, reflecting

stipulations of concurrent immigration policy. I also expect the Second Professional

Wave to have higher proportions of Asian Indian and Filipino immigrants, as these

immigrants are more likely to be able to secure employment visas because of their

stronger command of English (Min, 2006).

Hypothesis 2. Both the First and Second Professional Waves will have better

baseline health than other cohorts, reflecting health selectivity during these periods.

Hypothesis 3. Longer duration will be associated with worsening health. The

majority of cohorts have encountered negative social reception that can produce stressors

and barriers to upward mobility that take a cumulative toll on health.

The stress and coping view of the health impact of integration is a departure from

the majority of public health research, which attributes changing health trajectories to

behaviors that result from more Westernized lifestyles. While behaviors are certainly

proximal influences on health, they are not sole determinants of health trajectories. I

additionally control for health behaviors to examine whether health influences arise from

duration over and above health behaviors.

Hypothesis 4. The relationship between longer duration and worsening health

will grow stronger from earlier to more recent cohorts, reflecting growing negative social

reception.

Methods

An ideal exploration of cohort and duration effects would follow distinct cohorts

of immigrants over the course of many years and examine differences both within and

across cohorts (Lauderdale, 2001). While there is no dataset currently available that

contains a large enough sample size of Asian immigrants to test the duration effect

longitudinally, there are methods that enable a quasi-cohort analysis using multiple waves

of cross-sectional data. While the subjects are not interviewed repeatedly, a sample of a

cohort of immigrants that entered the U.S. in a certain year and are in a certain duration

group in the first dataset can be reproduced in the following datasets.

This method has precedent in economics and demography (Borjas, 1985; Myers

& Lee, 1996), but has not been used widely in the public health literature. Two

exceptions are Antecol and Bedard (2006) and Kaushal (2009). They combined multiple

waves of the National Health Interview Survey to create cohorts of immigrants and

follow them through several survey iterations. Antecol and Bedard examined self-rated

health, health conditions, activity limitation and BMI among Latino immigrants and

Kaushal analyzed obesity among Asian immigrants. I used these studies to inform my

analytic plan.

Data and Sample

The sample was all single-race Asian adults over the age of 18 from the 1995-

2005 waves of the National Health Interview Surveys (NHIS). The NHIS is an annual

nationwide in-person survey of approximately 40,000 households conducted by the

National Center for Health Statistics (NCHS) (CDC, 2010). The NHIS was the most

suitable dataset for this analyses because it is the only nationally-representative and

repeated cross-sectional dataset with a sizeable Asian sample.

In the publicly-available data, some of the Asians respondents can be further

identified by their specific Asian ethnicity: Chinese, Filipino or Asian Indian. Koreans,

Japanese, Vietnamese and smaller subgroups are classified into an "Other Asian"

category. This analysis examined Asian as an aggregated sample, controlling for the

available ethnicities. I did not disaggregate Asians into individual ethnicities, as I

hypothesized that different ethnicities are clustered by cohorts.

The dataset was downloaded from the Integrated Health Interview Series (IHIS),

which provides harmonized data and documentation for the NHIS. The IHIS facilitates

cross-time comparisons of the NHIS by coding variables identically across time and re-

weighting the survey weights according to the waves included in a given sample

(Ruggles et al., 2010). All analyses were matched to the appropriate samples and

weights, depending on the availability of the variables across survey waves and the

sample universe.

Measures

Outcomes

There were three general physical health outcomes measured in this paper:

disability, self-rated health, and obesity. Because I suggested that structural factors

impact the entire health profile of Asian immigrant cohorts, my measures were

accordingly broad enough to include a range of possible illnesses that can reflect the

overall state of population health. I chose to focus on overall measures of well-being to

align with the World Health Organization (WHO) definition of health as a "state of

complete physical, emotional and social well-being, and not merely the absence of

disease or infirmity," (WHO, 1946).

Like all health measures in the NHIS, each outcome measure was obtained

through self-report. While this may raise validity concerns about the measures, other

work has established their validity with objectively measured health outcomes among

other Asian American samples (Brunner Huber, 2007; Ro, 2010).

