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Self-rated health of Middle Eastern immigrants in the US: a national study
p u b l i c h e a l t h 1 8 0 ( 2 0 2 0 ) 6 4 e7 3
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Original Research
Self-rated health of Middle Eastern immigrants in the US: a national study M. Alkaid Albqoor a,*, J.L. Chen b,1, S. Weiss c,2, C. Waters c,3, J. Choi d,4 a
University of Jordan, Community Health Nursing, Jordan University of California San Francisco, Family Health Care Nursing, USA c University of California San Francisco, Community Health Systems, USA d University of California San Francisco, Institute for Health Aging, USA b
article info
abstract
Article history:
Objectives: The aim of the study was to examine self-rated health (SRH) of Middle Eastern
Received 30 May 2019
immigrants in the US compared with US-born non-Hispanic whites and to examine factors
Received in revised form
associated with fair/poor SRH among Middle Eastern immigrants in the US.
2 October 2019
Study design: We used a cross-sectional design to analyze the National Health Interview
Accepted 30 October 2019
Survey from 2001 to 2015. Methods: Secondary survey analysis procedures were conducted using the SAS program, with a total of 3,966 Middle Eastern and 731,285 US-born non-Hispanic whites. Descriptive
Keywords:
statistics and regression analyses were used.
Middle Eastern
Results: Middle Eastern immigrants had significantly higher rates of fair/poor SRH than US-
Immigrants
born whites across the three survey waves. Reporting symptoms of serious psychological
Self-rated health
distress, older age (60þ years), current alcohol-drinking status, and having a family member
Non-hispanic
with disability were the factors associated significantly with higher odds of reporting fair/poor SRH in Middle Eastern immigrants, whereas education was a protecting factor of fair/poor SRH. Conclusions: This study indicates that Middle Eastern immigrants are one of the US immigrant populations that report poor health status, which reveals the need for health policy attention to reduce health disparities. © 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Self-rated health (SRH) is a key indicator of individuals' health behavior and outcomes.1 The single question of SRH has been
implied globally as an outcome measure in different health research studies and programs.2 SRH is a strong predictive measure of mortality and morbidity.3e5 Research on SRH of different ethnic and racial groups showed significant
* Corresponding author. Tel.: þ962791163021. E-mail addresses: [email protected] (M. Alkaid Albqoor), [email protected] (J.L. Chen), [email protected] (S. Weiss), [email protected] (C. Waters), [email protected] (J. Choi). 1 Tel.: þ415 502 6015. 2 Tel.: þ415 476 3105. 3 Tel.: þ415 502 7995. 4 Tel.: þ415 514 2534. https://doi.org/10.1016/j.puhe.2019.10.019 0033-3506/© 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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variations on health outcomes in the US. For example, racial minority populations report worse health status than the general population.6e8 Research on factors affecting SRH of ethnic minorities in the US found that income, education, and employment are significant predictors of SRH.9e11 Better socioeconomic status (SES) including employment and education are significantly associated with better SRH.12e15
Middle Eastern immigrants in the US Most Middle Eastern immigrants in the US are from Arab countries that share the same historical, political, and cultural background.16e18 There are approximately 3.7 million Arabs living in the US.19 They are considered one of the fastest growing populations in the US.20 In 2000, there were approximately 1.8 million Arabs in the US, which contributed to less than 1% of the US population.21 In 2010, their numbers reached 3.7 million, with a growth rate of 47% during these 10 years.22 In general, Arab immigrants have higher levels of education and median annual household income, than the general US population in the US Census.23 Despite these facts, Arab immigrants have a higher proportion of people living in poverty and individuals with no health insurance.24 As most Middle Eastern immigrants are Arabs, the sample of this study reflects Arab immigrants in the US. Research on the health of Arab immigrants is very limited, and many of the studies were conducted on small convenient samples.25 Although this ethic group has been experiencing several forms of discrimination and media attention, the literature lacks studies that consider the effects of political and socio-economic factors on their health.25 Previous research outcomes on fair and poor SRH among Arab/Middle Eastern immigrants call for investigating this problem on a large sample size including all the years after September 11, 2001. This study is significant as it examines how Arabs' ethnicity plays a role in their SRH by comparing it with the SRH among US-born non-Hispanic whites, considering any effects of specific socio-economic conditions and acculturation.
Acculturation and SRH The unidimensional model of acculturation was developed to explain how immigrants acquire culture from a host country and how they reduce their alignment with their original culture.26 The unidimensional model of acculturation identifies three main stages occurring in acculturation; unacculturated, bicultural, and acculturated.27 These stages explain how immigrants step away from their inherited culture and acquire the host country's culture as they stay longer in the hosting culture.28 The main indicators of acculturation in this model are language, place of birth, citizenship, and length of stay in the host country. The unidimensional model of acculturation was used in this study to help explain the relationship of indicators of acculturation and sociodemographic status to SRH of Middle Eastern immigrants in the US. This model has been used in a large number of studies on Hispanic, Asian, and African-American populations.17,29e34 It has been used to guide research on mental and physical health issues among immigrants. According to the unidimensional model of
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acculturation, as immigrants encounter the foreign culture and move from being unacculturated to acculturated, they face stress that results from this process. The degree of difference between an immigrant's culture and a host country's culture is viewed as increasing the risk of greater stress. It is well documented in the literature that acculturative stress has a significant negative impact on the overall physical and mental health of immigrants.35e37 The indicators of acculturation in this study have been selected because of having significant effects on Arab immigrants' health.25,34,38 Rates of fair/poor SRH among Middle Eastern immigrants in the US in previous research studies varied widely from 4.7% to 41%.39 The prevalence was reported around 13% in two nationally representative samples.17,34 The literature on factors influencing SRH of Middle Eastern immigrants found that some proxies of acculturation significantly predicted their SRH and US nativity and English speaking significantly predicted better SRH, whereas US citizenship predicted opposite patterns (worse SRH), and the number of years lived in the US was not a significant predictor of SRH.39 However, previous research on the effect of acculturation on SRH of Asian and Latino immigrants in the US found that US nativity and limited English proficiency were associated with worse SRH.40 This suggests how the effect of acculturation may take different directions on immigrants' health. Higher income, education, and employment predicted better SRH of Middle Eastern immigrants.41 Previous research on Middle Eastern immigrants established some evidence on factors predicting higher or lower risk of fair/poor SRH. However, although rates of fair/poor SRH varied widely in this population, no previous studies examined the trends of these rates nationally. Moreover, most of these studies did not focus on first-generation Middle Eastern immigrants as a distinct group; they either compared them based on nativity or did not differentiate their nativity. Further factors such as family size, presence of children in the family, presence of individuals with a disability in the family, or smoking, drinking alcohol, or having symptoms of serious psychological distress (SPD) have not been examined in previous studies. The literature indicated that immigrant families have special circumstances that affect the overall health of their members, such as the process of transition and adjustment to a new society and culture, changes in the roles of family members, and new financial responsibilities. These conditions have been linked to higher risk of physical and mental health problems among immigrants.42 SPD is defined as a status of stress that indicates having a serious mental illness. SPD can be screened using the Kessler scale that evaluates depressive and anxiety symptoms, such as feeling nervous, feeling hopeless, feeling restless, feeling depressed, and feeling sad.43 Previous research showed that Arab immigrants in the US have significantly higher rates of SPD than foreign-born and native white populations.44 Therefore, there is a need in this study to examine the relationship between SPD and SRH of Middle Eastern immigrants in the US. The study aims were (1) to examine rates of fair/poor SRH among Middle Eastern immigrants in the US compared with those among US-born non-Hispanic whites for three survey waves from 2001 to 2015 and (2) to investigate the associations
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of variables including age, gender, income, education, SPD, family size, presence of children in the family, presence of individuals with a disability in the family, smoking, drinking alcohol, body weight, and acculturation with fair/poor SRH among Middle Eastern immigrants in the US.
