(Stroke. 1997;28:53-57.)
© 1997 American Heart Association, Inc.
Articles |
Geographic Distribution of Stroke Mortality Among Immigrants to the United States
the Departments of Neurology, Preventive Medicine, and Environmental Health, and the Sanders Brown Center on Aging, University of Kentucky Medical Center, Lexington, and the Neurology Service, Veterans Affairs Medical Center, Lexington, Ky.
Correspondence to Douglas J. Lanska, MD, Department of Neurology, Kentucky Clinic L412, University of Kentucky, Lexington, KY 40536-0284. E-mail DJLANSVA@UKCC.UKY.EDU.
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Abstract |
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Background and Purpose This study examines the geographic distribution of stroke mortality among immigrants and natives of the United States.
Methods National Center for Health Statistics and Bureau of the Census data were used to determine the geographic distribution of age-adjusted, race-, and race/sex-specific stroke mortality rates among immigrants and natives of the United States for 1979 to 1981.
Results For whites and blacks and for each of the respective race/sex groups, immigrants had markedly and highly statistically significantly lower age-adjusted stroke mortality rates than either the entire US-born resident population or the US-born interregional migrant population. The spatial pattern of immigrant rates did not parallel the patterns for US-born populations. Immigrant rates were highest in the West and lowest in the Midwest for whites and highest in the Midwest and lowest in the Northeast for blacks, whereas for both US-born whites and blacks, resident and native rates were highest in the South and lowest in the Midwest. With few exceptions, region-specific immigrant rates for whites and blacks were significantly lower than rates for either US-born regional residents, US-born migrants to the regions, or US-born natives of the regions. In contrast, white immigrants to the West had significantly higher rates than US-born groups in that region.
Conclusions Selection factors strongly influence stroke mortality rates among immigrants to the United States. The aberrantly high rates among white immigrants to the West may in part reflect a bias due to large census undercounts of this population.
Key Words: cerebrovascular disorders • death • epidemiology • mortality • risk factors
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Introduction |
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Although the overall large-scale spatial distribution of resident stroke mortality rates in the United States cannot be explained by migration effects,1 some individual states have rates that are strongly influenced by selective migration.1 2 3 4 In particular, selective elderly interstate migration strongly influences both stroke hospital admission rates and mortality from stroke in certain Sunbelt retirement destination states, especially Florida.1 2 3 For more than four decades, Florida has been the leading destination of elderly interstate migrants, receiving up to one quarter of all elderly migrants; in-migrants to Florida make up a remarkably high proportion (approximately 88%) of the resident elderly population of that state, with recent in-migrants (within the previous 5 years) accounting for approximately 20% of the elderly population. These in-migrants are almost exclusively white, and a large majority are healthy, independent, well educated, and financially secure. As a result of this selective in-migration of large numbers of healthy elderly whites, stroke mortality rates for white residents of Florida became significantly lower than the national rate after World War II and have remained low, in contrast to persistently significantly high rates among black residents of Florida, and in contrast to persistently high rates among both whites and blacks in other South Atlantic states during this period.1 3 This migration-induced selection by health status also produced lower than expected stroke hospitalization rates in Florida but not in other South Atlantic states.3
Immigration is even more highly selective than intranational (eg, interstate) migration and has become more selective in recent years.5 The personal and financial burdens associated with migration, especially long-distance and international migration, and restrictions at the destination (eg, in the form of immigration laws) tend to select relatively healthy individuals. Recent US immigration laws in particular emphasize job-related skills and thereby favor relatively healthy skilled working populations with relatively high income levels. Indeed, immigrants score higher on most respondent-assessed health indicators than do US-born individuals.5 In the 1989 and 1990 National Health Interview Surveys, immigrants consistently reported lower frequencies of chronic conditions or impairments limiting usual activities, lower numbers of days spent in bed because of health conditions, lower numbers of physician contacts, and better self-assessments of overall health compared with US-born individuals.5 The apparent health advantage of immigrants varies inversely with the length of residence in the United States.5
Environmental and sociocultural changes associated with migration may also modify morbidity and mortality, as has been well demonstrated for stroke and ischemic heart disease among Japanese immigrants to Hawaii and California.6 7 8 9 10 In 1957, Gordon11 compared mortality rates among Japanese in Japan, Hawaii, and the continental United States and demonstrated diverging gradients for stroke and ischemic heart disease: stroke mortality rates progressively decreased from Japan to Hawaii to the continental United States, while mortality rates for ischemic heart disease progressively increased. Subsequent studies verified and expanded these findings,7 9 12 13 documenting an incidence, prevalence, and mortality of stroke two to three times higher in Japan than in Japanese emigrants living in the United States, despite the same racial background of the study populations.7 9 13 Moreover, since 1965, collaborative epidemiological studies of stroke in which uniform criteria for diagnoses and comparable clinical, laboratory, and autopsy procedures were used have established that these divergent gradients are not due to artifacts of differing diagnostic or reporting practices, to differences in genetic background of the populations, to differences in atherosclerosis in coronary and major cerebral arteries, or to differences in blood pressure or other conventional stroke risk factors.6 7 8 13 14
The purposes of the present study were (1) to compare the stroke mortality experience of US immigrants with that of US-born residents and (2) to determine whether the regional distribution of stroke mortality rates is the same for these groups.
