The COVID-19 pandemic has revealed the challenges in gathering case and mortality data by race and ethnicity, especially for Asian Americans and Pacific Islanders (AAPIs). The typical response would be to gather and disaggregate data among AAPI people. However, to what purpose does data disaggregation serve outside of describing disparities? We argue that collection of data both during and after the COVID-19 pandemic should be framed within principles of equity and justice, ideas put forth by Public Health Critical Race Praxis (PHCRP). Applying a PHCRP framework to data collection and disaggregation allows for researchers and policy makers to approach pandemic data collection and future data collection with both equity and community partnership in mind.

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

Background

Immigrants to the United States are usually healthier than their U.S.-born counterparts, yet the health of immigrants declines with duration of stay in the U.S. This pattern is often seen for numerous health problems such as obesity, and is usually attributed to acculturation (the adoption of "American" behaviors and norms). However, an alternative explanation is secular trends, given that rates of obesity have been rising globally. Few studies of immigrants are designed to distinguish the effects of acculturation versus secular trends, in part because most studies of immigrants are cross-sectional, lack baseline data prior to migration, and do not have a comparison group of non-migrants in the country of origin. This paper describes the Health of Philippine Emigrants Study (HoPES), a study designed to address many of these limitations.

Methods

HoPES is a dual-cohort, longitudinal, transnational study. The first cohort consisted of Filipinos migrating to the United States (n = 832). The second cohort consisted of non-migrant Filipinos who planned to remain in the Philippines (n = 805). Baseline data were collected from both cohorts in 2017 in the Philippines, with follow-up data collection planned over 3 years in either the U.S. for the migrant cohort or the Philippines for the non-migrant cohort. At baseline, interviewers administered semi-structured questionnaires that assessed demographic characteristics, diet, physical activity, stress, and immigration experiences. Interviewers also measured weight, height, waist and hip circumferences, blood pressure, and collected dried blood spot samples.

Discussion

Migrants enrolled in the study appear to be representative of recent Filipino migrants to the U.S. Additionally, migrant and non-migrant study participants are comparable on several characteristics that we attempted to balance at baseline, including age, gender, and education. HoPES is a unique study that approximates a natural experiment from which to study the effects of immigration on obesity and other health problems. A number of innovative methodological strategies were pursued to expand the boundaries of current immigrant health research. Key to accomplishing this research was investment in building collaborative relationships with stakeholders across the U.S. and the Philippines with shared interest in the health of migrants.

PURPOSE:The Health of Philippine Emigrants Study (HoPES) longitudinally investigates over 3 years whether migrating from the Philippines to the USA results in increased risk for obesity relative to non-migrants in the Philippines. The study is designed to test the healthy immigrant hypothesis by collecting health measures from migrants starting from a pre-migration baseline and enrolling a non-migrant cohort matched on age, gender and education for comparison. PARTICIPANTS:A migrant cohort (n=832; 36.5% of eligible individuals) was recruited from clients of the Commission on Filipinos Overseas prior to exiting the Philippines. A non-migrant cohort (n=805; 68.6% eligible individuals) was recruited from community households in municipalities throughout the cities of Manila and Cebu. By intention, these two cohorts are comparable demographically, including urban/rural status of residency in the Philippines at baseline. FINDINGS TO DATE:At baseline, compared with non-migrants, migrants report significantly better self-rated health and less depression, and have significantly larger hip circumference and lower waist-to-hip ratio, as well as significantly higher mean systolic blood pressure and higher mean level of apolipoprotein B. Baseline results can offer insight into the health status of both migrant and non-migrant populations and may be useful for obesity prevention efforts. FUTURE PLANS:Longitudinal data collection is scheduled to be completed in December 2020 when the final data collection wave (36 months after baseline) will conclude. Both migrant and non-migrant cohorts will be maintained beyond the current prospective study, so long as research funding allows and emerges for new study questions. Findings from future longitudinal analyses can inform the need and design of health-related/relevant interventions, whether clinical, behavioural, educational, or policy, that can be implemented at the individual or population level.

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