Methods Sample We used data from the National Health Interview Survey (NHIS). This survey provides annual data on the health of the US population.24 The inclusion criteria for this study were adults aged 18 years and older, those self-identified as firstgeneration Middle Eastern immigrants in the US, or US-born non-Hispanic whites. Because Middle Eastern immigrants comprise a very small fraction of the NHIS samples, sampling weights were applied to the analyses to ensure reliable estimates and to ensure representation of all respondents regardless of their number in the sample. Thus, this study included all the available samples of Middle Eastern immigrants in the NHIS between 2001 and 2015, and three survey waves were used to allow for comparison overtime.
Procedures The NHIS is a primary source of health data for the US populations.45 It collects data through interviews conducted by the US Census Bureau staff. The interviews are conducted in the participants' homes. The survey covers two main types of questions: core questions and supplemental questions. The core questions assess issues about households, families, adults, and children, whereas the supplemental questions cover specific topics that depend on changes in the public health of the US.46 In this study, data on first-generation Middle Eastern immigrants in the US and US-born non-Hispanic whites from three NHIS files were used (family file, person file, and sample adult file). All interviews were conducted in English language. The NHIS design follows a multistage area probability selection that assures selecting the appropriate number of primary sampling units (PSUs) based on population density in these units. PSUs are nested within clusters; each PSU can be a county or a small group of adjacent counties.24 A more detailed study procedure of the NHIS can be found in the Centers for Disease Control and Prevention (CDC) NHIS website.47
status and years lived in the US (less than 5 years, five to 14 years, and 15 years or more). The intervals of these years were adopted from the previous national study on Middle Eastern immigrants and from previous research that examined the relationship between duration of stay in the US and immigrants' health.17,48 Other factors examined in this study included family size, family income, number of children in the family, presence of a family member who needs help with activities of daily living, age, sex, education, income, mental health care history, and health behaviors including smoking, alcohol drinking, and body mass index.
Statistical analyses The NHIS sampling design requires following special weighting adjustment in the data analysis procedures. Adjusted weighting variables for the combined 15 years in person, sample adult, and family files were used. Sampling weights were applied to the analyses to make reliable estimates of the analysis units. This procedure is required to ensure representation of the respondents and to eliminate possible effects of non-response and the poststratification factors.49 The NHIS variance estimation guidance was used to develop modified variance estimation variables in the conducted procedures on SAS and SASSUDAAN. Because the NHIS changed sampling designs between 1997e2005 and 2006e2015, variance estimation variables were modified to develop a pooled variance for the analyzed 15 surveys. The NHIS recommends using the variance approximation procedure to account for complex sample design called Taylor series linearization, which can be used in SAS and SASSUDAAN-Callable procedures.50 The NHIS recommends using SAS survey analysis procedures, such as SURVEYFREQ, SURVEYMEANS, and SURVEYLOGISTIC as not using survey analysis procedures leads to incorrect variance estimates.51 Appropriate variance estimation variables of pooled 15 years for the included PSUs and strata in the study were used. SAS survey procedures were used to conduct descriptive analysis to examine frequencies, proportions, and means. The domain analysis in survey procedures was used, and changes in rates of fair/poor SRH were tracked among Middle Eastern immigrants in 2001e2005, 2006e2010, and 2011e2015, compared with those among US-born non-Hispanic whites. The variables were tested for significant correlation with the outcome before entering the regression model. They were also tested for multicollinearity. Statistical analyses were conducted using the SAS program, and P value was set at a 0.05 significance level.
Variables and measures
Results The outcome in the study was SRH. It is measured in the NHIS by the question that asks individuals to rate their health by choosing one of the five Likert scale answers (excellent, very good, good, fair, or poor). This SRH measure has been widely tested and validated for individuals' health status and has been identified as a key predictor of mortality and morbidity.3e5 The independent variables examined in the study were ethnicity (Middle Eastern immigrants versus US-born nonHispanic whites), the survey years (2001e2005, 2006e2010, and 2011e2015), and two proxies of acculturation: citizenship
Sample characteristics The final number of adult Middle Eastern respondents for the 15 years (2001e2015) was 3,966, and the total number of adult US-born non-Hispanic white respondents for the same period was 731,285. The total number of strata in the study was 639, and the total number of PSUs was 1278. Table 1 shows descriptive characteristics of the two samples in the study. US-born non-Hispanic whites had significantly higher
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Table 1 e Descriptive characteristics. Characteristics
Middle Eastern immigrants, % (weighted n)
US-born non-Hispanic whites, % (weighted n)
11.49% (117,942) 49.4 (0.55)
9.47% (16,777,223) ** 41.9 (0.09) **
20.42% 22.06% 20.41% 17.53% 19.58% 47.21%
19.62%, not significant 15.98% ** 18.54% * 18.11%, not significant 27.73% ** 52.10% **
65.26% 22.14% 12.60%
58.49% ** 23.86% * 17.66% **
19.72% 21.37% 21.34% 37.56%
27.23% 24.30% 25.06% 23.42%
30.06% 46.87% 18.93% 6.26%
34.98% ** 49.96% * 9.31% ** 8.66%, not significant
63.64% 18.40% 17.95%
51.69%, not significant 26.88% ** 21.44% *
42.88% 7.56% 49.57%
16.23% ** 16.80% ** 66.97% **
Reported fair/poor SRH Mean age in years (SD) Age group (years) 18e29 30e39 40e49 50e59 60 Female Marital status Married Never married Separated/widow/divorced Education6 members Number of family members aged <18 years 1 2 or 3 4 or 5 >5 Any family member who needs help with ADL (yes) Reported SPD
** ** ** **
19.27% 27.43% 53.30% 62.13% 38.60% 36.15% 17.17% 8.08%
42.44% ** 37.04%, not significant 13.80% ** 6.72% **
66.41% 26.14% 5.85% 1.60% 5.32% 5.10% (14,915)
64.31%, not significant 29.14% ** 5.65%, not significant 0.89%, not significant 3.54% ** 3.43% (174,7583) **
SPD, serious psychological distress; SD, standard deviation; SRH, self-rated health; NHIS, National Health Interview Survey; ADL, activities of daily living; FDL, federal poverty line. Weighted frequencies are shown for the two subsamples (Middle Easteborn immigrants) and (US-born non-Hispanic whites) from the NHIS 2001e2015 (N ¼ 233,638 of the 15-year sample).*P value < 0.05. **P value < 0.01.
proportion of females (P < 0.01) than Middle Eastern immigrants. Middle Eastern immigrants had significantly higher proportion of adults with bachelor's degree or higher and lower proportion of adults with less than high-school education (P < 0.01). They have significantly higher proportions of low levels of ratio of income to poverty level. Middle Eastern immigrants were also significantly younger in age and have significantly higher proportion of individuals with SPD
(P < 0.001). Other differences in the characteristics of the two samples are displayed in Table 1.
The rates of fair/poor SRH In the first examined survey wave (2001e2005), the rate of fair/ poor SRH was 11.31% among Middle Eastern immigrants and 8.92% among US-born non-Hispanic whites. The rate declined
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to 10.34% in the Middle Eastern group in 2006e2010 (P value ¼ 0.538), whereas it went up significantly to 9.45% among US-born non-Hispanic whites (P value < 0.001). The rate increased to 12.62% in the Middle Eastern group in the third wave from 2011 to 2015 (P ¼ 0.379) and increased significantly to 10.08% among US-born non-Hispanic whites (P < 0.001) (Fig. 1). These changes were significant among USborn non-Hispanic whites across the survey waves (P < 0.001); however, they were not significant in the Middle Eastern group. The rate of fair/poor SRH for the 15 years was also significantly higher among Middle Eastern immigrants (11.49%), than among US-born non-Hispanic whites (9.47%, P ¼ 0.001).