Disability- This outcome refers to limitations in tasks and roles that one is

expected to be able to do that are caused by one or more health conditions (Pope &

Tarlov, 1991). It is a useful measure of overall health because it encompasses specific

health problems (disease or condition, a missing extremity or organ, or any type of

impairment), as well as disorders not always thought of as health-related problems (i.e.,

alcoholism, drug dependency or reaction, senility, depression, retardation) (IHIS, 2010).

Disability is detrimental to one's quality of life and is predictive of mortality (Scott,

Macera, Cornman, & Sharpe, 1997).

Disability was analyzed as a binary variable that indicated whether a person is

limited in any way. This was a recoded variable from a series of questions about

limitations in working, mobility and memory, and the presence of physical conditions.

An affirmative response to any of these questions indicated that the person had a

limitation. This question wording was changed after 1996; to account for the effect of

potential question wording differences, I included only the 1997-2005 waves of the

survey in analyses with this measure.

Fair/Poor Self-Rated Health - Self-rated health assesses health across a broad

range of illnesses and is understood as "a summary statement about the way in which

numerous aspects of health, both subjective and objective, are combined within the

perceptual framework of the individual respondent," (Tissue, 1972). It has been found to

be a predictor of mortality, health utilization behaviors, and disability (Benyamini &

Idler, 1999; Ferraro, Farmer, & Wybraniec, 1997; Idler & Benyamini, 1997; Idler &

Kasl, 1995).

Self-rated health measured respondents' self-reported general health on a five-

point Likert scale that had the following responses: "Excellent", "Very good", "Good",

"Fair" and "Poor", along with an unrated "unknown" category. The question wording

was consistent throughout 1995 to 2005. This outcome was dichotomized; respondents

who answered fair or poor were coded as 1, all others 0.

Obesity - This is a measure of body composition that is a strong risk factor for

chronic diseases, including Type II diabetes, gallbladder disease, high blood pressure and

osteoarthritis (Must et al., 1999).

Obesity was calculated by self-reported heights and weights using the standard

formula (weight in kilograms divided by the square of the height in meters). In

accordance to the suggested guidelines by IHIS, I restricted the height range to 59 and 76

inches and the weight range to 98 to 289 pounds to account for the changing top and

bottom codes across different survey waves of the NHIS. I categorized BMI according

to the CDC-issued guidelines for obese.

Key Independent Variables

Cohorts - Because of data limitations on visa status and country of origin, I

identified cohorts only through years of entry. This was a series of indicator variables

that represented the years an immigrant entered the United States. There were six

different year-of-entry cohorts that were examined in the analyses: Pre-1980, 1981-1985,

1986-1990, 1991-1995, 1996-2000, 2001-2005. Respondents were categorized into these

cohorts by their years of U.S. residence in a given survey year.

The table below details how the cohort coding corresponds to the historical Asian

immigrant cohorts I previously discussed.

Table 3-1. Historical Cohorts and Corresponding Year of Entry Cohorts

First Professional Wave

Pre-1980

Family Reunification Wave

1981-1985 1986-1990

Refugee Wave

1981-1985 1986-1990

Second Professional Wave

1991-1995 1996-2000 2001-2005

The year of entry cohorts did not exactly match the historical cohorts, but they

offer a rough approximation of their boundaries. While this coding scheme contains

some limitations in examining historical waves of Asian immigration, it enables an

examination of overall health trends across different time periods.

Nativity/Duration - This variable designated the nativity and years of U.S.

residence for the sample. The variable was divided into the following categories: US-

born, 0-4 years, 5-9 years, 10-14 years and over 15 years duration. This coding scheme

was used in previous studies (Cho & Hummer, 2001; Frisbie, Cho, & Hummer, 2001).

The inclusion of a US-born comparison group separates age trends from duration

trends. I used US-born Asians as a reference group because of similarities in educational,

employment, economic and residential characteristics with the Asian foreign-born.

Similar patterns across these common health confounders can narrow down differences

between the foreign-born and US-born comparison groups to migration-related factors.

Because US-born Asians may also experience the consequences of negative societal

reception, I re-ran my analyses with a US-born, non-Hispanic White comparison group

and obtained similar results.

Health Behaviors

I included three health behavior variables, smoking, alcohol use and exercise.