Factors associated with SPD among Middle Eastern immigrants The analysis revealed that SPD, age, alcohol drinking, and having a family member that needs help with activities of daily living (ADL) were associated with higher risk of fair/poor SRH, whereas higher education was associated with lower risk of fair/poor SRH among Middle Eastern immigrants between 2001 and 2015 (Table 2). Middle Eastern immigrants who reported having symptoms of SPD had almost three times significantly higher odds of reporting fair/poor SRH than those who did not have SPD (odds ratio ¼ 2.99, 95% confidence interval [CI] ¼ 1.40e6.41, P ¼ 0.005). Older age was also a significant predictor of low SRH; Middle Eastern immigrants who were aged 60 years or older had 3.52 times significantly higher odds of reporting fair/poor SRH, than those aged 18 and 29 years (95% CI ¼ 1.28e9.67, P ¼ 0.015). Those who reported that they currently consume alcohol had 2.37 times significantly higher odds of reporting fair/poor SRH than alcohol abstainers (95% CI ¼ 1.29e4.33, P ¼ 0.005), and having a family member who needs help with ADL was associated with 4.46 times significantly higher odds of reporting fair/poor SRH (95% CI ¼ 1.37e14.49, P < 0.001). Higher education levels were associated with lower risk of fair/poor SRH than having less
than high-school education, high-school graduates had 61% significantly lower risk of reporting fair/poor SRH (95% CI ¼ 0.21e0.71, P ¼ 0.002), having some college degree was associated with 64% significantly lower risk of reporting fair/ poor SRH (95% CI ¼ 0.18e0.74, P ¼ 0.006), and having bachelor's degree or higher was associated with 80% significantly lower risk of reporting fair/poor SRH (95% CI ¼ 0.10e0.42, P < 0.001) among Middle Eastern immigrants.
Discussion A significant increase in the rate of fair/poor SRH was observed among US-born non-Hispanic whites across the three survey periods, whereas Middle Eastern immigrants had a drop in the rate between 2006 and 2010, but then the rate increased to the highest level in the last period (2011e2015) for both populations. Tracking these changes in rates of SRH in the US population has shown some discrepancies; however, the increase in rates of fair/poor SRH was reported in some national surveys, such as the Behavioral Risk Factor Surveillance System between 1993 and 2007. Discrepancies in the rates of this survey condensed after adjusting for age, education, and ethnicities.52 Although the previous literature reported wide variations in rates of fair/poor SRH among Middle Eastern immigrants, the national studies on Middle Eastern immigrants reported rates around 13%,17,34 which is very close to the results of this study. The overall increase in the rates of fair/poor SRH in the Middle Eastern sample reflects that despite the healthcare policy improvements in the few recent years, such as implanting plans of the Affordable Care Act, there is a deterioration in US immigrants' health, possibly due to increased sociopolitical tension and anti-immigration attitudes in some US communities.53 Previous research that compared SRH between Middle Eastern immigrants and USborn whites indicated significantly higher risk of fair/poor SRH among Middle Eastern immigrants.34 This could be explained by outcomes of previous research that Middle
% of F/P SRH
F/P SRH Rates in Middle East Group & US-born Whites 14 13 12 11 10 9 8 7 6 5 2001-2005
2006-2010
2011-2015
Survey Years Middle Eastern immigrants
US-born Whites
Fig. 1 e Trends of fair/poor (F/P) SRH rates. SRH, self-rated health.
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Table 2 e Odds ratios, P values, and 95% CIs of reporting fair/poor SRH. Covariates SPD No Yes Age group (years) 18e29 30e39 40e49 50e59 60þ Sex Male Female Education level6 members Years lived in the US <5 years 5e14 years 15 years US citizenship No Yes
OR
P value
95% CI
0.005** 1.00 2.99 1.00 1.93 1.64 1.47 3.52 1.00 0.94 1.00 0.39 0.36 0.20 0.96
1.00 1.07 1.00 1.37 0.92 1.00 1.00 0.72 1.00 1.14 2.37
1.00 4.46 0.89 1.00 0.77 1.14 2.12 1.00 0.48 0.49 1.00 0.77
0.005** 0.089
1.40e6.41
0.143 0.293 0.444 0.015* 0.817
0.80e4.62 0.65e4.11 0.55e3.97 1.28e9.67
0.817 <0.001**
0.55e1.61
0.002** 0.006** <0.001** 0.099 0.899
0.21e0.71 0.18e0.74 0.10e0.42 0.92e1.01
0.899 0.471
0.37e3.07
0.310 0.824 0.675
0.75e2.53 0.42e2.01
0.995 0.388 0.027*
0.53e1.89 0.34e1.53
0.825 0.005** <0.001**
0.35e3.74 1.29e4.33
<0.001** 0.741 0.500
1.37e14.49 0.43e1.82
0.439 0.821 0.330 0.297
0.39e1.51 0.36e3.65 0.47e9.53
0.132 0.153 0.457
0.18e1.25 0.18e1.30
0.457
0.38e1.54
SPD, serious psychological distress; OR, odds ratio; CI, confidence interval; BMI, body mass index; SRH, self-rated health. *P value < 0.05. **P value < 0.01.
Eastern immigrants lack the “healthy immigrant effect” and they have poor general health status compared with that of the general US population.25,34 A possible explanation for the absence of the healthy immigrant effect is the perspective of experiencing racial discrimination. Research found that immigrants belonging to minorities who are prejudiced against and new immigrants who are discriminated against in their
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housing, education, transportation, and receiving health care have a significant negative effect on their mental and physical health, such as hypertension, depression, and psychological distress.54e56 Middle Eastern immigrants who reported having SPD symptoms were at a significantly higher risk of fair/poor SRH than those who did not report SPD. There is substantial evidence on the robust relationship between psychological wellbeing and self-assessed health; studies found that individuals who report psychological distress, including SPD, have higher risk of fair/poor SRH.57e59 Psychological distress may lead to poor health behaviors that introduce individuals to physical illness.60 Evidence showed that mental illness is also associated with some types of chronic diseases.61 We also found that Middle Eastern immigrants who were aged 60 years or older had significantly higher risk of fair/poor SRH than those of younger ages. This outcome is consistent with previous research on the relationship between aging and poor selfassessed health in immigrants and general populations.2,62e64 Although many previous studies attributed this decline in SRH to the aging process and declining functionality, some other studies showed opposite outcomes regarding the effect of aging on subjective health assessment. These studies were based on the ‘social comparison theory’ that suggests people of older ages tend to rate their health status based on their other age peers' health and norms, which results in an optimistic assessment of their own health status (better SRH) and lower correlation with objective health markers.65 Current alcohol drinking status was significantly associated with higher risk of fair/poor SRH among Middle Eastern immigrants. This outcome was consistent with previous research outcomes66 on negative influence of alcohol drinking on SRH, including harmful drinking patterns.67 Consistent with the theoretical explanation of the mental health effect on health behaviors, living in stress owing to discrimination or stigmatization results in poor health behaviors as maladaptation.68 In the case of alcohol drinking, this poor behavior is associated with poor SRH. Having a person in the family who needs help with ADL was a significant predictor of reporting fair/poor SRH among Middle Eastern immigrants. Significant poor physical and mental health outcomes, including low SRH, depression, anxiety, musculoskeletal disease, and heart disease, were found among individuals who provide care to a family member with disability.69,70 A possible explanation for these poor outcomes is that caregivers in families devote a great deal of time caring for the disabled family member, which impacts the quality time they spend in taking care of their personal needs. Emotional distress also has been found to be associated with the presence of disabled individuals in families. Moreover, complex health insurance plans for disabled individuals, expensive home healthcare plans, and quick hospital discharge plans increased pressure and responsibilities on families with disabled individuals, which negatively affected the SRH of family members.71 Finally, education was the only socio-economic significant predictor of lower fair/poor SRH risk among Middle Eastern immigrants. Evidence on the robust relationship between education as a measure of socio-economic status and selfassessed health is well established.14,72,73 An explanation for
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this finding can be derived from theories of healthy lifestyle that physical and psychological health is affected by personal life choices and the social structure of in which people live. Throughout their life, individuals are affected by these social structures, and they consequently acquire their health behaviors that affect their health.74 Unlike the previous literature on some immigrant populations,75 years lived in the US and citizenship were not associated with SRH of firstgeneration Middle Eastern immigrants in this study. A previous national study on first-generation Middle Eastern immigrants found no significant effect of years lived in the US on their SRH, whereas having US citizenship was associated with poor SRH.34 This pattern could be best explained by lack of “healthy immigrant effect” among this population; the previous literature on the health of Middle Eastern immigrants indicated that these immigrants might come to the US with an existing poor health status or lacking protective health behavior patterns, such as physical activity and consuming healthy food.25,76
economic status are the factors that require more attention. This study adds to the current knowledge of SRH of Middle Eastern immigrants in the US. This population has been suffering higher rates of fair/poor SRH than the US-born white population. In the light of these outcomes, public health policies should focus on mental health and sociocultural characteristics of immigrants. Public health interventions need to consider the effect of health behaviors on improving the health of Middle Eastern immigrants. These interventions include conducting public health programs that encourage healthy behaviors among immigrants. Health promotion and illness prevention programs that emphasize on health behavior change may include community- and familyfocused programs that can reach Middle Eastern immigrants with lower SES. These public health interventions would help create a culturally and socially supportive environment for Middle Eastern immigrants that could improve their mental health and eventually improve their SRH.
Limitations
Author statements
Although we used the largest national dataset on Middle Eastern immigrants in the US, there were some limitations related to the use of this survey, such as limitations of secondary data analysis including the lack of further variables needed to be investigated. For example, there were no more than two proxies to measure acculturation in the survey. Language spoken was not a measure of acculturation in this study as all interviews were conducted in English language. Studying important social and psychological patterns of immigrants' health requires more than two acculturation indicators to find significant evidence. Although the single question of SRH is considered a strong indicator of individuals' health, some research still finds that this question could be affected by the effect of younger age, lower education levels, and its cultural meaning in different minorities and immigrant groups' SRH and other examined factors.38,65 The dataset that we accessed included information about immigrants' origins, which is restricted by the CDC to ensure confidentiality. The outcomes of this study can be generalized to Middle Eastern immigrants in the US because these data were gathered from the single and largest national dataset on this population. Because most Middle Easterners in the US are Arabs, the study results apply to Arab Americans who were born in the Middle East. However, the NHIS does not identify Arabs or Middle Easterners who were born in the US, which makes the outcomes restricted to those born in the Middle East. While the multidimensional model of acculturation explains more dimensions of the acculturation process that cannot be explained by the unidimensional acculturation,77,78 all the available proxies of the unidimensional acculturation were examined in this national survey.
Ethical approval
Conclusions The outcomes of this study have an important implication on immigrants' public healthcare policy. The health of Middle Eastern immigrants is not affected by some acculturation predictors. In contrast, their mental well-being and socio-
Data collection for the NHIS data was approved by the NCHS Research Ethics Review Board (ERB). Analysis of deidentified data from the survey is exempt from the federal regulations for the protection of human research participants. Analysis of restricted data through the NCHS Research Data Center was also approved by the NCHS ERB.
Funding None declared.
Competing interests None declared.
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40. Lommel LL, Chen J-L. The relationship between self-rated health and acculturation in hispanic and asian adult immigrants: a systematic review. Journal of Immigrant and Minority Health/Center for Minority Public Health 2015. https:// doi.org/10.1007/s10903-015-0208-y. 41. Abdulrahim S, Baker W. Differences in self-rated health by immigrant status and language preference among Arab Americans in the Detroit Metropolitan Area. Soc Sci Med 2009;68(12):2097e103. https://doi.org/10.1016/ j.socscimed.2009.04.017. 42. Grewal S, Bottorff JL, Hilton BA. The influence of family on immigrant south asian women's health. J Fam Nurs 2005;11(3):242e63. https://doi.org/10.1177/1074840705278622. 43. National Comorbidity Survey. K10 and K6 scales. 2005. Retrieved from, https://www.hcp.med.harvard.edu/ncs/k6_scales.php. 44. Dallo FJ, Kindratt TB, Snell T. Serious psychological distress among non-Hispanic whites in the United States: the importance of nativity status and region of birth. Soc Psychiatry Psychiatr Epidemiol 2013;48(12):1923e30. https:// doi.org/10.1007/s00127-013-0703-1. 45. Centers for Disease control and prevention (CDC). National health interview survey. 2017. Retrieved from, https://www.cdc. gov/nchs/nhis/index.htm. 46. Centers for Disease Control Prevention & U.S. Department of Health and Human Services. NHIS survey description. 2013. Retrieved from, http://ftp.cdc.gov/pub/Health_Statistics/ NCHS/Dataset_Documentation/NHIS/2012/srvydesc.pdf. 47. Centers for Disease Control Prevention. National health interview survey. 2016. Retrieved from, https://www.cdc.gov/ nchs/nhis/index.htm. 48. Afable A, Ursua R, Wyatt LC, Aguilar D, Kwon SC, Islam NS, Trinh-Shevrin C. Duration of US residence is associated with overweight risk in Filipino immigrants living in New York metro area. Fam Community Health 2016;39(1):13e23. https:// doi.org/10.1097/fch.0000000000000086. 49. Construction and use of sample weights. 2008. https://doi.org/ 10.18356/e5b16f50-en. 50. Survival Analysis with Complex Survey Data. Complex survey data analysis with SAS®. 2016. p. 157e85. https://doi.org/ 10.1201/9781315366906-8. 51. Moriarity C. Analysis of national health interview survey data. 2010. Retrieved from, https://www.cdc.gov/nchs/ppt/ nchs2010/46_moriarity.pdf. 52. Salomon JA, Nordhagen S, Oza S, Murray CJL. Are Americans feeling less healthy? The puzzle of trends in self-rated health. Am J Epidemiol 2009;170(3):343e51. https://doi.org/10.1093/aje/ kwp144. 53. Hall E, Cuellar NG. Immigrant health in the United States: a trajectory toward change. J Transcult Nurs 2016;27(6):611e26. https://doi.org/10.1177/1043659616672534. 54. Lee R. Does the healthy immigrant effect apply to mental health? Examining the effects of immigrant generation and racial and ethnic background among Australian adults. SSM Population Health 2019;7:100311. https://doi.org/10.1016/ j.ssmph.2018.10.011. 55. Dolezsar CM, Mcgrath JJ, Herzig AJM, Miller SB. Perceived racial discrimination and hypertension: a comprehensive systematic review. Health Psychol 2014;33(1):20e34. https:// doi.org/10.1037/a0033718. 56. Viruell-Fuentes EA, Miranda PY, Abdulrahim S. More than culture: structural racism, intersectionality theory, and immigrant health. Soc Sci Med 2012;75(12):2099e106. https:// doi.org/10.1016/j.socscimed.2011.12.037. 57. Amstadter AB, Begle AM, Cisler JM, Hernandez MA, Muzzy W, Acierno R. Prevalence and correlates of poor self-rated health in the United States: the national elder mistreatment study. Am J Geriatr Psychiatry 2010;18(7):615e23. https://doi.org/ 10.1097/JGP.0b013e3181ca7ef2.