Smoking was included as a binary variable that indicated whether a person was current

smoker. Alcohol was a binary variable that indicated whether a respondent was a

moderate or heavy drinker. I used the CDC guidelines for alcohol use and categorized

moderate or heavy drinkers as current drinkers who drank more than one drink per sitting

for women and two drinks for men (USDA & DHHS, 2005). Exercise was a binary

variable that indicated whether a respondent engaged in the CDC-recommended levels of

physical activity (moderate physical activity at least 5 times a week for 30 minutes or

vigorous physical activity at least 3 times a week for 20 minutes) (CDC, 2005).

Sociodemographic variables

Sociodemographic variables were first examined as outcomes in Hypothesis 1.

Indicator variables for Chinese ethnicity, Filipino ethnicity, Asian Indian ethnicity,

college graduate and self-employed/working without pay for a family business were

tested as outcomes.

For the remaining multivariate models, I included ethnicity, gender and age as

sociodemographic controls. Because of the quasi-cohort design, I controlled for

characteristics that either remained constant through the survey waves (i.e, gender) or did

not have a differential effect through time; for example, everyone in the sample aged at

the same rate and thus had the same age effect.

Cohort Coding

I was not able to recreate the same five-year year-of-entry cohorts across every

survey year from 1995-2005 due to the categorical coding of years of U.S. residence in

the NHIS (0-4 years, 5-9 years, 10-14 years, 15 plus). To classify respondents into

cohorts, I utilized a weighting strategy whereby I calculated the likelihood that a

respondent was in a cohort (pre- 1980, 1981-1985, 1986-1990, 1991-1995, 1996-2000,

2001-2005) based on their years of U.S. residence in a given survey year. I derived the

weights using the Current Population Survey (CPS), which contains information on an

immigrant's year of entry in single or double year intervals. For each NHIS survey year

between 1995-2005,1 used the CPS to calculate the percent of Asian immigrants who

entered the U.S. in a given year.

Table 3-2 demonstrates my weighting process with an example. In the NHIS

survey year 2002, an immigrant who is categorized as having 5-9 years of U.S. residence

entered in the United States between 1993 and 1997. This interval straddles the 1991-

1995 and 1996-2000 cohorts. According to the CPS, 15% of Asian immigrants with 5-9

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years duration in 2002 entered in 1997, 20% of these immigrants entered in 1996, 22% in

1995 and so on. To calculate the likelihood that the respondent was in the 1991-1995

cohort, I summed the prevalence for 1993, 1994 and 1995, the three years of overlap

between the actual year-of-entry interval and the analysis cohort (in gray). I then created

a duplicate copy of the observation. One observation received a weight of .65 to

correspond to the likelihood of being in the 1991-1995 cohort. The second copy received

a weight of .35 to represent its likelihood of being in the 1996-2000 cohort. This cohort

weight was multiplied by the person weight in the complex survey weighting scheme for

a new person weight. For the full weighting scheme, see Appendix A.

Table 3-2. Weighting Example for NHIS Survey Year 2002, 5-9 years of U.S. Residence

Years in the US 3 4

5 6

7 M l '

8 9 10 11

12 13 14

Year of Entry 1999 1998

1997 1996

1995 1994 i 199 V" 1992 1991

1990 1989 1988

Weight for 1991-1995 cohort Weight for 1996-2000 cohort

Distribution from CPS 0 0

0.15

0.2

0.22

0.25 , - 0.18 , , 0 0

0 0 0 0.65 0.35

Actual years of entry

k Analvsis Cohort

Table 3-3 displays the sample sizes and cohorts represented in the 11-year period

included in this analysis, weighted by the CPS-derived cohort weights.

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To check the robustness of the findings among this sample, I performed the

analyses across an additional sample that used the 1995-2005 NHIS waves, but did not

use CPS weights to classify respondents into cohorts. Instead, a duration category for a

given cluster of survey waves was coded in same cohort group. For example, all

respondents with 0-4 years duration during the 1995, 1996, 1997 and 1998 waves were

coded as entering the United States between 1991 and 1995. As a result, neighboring

cohorts have overlapping years, but the general pattern across cohorts should remain the

same. This method has been used in previous research examining cohort effects

(Antecol & Bedard, 2006; Kaushal, 2009). This additional sample produced similar

results for the analyses presented.

Analyses

All analyses were conducted on Stata version 11.2. I also accounted for the ACS

complex survey design using Stata's svy function that accounted for person weights,

strata and cluster design effects.

Model 1- Sociodemographic differences across cohorts

This model examined differences in sociodemographic characteristics across

cohorts. I conducted separate regression models for each sociodemographic outcome

using the following model:

Y i = p , X i + p2Ci + + (33Ni + si

Where Y was the log odds of having a college degree, being Chinese, Filipino, or

Asian Indian or being self-employed or an unpaid family worker. X represented a vector

of covariates (age, gender, US-born, nativity by gender interaction), C represented

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dummy variables for each of the cohorts, with the 1986-1990 cohort as baseline. Using

this reference group enabled comparisons between cohorts representing the Family

Reunification/Refugee waves versus the First and Second Professional waves. N was a

series of dummy variables for the nativity/duration categories. With the addition of the

duration indicator variables, the cohort regression coefficients provided the cohort's

demographic profile at baseline (0-4 years duration) compared to the 1986-1990 cohort.

The regression coefficients for N represent the relative comparison of each duration

group to the 0-4 year group across the entire foreign-born sample.

Model 2 - Baseline health differences across cohorts and duration effects

This model was nearly the same as the previous one, except with disability, self-

rated health or obesity as the outcome. It provided estimates for baseline health across

cohorts as well as the effects of years in the United States across the foreign-born sample,

controlling for cohort baseline health differences. Y was the predicted health outcome, X

was a vector of covariates and C represented dummy variables for each of the cohorts,

with the 1986-1990 cohort as the reference group. N was a series of dummy variables for

the nativity/duration categories.

Y1=p1X1 + p2C, + p3N1 + e1

Additional models included health behavior variables of smoking, alcohol use and

exercise.

Model 3 — Duration difference across cohorts

The final model examined the duration effect among different cohorts.

Y1=p,X, + p2N1 + s,

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Where Y represented the predicted physical health outcomes and N was the

available duration effects for each cohort. I conducted the model separately for each

cohort. To examine differences in duration effects across cohorts, I compared the

strength and direction of the duration coefficients to one another.

Results

Sample Characteristics

Table 3-4 illustrates the sample's demographic and health characteristics by

cohort. While the percent of high school graduates across all cohorts is above the

national average of 84% in the same period (Newburger & Curry, 2000), the most recent

cohorts had the highest percentages with over 90% with a high school education. The

same was also true for college graduation; the most recent cohorts had well over 50%

college graduates. There were some occupational patterns as well; the earliest cohorts

had the highest rates of self-employment and this decreased with more recent cohorts.

Table 3-5 provides the prevalence of health outcomes for each cohort and

duration sample, along with the prevalence for a gender and age-matched comparison

group from the US-born Asian sample. These matched comparison groups enable some

distinction between age and duration patterns among the foreign-born, as age is

confounded with duration. If the ratio of the US-born to foreign-born prevalence remains

constant across duration categories, we can assume that differences among the duration

groups are due to aging.

Within each cohort, the prevalence of each health condition rises with longer

duration. For example, the prevalence of disability for the cohort entering between 1991

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and 1995 grew from 1.8%, 4.0% to 4.4% over the respective duration groups. The

corresponding matched comparison groups also rose within cohorts across all outcomes,

suggesting that some of this upward trend is due to age. For disability and obesity,

however, the ratio of the US-born and foreign-born prevalence decreases within each

cohort, implying that duration may increase prevalence over and above the aging effect.

For self-rated health, however, the ratios remain consistent, suggesting that the upward

trend in reporting fair/poor health across duration categories may be due to increasing

age.

Regression Results

Demographic Characteristics

The regression results for the demographic characteristics confirmed the bivariate

findings that cohorts differ across Asian ethnicity, education and occupational status

(Table 3-6). These patterns coincide with the hypothesized effects of immigration policy.