58. Krieger N, Kosheleva A, Waterman PD, Chen JT, Koenen K. Racial discrimination, psychological distress, and self-rated health among US-born and foreign-born black Americans. Am J Public Health 2011;101(9):1704e13. https://doi.org/10.2105/ AJPH.2011.300168. 59. Torres JM, Wallace SP. Migration circumstances, psychological distress, and self-rated physical health for Latino immigrants in the United States. Am J Public Health 2013;103(9):1619e27. https://doi.org/10.2105/ AJPH.2012.301195. 60. Ohrnberger J, Fichera E, Sutton M. The relationship between physical and mental health: a mediation analysis. Soc Sci Med 2017;195:42e9. https://doi.org/10.1016/ j.socscimed.2017.11.008. 61. Hemingway H, Marmot M. Evidence based cardiology: psychosocial factors in the aetiology and prognosis of coronary heart disease: systematic review of prospective cohort studies. BMJ 1999;318(7196):1460e7. https://doi.org/ 10.1136/bmj.318.7196.1460. 62. Arnadottir SA, Gunnarsdottir ED, Stenlund H, LundinOlsson L. Determinants of self-rated health in old age: a population-based, cross-sectional study using the International Classification of Functioning. BMC Public Health 2011;11:670. https://doi.org/10.1186/1471-2458-11-670. 63. Kawada T, Wakayama Y, Katsumata M, Inagaki H, Otsuka T, Hirata Y, Li Q. Patterns in self-rated health according to age and sex in a Japanese national survey, 1989e2004. Gend Med 2009;6(1):329e34. https://doi.org/ 10.1016/j.genm.2009.04.001. € m E, 64. Molarius A, Berglund K, Eriksson C, Lambe M, Nordstro Eriksson HG, Feldman I. Socioeconomic conditions, lifestyle factors, and self-rated health among men and women in Sweden. Eur J Public Health 2007;17(2):125e33. https://doi.org/ 10.1093/eurpub/ckl070. 65. Schnittker J. The shifting signification of self-rated health. 2003. Retrieved from, http://parc.pop.upenn.edu/sites/parc.pop. upenn.edu/files/parc/PARCwps03-03.pdf. 66. Demirchyan A, Petrosyan V, Thompson ME. Gender differences in predictors of self-rated health in Armenia: a population-based study of an economy in transition. Int J Equity Health 2012;11:67. https://doi.org/10.1186/1475-9276-11-67. 67. Jepsen R, Dogisso TW, Dysvik E, Andersen JR, Natvig GK. A cross-sectional study of self-reported general health, lifestyle factors, and disease: the Hordaland Health Study. PeerJ 2014;2. https://doi.org/10.7717/peerj.609. e609. 68. Hatzenbuehler ML, Phelan JC, Link BG. Stigma as a fundamental cause of population health inequalities. Am J Public Health 2013;103(5):813e21. https://doi.org/10.2105/ajph.2012.301069. 69. Lu W-H, Chiou S-T, Chen L-K, Hsiao F-Y. Functional and mental health outcomes of the joint effects of spousal health: the potential threats of “concordant frailty. J Am Med Dir Assoc 2016;17(4):324e30. https://doi.org/10.1016/ j.jamda.2016.01.006. € rensen S. Differences between caregivers and 70. Pinquart M, So noncaregivers in psychological health and physical health: a meta-analysis. Psychol Aging 2003;18(2):250e67. https:// doi.org/10.1037/0882-7974.18.2.250. 71. Family Caregiver Alliance. Caregiver health. 2006. Retrieved from, https://www.caregiver.org/caregiver-health. 72. Adler NE, Boyce T, Chesney MA, Cohen S, Folkman S, Kahn RL, Syme SL. Socioeconomic status and health. The challenge of the gradient. Am Psychol 1994;49(1):15e24. 73. Kitagawa EM, Hauser PM. Differential mortality in the United States: a study in socioeconomic epidemiology. 1973. from, https:// repository.library.georgetown.edu/handle/10822/764543. [Accessed 8 August 2017]. 74. Wang J, Geng L. Effects of socioeconomic status on physical and psychological health: lifestyle as a mediator. Int J Environ
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Original Research
Self-rated health of Middle Eastern immigrants in the US: a national study M. Alkaid Albqoor a,*, J.L. Chen b,1, S. Weiss c,2, C. Waters c,3, J. Choi d,4 a
University of Jordan, Community Health Nursing, Jordan University of California San Francisco, Family Health Care Nursing, USA c University of California San Francisco, Community Health Systems, USA d University of California San Francisco, Institute for Health Aging, USA b
article info
abstract
Article history:
Objectives: The aim of the study was to examine self-rated health (SRH) of Middle Eastern
Received 30 May 2019
immigrants in the US compared with US-born non-Hispanic whites and to examine factors
Received in revised form
associated with fair/poor SRH among Middle Eastern immigrants in the US.
2 October 2019
Study design: We used a cross-sectional design to analyze the National Health Interview
Accepted 30 October 2019
Survey from 2001 to 2015. Methods: Secondary survey analysis procedures were conducted using the SAS program, with a total of 3,966 Middle Eastern and 731,285 US-born non-Hispanic whites. Descriptive
Keywords:
statistics and regression analyses were used.
Middle Eastern
Results: Middle Eastern immigrants had significantly higher rates of fair/poor SRH than US-
Immigrants
born whites across the three survey waves. Reporting symptoms of serious psychological
Self-rated health
distress, older age (60þ years), current alcohol-drinking status, and having a family member
Non-hispanic
with disability were the factors associated significantly with higher odds of reporting fair/poor SRH in Middle Eastern immigrants, whereas education was a protecting factor of fair/poor SRH. Conclusions: This study indicates that Middle Eastern immigrants are one of the US immigrant populations that report poor health status, which reveals the need for health policy attention to reduce health disparities. © 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Self-rated health (SRH) is a key indicator of individuals' health behavior and outcomes.1 The single question of SRH has been
implied globally as an outcome measure in different health research studies and programs.2 SRH is a strong predictive measure of mortality and morbidity.3e5 Research on SRH of different ethnic and racial groups showed significant
* Corresponding author. Tel.: þ962791163021. E-mail addresses: [email protected] (M. Alkaid Albqoor), [email protected] (J.L. Chen), [email protected] (S. Weiss), [email protected] (C. Waters), [email protected] (J. Choi). 1 Tel.: þ415 502 6015. 2 Tel.: þ415 476 3105. 3 Tel.: þ415 502 7995. 4 Tel.: þ415 514 2534. https://doi.org/10.1016/j.puhe.2019.10.019 0033-3506/© 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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variations on health outcomes in the US. For example, racial minority populations report worse health status than the general population.6e8 Research on factors affecting SRH of ethnic minorities in the US found that income, education, and employment are significant predictors of SRH.9e11 Better socioeconomic status (SES) including employment and education are significantly associated with better SRH.12e15
Middle Eastern immigrants in the US Most Middle Eastern immigrants in the US are from Arab countries that share the same historical, political, and cultural background.16e18 There are approximately 3.7 million Arabs living in the US.19 They are considered one of the fastest growing populations in the US.20 In 2000, there were approximately 1.8 million Arabs in the US, which contributed to less than 1% of the US population.21 In 2010, their numbers reached 3.7 million, with a growth rate of 47% during these 10 years.22 In general, Arab immigrants have higher levels of education and median annual household income, than the general US population in the US Census.23 Despite these facts, Arab immigrants have a higher proportion of people living in poverty and individuals with no health insurance.24 As most Middle Eastern immigrants are Arabs, the sample of this study reflects Arab immigrants in the US. Research on the health of Arab immigrants is very limited, and many of the studies were conducted on small convenient samples.25 Although this ethic group has been experiencing several forms of discrimination and media attention, the literature lacks studies that consider the effects of political and socio-economic factors on their health.25 Previous research outcomes on fair and poor SRH among Arab/Middle Eastern immigrants call for investigating this problem on a large sample size including all the years after September 11, 2001. This study is significant as it examines how Arabs' ethnicity plays a role in their SRH by comparing it with the SRH among US-born non-Hispanic whites, considering any effects of specific socio-economic conditions and acculturation.