Two of the cohorts corresponding to the Second Professional Wave (1996-2000, 2001-

2005) were more likely to have a college education and were less likely to be self-

employed than the cohort representing the Family Reunification/Refugee waves (1986-

1990, reference). These cohorts were also more likely to be Asian Indian and less likely

to be Filipino or Chinese, reflecting changes in countries of origin as occupation

concentration in employment visas shifted from healthcare to the high-tech industry.

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Cohort Baseline Health Status and Duration Effects

Disability. The odds for baseline disability status relative to the cohort

representing the latter Family Reunification/Refugee waves (1986-1990, reference) did

not differ across cohorts.

Among the duration categories, the odds of disability increased compared to the

0-4 year reference group. The odds ratios for the 5-9 and 10-14 year categories were 1.70

and 1.69, respectively, and the 15+ year odds was the highest at 1.9. Table 3-7 provides

the regression results for this model.

Self-Rated Health. There were only minor baseline health differences in fair/poor

self-rated health. The cohorts representing the Second Professional Wave (1991-1995,

1996-2000 and 2001-2005) had lower odds for fair/poor self-rated health compared to the

1986-1990 reference group, but only the 1996-2000 cohort was significantly lower.

There was no duration pattern across the cohorts. None of the duration categories

had a significantly different odds ratio for fair/poor self-rated health than the 0-4 year

reference group.

Obesity. The cohorts corresponding to the First Professional Wave (Pre-1980)

and the beginning of the Family Reunification/Refugee wave (1981-1985) had

significantly lower odds for obesity compared to the 1986-1990 reference group. Other

cohorts displayed higher odds, but were not significantly different. The duration

categories displayed an upward trend whereby the longest term duration category had the

highest odds for being overweight or obese relative to the 0-4 year group.

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To determine whether the cohort and duration patterns were driven by health

behaviors, I included health behaviors in the previous analyses (results not shown).

While the health behaviors themselves were related to the health outcomes, their

inclusion did not change the cohort and duration patterns. This is particularly important

for the duration results, which suggests that there are other health-related factors that

progress with longer residence in the United States over and above changing health

patterns.

Duration Differences across Cohorts

I was not able to examine full duration patterns across all of the cohorts because

of the time period of the NHIS survey waves. Instead, I constructed partial duration

analyses for the 1981-1985, 1985-1990, and 1991-1995 and 1996-2000 cohorts. The first

two cohorts corresponded to the Family Reunification/Refugee wave (1981-1985, 1986-

1990) and the latter two corresponded to the Second Professional wave (1991-1995,

1996-2000). The results are listed in Table 3-9.

Disability. In the previous set of results, the odds of disability increased with

longer duration. This pattern was present across all of the examined cohorts, yet did not

reach significance. One exception was the 1991-1995 cohort, in which 5-9 year group

was significantly higher than the 0-4 year reference group.

Self-Rated Health. The only cohort that displayed a significant duration effect

was the 1986-1990 cohort. Longer-term immigrants reported lower odds for fair/poor

self-rated health compared to more recently arrived immigrants. Both the 10-14 year and

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15 years plus categories had lower odds for reporting fair/poor self-rated health than the

5-9 year baseline group (OR=0.79, 0.75, respectively).

Obesity. For all cohorts, the odds for obesity increased with longer duration. The

only exception was the 1996-2000 cohort, in which the obesity odds for the 0-4 year and

5-9 year group did not significantly differ from one another.

Discussion

This paper examined differences in health trajectories among cohorts of Asian

immigrants. I contended that changing circumstances of migration and contexts

reception would impact immigrants' stress and coping processes that proceed with

integration.

I first argued that circumstances of migration would change the characteristics of

incoming migrants. This could impact the stress and coping process by altering potential

coping resources immigrants bring with them and their baseline health status. My results

supported this, as some cohorts appeared to have unique demographic and health profiles.

Both the First and Second Professional Waves were shaped by immigration

policies that preferenced the highly-skilled. The 1965 Immigration Act created visa

preference categories for certain occupations and the 1990 Immigration Act increased

employment-based visas and created a temporary visa for high-skilled workers. The

results pointed to a stronger impact of the 1990 Act in demographic characteristics,

however. Cohorts corresponding to the Second Professional Wave were more likely to

be college educated and less likely to be self-employed compared to Family

Reunification and Refugee waves. The only cohort corresponding to the Second

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Professional Wave that did not have significantly higher college attainment or lower self-

employment was the 1991-1995 cohort. This group straddled the Family

Reunification/Refugee Wave and the Second Professional Wave and their characteristics

may reflect a lag between enactment of the policy and resulting shift in immigrant

characteristics. The First Professional Wave did not show any significant differences in

college graduation compared to the reference group.