Acculturation and SRH The unidimensional model of acculturation was developed to explain how immigrants acquire culture from a host country and how they reduce their alignment with their original culture.26 The unidimensional model of acculturation identifies three main stages occurring in acculturation; unacculturated, bicultural, and acculturated.27 These stages explain how immigrants step away from their inherited culture and acquire the host country's culture as they stay longer in the hosting culture.28 The main indicators of acculturation in this model are language, place of birth, citizenship, and length of stay in the host country. The unidimensional model of acculturation was used in this study to help explain the relationship of indicators of acculturation and sociodemographic status to SRH of Middle Eastern immigrants in the US. This model has been used in a large number of studies on Hispanic, Asian, and African-American populations.17,29e34 It has been used to guide research on mental and physical health issues among immigrants. According to the unidimensional model of
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acculturation, as immigrants encounter the foreign culture and move from being unacculturated to acculturated, they face stress that results from this process. The degree of difference between an immigrant's culture and a host country's culture is viewed as increasing the risk of greater stress. It is well documented in the literature that acculturative stress has a significant negative impact on the overall physical and mental health of immigrants.35e37 The indicators of acculturation in this study have been selected because of having significant effects on Arab immigrants' health.25,34,38 Rates of fair/poor SRH among Middle Eastern immigrants in the US in previous research studies varied widely from 4.7% to 41%.39 The prevalence was reported around 13% in two nationally representative samples.17,34 The literature on factors influencing SRH of Middle Eastern immigrants found that some proxies of acculturation significantly predicted their SRH and US nativity and English speaking significantly predicted better SRH, whereas US citizenship predicted opposite patterns (worse SRH), and the number of years lived in the US was not a significant predictor of SRH.39 However, previous research on the effect of acculturation on SRH of Asian and Latino immigrants in the US found that US nativity and limited English proficiency were associated with worse SRH.40 This suggests how the effect of acculturation may take different directions on immigrants' health. Higher income, education, and employment predicted better SRH of Middle Eastern immigrants.41 Previous research on Middle Eastern immigrants established some evidence on factors predicting higher or lower risk of fair/poor SRH. However, although rates of fair/poor SRH varied widely in this population, no previous studies examined the trends of these rates nationally. Moreover, most of these studies did not focus on first-generation Middle Eastern immigrants as a distinct group; they either compared them based on nativity or did not differentiate their nativity. Further factors such as family size, presence of children in the family, presence of individuals with a disability in the family, or smoking, drinking alcohol, or having symptoms of serious psychological distress (SPD) have not been examined in previous studies. The literature indicated that immigrant families have special circumstances that affect the overall health of their members, such as the process of transition and adjustment to a new society and culture, changes in the roles of family members, and new financial responsibilities. These conditions have been linked to higher risk of physical and mental health problems among immigrants.42 SPD is defined as a status of stress that indicates having a serious mental illness. SPD can be screened using the Kessler scale that evaluates depressive and anxiety symptoms, such as feeling nervous, feeling hopeless, feeling restless, feeling depressed, and feeling sad.43 Previous research showed that Arab immigrants in the US have significantly higher rates of SPD than foreign-born and native white populations.44 Therefore, there is a need in this study to examine the relationship between SPD and SRH of Middle Eastern immigrants in the US. The study aims were (1) to examine rates of fair/poor SRH among Middle Eastern immigrants in the US compared with those among US-born non-Hispanic whites for three survey waves from 2001 to 2015 and (2) to investigate the associations
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of variables including age, gender, income, education, SPD, family size, presence of children in the family, presence of individuals with a disability in the family, smoking, drinking alcohol, body weight, and acculturation with fair/poor SRH among Middle Eastern immigrants in the US.
Methods Sample We used data from the National Health Interview Survey (NHIS). This survey provides annual data on the health of the US population.24 The inclusion criteria for this study were adults aged 18 years and older, those self-identified as firstgeneration Middle Eastern immigrants in the US, or US-born non-Hispanic whites. Because Middle Eastern immigrants comprise a very small fraction of the NHIS samples, sampling weights were applied to the analyses to ensure reliable estimates and to ensure representation of all respondents regardless of their number in the sample. Thus, this study included all the available samples of Middle Eastern immigrants in the NHIS between 2001 and 2015, and three survey waves were used to allow for comparison overtime.
Procedures The NHIS is a primary source of health data for the US populations.45 It collects data through interviews conducted by the US Census Bureau staff. The interviews are conducted in the participants' homes. The survey covers two main types of questions: core questions and supplemental questions. The core questions assess issues about households, families, adults, and children, whereas the supplemental questions cover specific topics that depend on changes in the public health of the US.46 In this study, data on first-generation Middle Eastern immigrants in the US and US-born non-Hispanic whites from three NHIS files were used (family file, person file, and sample adult file). All interviews were conducted in English language. The NHIS design follows a multistage area probability selection that assures selecting the appropriate number of primary sampling units (PSUs) based on population density in these units. PSUs are nested within clusters; each PSU can be a county or a small group of adjacent counties.24 A more detailed study procedure of the NHIS can be found in the Centers for Disease Control and Prevention (CDC) NHIS website.47
status and years lived in the US (less than 5 years, five to 14 years, and 15 years or more). The intervals of these years were adopted from the previous national study on Middle Eastern immigrants and from previous research that examined the relationship between duration of stay in the US and immigrants' health.17,48 Other factors examined in this study included family size, family income, number of children in the family, presence of a family member who needs help with activities of daily living, age, sex, education, income, mental health care history, and health behaviors including smoking, alcohol drinking, and body mass index.
Statistical analyses The NHIS sampling design requires following special weighting adjustment in the data analysis procedures. Adjusted weighting variables for the combined 15 years in person, sample adult, and family files were used. Sampling weights were applied to the analyses to make reliable estimates of the analysis units. This procedure is required to ensure representation of the respondents and to eliminate possible effects of non-response and the poststratification factors.49 The NHIS variance estimation guidance was used to develop modified variance estimation variables in the conducted procedures on SAS and SASSUDAAN. Because the NHIS changed sampling designs between 1997e2005 and 2006e2015, variance estimation variables were modified to develop a pooled variance for the analyzed 15 surveys. The NHIS recommends using the variance approximation procedure to account for complex sample design called Taylor series linearization, which can be used in SAS and SASSUDAAN-Callable procedures.50 The NHIS recommends using SAS survey analysis procedures, such as SURVEYFREQ, SURVEYMEANS, and SURVEYLOGISTIC as not using survey analysis procedures leads to incorrect variance estimates.51 Appropriate variance estimation variables of pooled 15 years for the included PSUs and strata in the study were used. SAS survey procedures were used to conduct descriptive analysis to examine frequencies, proportions, and means. The domain analysis in survey procedures was used, and changes in rates of fair/poor SRH were tracked among Middle Eastern immigrants in 2001e2005, 2006e2010, and 2011e2015, compared with those among US-born non-Hispanic whites. The variables were tested for significant correlation with the outcome before entering the regression model. They were also tested for multicollinearity. Statistical analyses were conducted using the SAS program, and P value was set at a 0.05 significance level.