While the 1990 Act coincided with demographic differences, it did not appear to

impact cohort health selectivity to the same extent. In fair/poor self-rated health, there

was some indication that the Second Professional Wave had lower odds for this outcome,

yet only one of the three corresponding cohorts had significantly lower odds than the

reference group. Cohorts did not differ in their baseline disability status. The "healthy

immigrant effect" has argued that immigrants are positively selected on health compared

to their native country counterparts, as the act of migration requires physical robustness

(Abraido-Lanza, Dohrenwend, Ng-Mak, & Turner, 1999). Perhaps immigrants across all

cohorts have already been undergone positive health selection to such a degree that

changes in immigration policy may not have noticeably affected their disability or self-

rated health profiles.

There were baseline differences in obesity, but these seem to point to the salience

of geopolitical circumstances in the sending countries over immigration policy influence.

Earlier cohorts displayed significantly lower odds of obesity and odds steadily increased

with more recent cohorts. This finding coincides with other research that has

documented a global increase in BMI in the past 30 years (Caballero, 2007). Such an

109

increase is often attributed to urbanization and the globalization of food production and

marketing (Caballero, 2007). These changes characterize Asian countries particularly

well. Common sending countries, such as India, China, Korea and Taiwan, have seen

accelerated economic growth , accompanied by equally rapid dietary shifts in the past

fifty years (Yoon et al., 2006). The rise of obesity across cohorts suggests that the health

effects of obesity have yet to pose a barrier to migration.

I also argued that contexts of reception were a driving force of integration

experiences and that the accumulated impact of associated stressors would result in

worsening health with duration. Negative societal reception may give rise to stressors

such as racial discrimination, blocked labor market opportunities or nativist domestic

policies that can accumulate over US residence and take a physiological health toll. This

duration analysis was more rigorous than traditional duration analyses, as I controlled for

baseline cohort effects as well as considered the potential mediating effect of health

behaviors. In both disability and obesity, groups with longer duration displayed higher

odds compared to the most recently arrived immigrants, even after controlling for

smoking, alcohol use and exercise. This finding implies that regardless of different

baseline health status, factors related to integration negatively impact health over and

above changing health behaviors.

When coupled with other previously published research, this finding reveals the

salience of stress and coping processes in shaping immigrant health trajectories.

Uppaluri et al. (2001) found that Asian immigrants report more stress as they live longer

in the United States. Potential immigration-related stressors, such as racial

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discrimination, adjustment stress, and language use are regularly associated with negative

health outcomes (Gee, Ro, Gavin, & Takeuchi, 2008; Takeuchi et al., 2007). This

viewpoint can provide a useful counter point to the widespread assumption that health

trajectories are driven by changing health behaviors. Instead, it appears that societal

stressors also have a direct influence on immigrant health patterns.

Finally, I suggested that changes in reception would create differential stressors

and resources across cohorts, which would be seen in dissimilar health trajectories. In

disability and obesity, there were no clear differences across cohorts. While not all of the

duration patterns reached significance, they maintained the same pattern throughout. The

lack of significant effects within cohorts could be due to smaller sample sizes and not to

any true differences in the duration patterns. The similar disability and obesity

trajectories indicate that stressors are consistent across all cohorts and that all immigrants

experience their negative effects. Immigrants in the Second Professional Wave should

have better theorized resources against stressors due to their higher educational and

occupational characteristics, but the limited datas preclude any definitive conclusions. I

was only able to examine duration patterns among two cohorts corresponding to this

wave, the 1991-1995 and 1996-2000 cohorts. Of these, only the latter showed

significantly higher college attainment or occupational patterns. Within this cohort, there

were no significant differences between more recent and older duration groups, although

it is unclear whether this is due to the protective effect of their more favorable

demographic characteristics or because of their relatively short tenure in the United

States.

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