Variables and measures
Results The outcome in the study was SRH. It is measured in the NHIS by the question that asks individuals to rate their health by choosing one of the five Likert scale answers (excellent, very good, good, fair, or poor). This SRH measure has been widely tested and validated for individuals' health status and has been identified as a key predictor of mortality and morbidity.3e5 The independent variables examined in the study were ethnicity (Middle Eastern immigrants versus US-born nonHispanic whites), the survey years (2001e2005, 2006e2010, and 2011e2015), and two proxies of acculturation: citizenship
Sample characteristics The final number of adult Middle Eastern respondents for the 15 years (2001e2015) was 3,966, and the total number of adult US-born non-Hispanic white respondents for the same period was 731,285. The total number of strata in the study was 639, and the total number of PSUs was 1278. Table 1 shows descriptive characteristics of the two samples in the study. US-born non-Hispanic whites had significantly higher
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Table 1 e Descriptive characteristics. Characteristics
Middle Eastern immigrants, % (weighted n)
US-born non-Hispanic whites, % (weighted n)
11.49% (117,942) 49.4 (0.55)
9.47% (16,777,223) ** 41.9 (0.09) **
20.42% 22.06% 20.41% 17.53% 19.58% 47.21%
19.62%, not significant 15.98% ** 18.54% * 18.11%, not significant 27.73% ** 52.10% **
65.26% 22.14% 12.60%
58.49% ** 23.86% * 17.66% **
19.72% 21.37% 21.34% 37.56%
27.23% 24.30% 25.06% 23.42%
30.06% 46.87% 18.93% 6.26%
34.98% ** 49.96% * 9.31% ** 8.66%, not significant
63.64% 18.40% 17.95%
51.69%, not significant 26.88% ** 21.44% *
42.88% 7.56% 49.57%
16.23% ** 16.80% ** 66.97% **
Reported fair/poor SRH Mean age in years (SD) Age group (years) 18e29 30e39 40e49 50e59 60 Female Marital status Married Never married Separated/widow/divorced Education
** ** ** **
19.27% 27.43% 53.30% 62.13% 38.60% 36.15% 17.17% 8.08%
42.44% ** 37.04%, not significant 13.80% ** 6.72% **
66.41% 26.14% 5.85% 1.60% 5.32% 5.10% (14,915)
64.31%, not significant 29.14% ** 5.65%, not significant 0.89%, not significant 3.54% ** 3.43% (174,7583) **
SPD, serious psychological distress; SD, standard deviation; SRH, self-rated health; NHIS, National Health Interview Survey; ADL, activities of daily living; FDL, federal poverty line. Weighted frequencies are shown for the two subsamples (Middle Easteborn immigrants) and (US-born non-Hispanic whites) from the NHIS 2001e2015 (N ¼ 233,638 of the 15-year sample).*P value < 0.05. **P value < 0.01.
proportion of females (P < 0.01) than Middle Eastern immigrants. Middle Eastern immigrants had significantly higher proportion of adults with bachelor's degree or higher and lower proportion of adults with less than high-school education (P < 0.01). They have significantly higher proportions of low levels of ratio of income to poverty level. Middle Eastern immigrants were also significantly younger in age and have significantly higher proportion of individuals with SPD
(P < 0.001). Other differences in the characteristics of the two samples are displayed in Table 1.
The rates of fair/poor SRH In the first examined survey wave (2001e2005), the rate of fair/ poor SRH was 11.31% among Middle Eastern immigrants and 8.92% among US-born non-Hispanic whites. The rate declined
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to 10.34% in the Middle Eastern group in 2006e2010 (P value ¼ 0.538), whereas it went up significantly to 9.45% among US-born non-Hispanic whites (P value < 0.001). The rate increased to 12.62% in the Middle Eastern group in the third wave from 2011 to 2015 (P ¼ 0.379) and increased significantly to 10.08% among US-born non-Hispanic whites (P < 0.001) (Fig. 1). These changes were significant among USborn non-Hispanic whites across the survey waves (P < 0.001); however, they were not significant in the Middle Eastern group. The rate of fair/poor SRH for the 15 years was also significantly higher among Middle Eastern immigrants (11.49%), than among US-born non-Hispanic whites (9.47%, P ¼ 0.001).
Factors associated with SPD among Middle Eastern immigrants The analysis revealed that SPD, age, alcohol drinking, and having a family member that needs help with activities of daily living (ADL) were associated with higher risk of fair/poor SRH, whereas higher education was associated with lower risk of fair/poor SRH among Middle Eastern immigrants between 2001 and 2015 (Table 2). Middle Eastern immigrants who reported having symptoms of SPD had almost three times significantly higher odds of reporting fair/poor SRH than those who did not have SPD (odds ratio ¼ 2.99, 95% confidence interval [CI] ¼ 1.40e6.41, P ¼ 0.005). Older age was also a significant predictor of low SRH; Middle Eastern immigrants who were aged 60 years or older had 3.52 times significantly higher odds of reporting fair/poor SRH, than those aged 18 and 29 years (95% CI ¼ 1.28e9.67, P ¼ 0.015). Those who reported that they currently consume alcohol had 2.37 times significantly higher odds of reporting fair/poor SRH than alcohol abstainers (95% CI ¼ 1.29e4.33, P ¼ 0.005), and having a family member who needs help with ADL was associated with 4.46 times significantly higher odds of reporting fair/poor SRH (95% CI ¼ 1.37e14.49, P < 0.001). Higher education levels were associated with lower risk of fair/poor SRH than having less
than high-school education, high-school graduates had 61% significantly lower risk of reporting fair/poor SRH (95% CI ¼ 0.21e0.71, P ¼ 0.002), having some college degree was associated with 64% significantly lower risk of reporting fair/ poor SRH (95% CI ¼ 0.18e0.74, P ¼ 0.006), and having bachelor's degree or higher was associated with 80% significantly lower risk of reporting fair/poor SRH (95% CI ¼ 0.10e0.42, P < 0.001) among Middle Eastern immigrants.
Discussion A significant increase in the rate of fair/poor SRH was observed among US-born non-Hispanic whites across the three survey periods, whereas Middle Eastern immigrants had a drop in the rate between 2006 and 2010, but then the rate increased to the highest level in the last period (2011e2015) for both populations. Tracking these changes in rates of SRH in the US population has shown some discrepancies; however, the increase in rates of fair/poor SRH was reported in some national surveys, such as the Behavioral Risk Factor Surveillance System between 1993 and 2007. Discrepancies in the rates of this survey condensed after adjusting for age, education, and ethnicities.52 Although the previous literature reported wide variations in rates of fair/poor SRH among Middle Eastern immigrants, the national studies on Middle Eastern immigrants reported rates around 13%,17,34 which is very close to the results of this study. The overall increase in the rates of fair/poor SRH in the Middle Eastern sample reflects that despite the healthcare policy improvements in the few recent years, such as implanting plans of the Affordable Care Act, there is a deterioration in US immigrants' health, possibly due to increased sociopolitical tension and anti-immigration attitudes in some US communities.53 Previous research that compared SRH between Middle Eastern immigrants and USborn whites indicated significantly higher risk of fair/poor SRH among Middle Eastern immigrants.34 This could be explained by outcomes of previous research that Middle
% of F/P SRH
F/P SRH Rates in Middle East Group & US-born Whites 14 13 12 11 10 9 8 7 6 5 2001-2005
2006-2010
2011-2015
Survey Years Middle Eastern immigrants
US-born Whites
Fig. 1 e Trends of fair/poor (F/P) SRH rates. SRH, self-rated health.
p u b l i c h e a l t h 1 8 0 ( 2 0 2 0 ) 6 4 e7 3
Table 2 e Odds ratios, P values, and 95% CIs of reporting fair/poor SRH. Covariates SPD No Yes Age group (years) 18e29 30e39 40e49 50e59 60þ Sex Male Female Education level
OR
P value
95% CI
0.005** 1.00 2.99 1.00 1.93 1.64 1.47 3.52 1.00 0.94 1.00 0.39 0.36 0.20 0.96
1.00 1.07 1.00 1.37 0.92 1.00 1.00 0.72 1.00 1.14 2.37
1.00 4.46 0.89 1.00 0.77 1.14 2.12 1.00 0.48 0.49 1.00 0.77
0.005** 0.089
1.40e6.41
0.143 0.293 0.444 0.015* 0.817
0.80e4.62 0.65e4.11 0.55e3.97 1.28e9.67
0.817 <0.001**
0.55e1.61
0.002** 0.006** <0.001** 0.099 0.899
0.21e0.71 0.18e0.74 0.10e0.42 0.92e1.01
0.899 0.471
0.37e3.07
0.310 0.824 0.675
0.75e2.53 0.42e2.01
0.995 0.388 0.027*
0.53e1.89 0.34e1.53
0.825 0.005** <0.001**
0.35e3.74 1.29e4.33
<0.001** 0.741 0.500
1.37e14.49 0.43e1.82
0.439 0.821 0.330 0.297
0.39e1.51 0.36e3.65 0.47e9.53
0.132 0.153 0.457
0.18e1.25 0.18e1.30
0.457
0.38e1.54
SPD, serious psychological distress; OR, odds ratio; CI, confidence interval; BMI, body mass index; SRH, self-rated health. *P value < 0.05. **P value < 0.01.
Eastern immigrants lack the “healthy immigrant effect” and they have poor general health status compared with that of the general US population.25,34 A possible explanation for the absence of the healthy immigrant effect is the perspective of experiencing racial discrimination. Research found that immigrants belonging to minorities who are prejudiced against and new immigrants who are discriminated against in their
69
housing, education, transportation, and receiving health care have a significant negative effect on their mental and physical health, such as hypertension, depression, and psychological distress.54e56 Middle Eastern immigrants who reported having SPD symptoms were at a significantly higher risk of fair/poor SRH than those who did not report SPD. There is substantial evidence on the robust relationship between psychological wellbeing and self-assessed health; studies found that individuals who report psychological distress, including SPD, have higher risk of fair/poor SRH.57e59 Psychological distress may lead to poor health behaviors that introduce individuals to physical illness.60 Evidence showed that mental illness is also associated with some types of chronic diseases.61 We also found that Middle Eastern immigrants who were aged 60 years or older had significantly higher risk of fair/poor SRH than those of younger ages. This outcome is consistent with previous research on the relationship between aging and poor selfassessed health in immigrants and general populations.2,62e64 Although many previous studies attributed this decline in SRH to the aging process and declining functionality, some other studies showed opposite outcomes regarding the effect of aging on subjective health assessment. These studies were based on the ‘social comparison theory’ that suggests people of older ages tend to rate their health status based on their other age peers' health and norms, which results in an optimistic assessment of their own health status (better SRH) and lower correlation with objective health markers.65 Current alcohol drinking status was significantly associated with higher risk of fair/poor SRH among Middle Eastern immigrants. This outcome was consistent with previous research outcomes66 on negative influence of alcohol drinking on SRH, including harmful drinking patterns.67 Consistent with the theoretical explanation of the mental health effect on health behaviors, living in stress owing to discrimination or stigmatization results in poor health behaviors as maladaptation.68 In the case of alcohol drinking, this poor behavior is associated with poor SRH. Having a person in the family who needs help with ADL was a significant predictor of reporting fair/poor SRH among Middle Eastern immigrants. Significant poor physical and mental health outcomes, including low SRH, depression, anxiety, musculoskeletal disease, and heart disease, were found among individuals who provide care to a family member with disability.69,70 A possible explanation for these poor outcomes is that caregivers in families devote a great deal of time caring for the disabled family member, which impacts the quality time they spend in taking care of their personal needs. Emotional distress also has been found to be associated with the presence of disabled individuals in families. Moreover, complex health insurance plans for disabled individuals, expensive home healthcare plans, and quick hospital discharge plans increased pressure and responsibilities on families with disabled individuals, which negatively affected the SRH of family members.71 Finally, education was the only socio-economic significant predictor of lower fair/poor SRH risk among Middle Eastern immigrants. Evidence on the robust relationship between education as a measure of socio-economic status and selfassessed health is well established.14,72,73 An explanation for
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this finding can be derived from theories of healthy lifestyle that physical and psychological health is affected by personal life choices and the social structure of in which people live. Throughout their life, individuals are affected by these social structures, and they consequently acquire their health behaviors that affect their health.74 Unlike the previous literature on some immigrant populations,75 years lived in the US and citizenship were not associated with SRH of firstgeneration Middle Eastern immigrants in this study. A previous national study on first-generation Middle Eastern immigrants found no significant effect of years lived in the US on their SRH, whereas having US citizenship was associated with poor SRH.34 This pattern could be best explained by lack of “healthy immigrant effect” among this population; the previous literature on the health of Middle Eastern immigrants indicated that these immigrants might come to the US with an existing poor health status or lacking protective health behavior patterns, such as physical activity and consuming healthy food.25,76
economic status are the factors that require more attention. This study adds to the current knowledge of SRH of Middle Eastern immigrants in the US. This population has been suffering higher rates of fair/poor SRH than the US-born white population. In the light of these outcomes, public health policies should focus on mental health and sociocultural characteristics of immigrants. Public health interventions need to consider the effect of health behaviors on improving the health of Middle Eastern immigrants. These interventions include conducting public health programs that encourage healthy behaviors among immigrants. Health promotion and illness prevention programs that emphasize on health behavior change may include community- and familyfocused programs that can reach Middle Eastern immigrants with lower SES. These public health interventions would help create a culturally and socially supportive environment for Middle Eastern immigrants that could improve their mental health and eventually improve their SRH.
Limitations
Author statements
Although we used the largest national dataset on Middle Eastern immigrants in the US, there were some limitations related to the use of this survey, such as limitations of secondary data analysis including the lack of further variables needed to be investigated. For example, there were no more than two proxies to measure acculturation in the survey. Language spoken was not a measure of acculturation in this study as all interviews were conducted in English language. Studying important social and psychological patterns of immigrants' health requires more than two acculturation indicators to find significant evidence. Although the single question of SRH is considered a strong indicator of individuals' health, some research still finds that this question could be affected by the effect of younger age, lower education levels, and its cultural meaning in different minorities and immigrant groups' SRH and other examined factors.38,65 The dataset that we accessed included information about immigrants' origins, which is restricted by the CDC to ensure confidentiality. The outcomes of this study can be generalized to Middle Eastern immigrants in the US because these data were gathered from the single and largest national dataset on this population. Because most Middle Easterners in the US are Arabs, the study results apply to Arab Americans who were born in the Middle East. However, the NHIS does not identify Arabs or Middle Easterners who were born in the US, which makes the outcomes restricted to those born in the Middle East. While the multidimensional model of acculturation explains more dimensions of the acculturation process that cannot be explained by the unidimensional acculturation,77,78 all the available proxies of the unidimensional acculturation were examined in this national survey.
Ethical approval
Conclusions The outcomes of this study have an important implication on immigrants' public healthcare policy. The health of Middle Eastern immigrants is not affected by some acculturation predictors. In contrast, their mental well-being and socio-
Data collection for the NHIS data was approved by the NCHS Research Ethics Review Board (ERB). Analysis of deidentified data from the survey is exempt from the federal regulations for the protection of human research participants. Analysis of restricted data through the NCHS Research Data Center was also approved by the NCHS ERB.
Funding None declared.
Competing interests None declared.
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