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Methods |
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Vital Statistics Mortality Data
Data on deaths with cerebrovascular disease listed as the underlying or a contributing cause of death were obtained from public-use, multiple-cause-of-death, machine-readable, US mortality data files created by the National Center for Health Statistics.15 16 17 Data were tabulated for the 3-year period centered on the 1980 decennial census year. Stroke deaths were defined as those coded to rubrics 430 through 438 according to the International Classification of Diseases, 9th Revision, Clinical Modification.18
For multiple-cause tabulations, "record-axis" codes were used; these codes represent the best person-level description of all conditions listed in the medical certification portion of the death certificate. The National Center for Health Statistics derived record-axis codes from "entity-axis codes" of the individual conditions reported by utilizing traditional linkage and modification rules for mortality coding; each entity axis code was examined and modified as appropriate to create a set of record-axis codes that are free of contradictions and duplications and are the most precise within the constraints of the disease classification system and the medical information on the record.19
Census Data
The racial classification used for data collected in the 1980 census differs from that used for vital statistics data and for data collected in previous censuses. Racial counts in the 1980 census were particularly affected by changes in reporting among the Hispanic population and by changes in coding and classification of racial groups. In censuses before 1980, virtually all persons of Hispanic origin were considered white, whereas in the 1980 census, almost 6.7 million people, mostly of Hispanic origin, reported in a residual "other (not specified)" category.20 Although vital statistics data do not include the residual category, routine 1980 census publications and summary tape files present unmodified data with the categories in which the data were collected.
To maintain comparability with the racial designations used in the vital statistics data and to obtain data on lifetime net interregional migration, it was necessary to use individual-level census data and modify the self-reported racial categories. For this purpose, public-use microdata sample A (PUMS-A) was used for the 1980 census, which is an edited abstract of the census basic record tapes for a stratified random subsample of the full census sample that received long-form questionnaires. PUMS-A represents 5% of the US population and contains census records for more than 11 million persons.21 22
Before modification, the PUMS-A population estimates for whites were low compared with Census Bureau modified-race estimates20 23 in states with large Hispanic populations. As an approximation of the complex racial category modification algorithm used by the Bureau of the Census for the preparation of special modified-race summary data files,24 all individuals of Hispanic origin who were originally in the "other (not specified)" race category were reassigned to a modified white race group. After modification, all of the state population estimates for whites were within 1% of the Census Bureau modified-race estimates.20 23
No modification of black census counts was performed for these analyses. For blacks, 14 states had very small black populations (<50 000), which contributed little to regional estimates: Idaho, Iowa, Maine, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, Rhode Island, South Dakota, Utah, Vermont, and Wyoming. Three states had low black population estimates compared with Census Bureau modified-race estimates, with the percent differences as follows: Massachusetts, 7.4%; Minnesota, 3.7%; and New York, 2.5%. Eight additional states had black population estimates that differed from Census Bureau modified-race estimates20 23 by 1% to 2%, but six of these were overestimates.
Coverage of the white population in the 1980 census was fairly complete, but blacks showed a net 5% omission rate.25 The vast majority of omissions among blacks, however, occurred among children younger than 5 years and men aged 20 to 54 years.25 As such, this undercount is unlikely to distort significantly the age-adjusted stroke mortality rates, which typically receive their greatest contribution from older age groups. Regional data on coverage are not available.
Analyses
Lifetime net migration was determined by a difference between place of birth and current place of residence for census data or by a difference between place of birth and place of residence at death for mortality data. Immigrants were those whose place of birth was outside of the United States but whose place of residence or place of residence at death was within the United States. US-born interregional migrants were those whose place of birth was in one region of the United States and whose place of residence or place of residence at death was in another region of the United States. For those whose place of residence at birth differed from their current residence or their residence at death, this is a valid indication of migration. The age at which migration took place, the influence of disease on migration, and the frequency and duration of intervening migrations are not available.
Age-, race-, and sex-specific rates were calculated by region for each migrant group with the appropriate migrant group population as the denominator. Average, annual, age-adjusted, race-specific rates (per 100 000 population) were computed by the direct method, that is, by applying the age-specific death rates for stroke to the standard population distributed by age. The reference population used was the total US population enumerated on April 1, 1980. For standardization, age was stratified by 5-year intervals to age 89, plus an additional grouping of those aged 90 years and older. Statistical significance of differences in age-adjusted rates was determined by means of formulas given by Kahn and Sempos.26
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Results |
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In 1980 there were an estimated 11 637 980 white and black immigrants (foreign-born) residing in the United States, representing approximately 5.3% of the corresponding total US population (foreign- and native-born). The 10 700 640 white immigrants were distributed by region as follows: Midwest, 3 788 500; Northeast, 1 767 720; South, 2 383 120; and West, 2 761 300. The 937 340 black immigrants were distributed by region as follows: Midwest, 540 860; Northeast, 75 480; South, 248 260; and West, 72 740.
Stroke mortality rates by race and sex are tabulated for immigrants and US-born population groups in Table 1
. For whites and blacks and for each of the respective race/sex groups, immigrants had markedly and highly statistically significantly lower age-adjusted stroke mortality rates than either the entire US-born resident population or the US-born interregional migrant population. The absolute and relative differences between immigrant and US-born rates were larger for blacks than whites and within each racial group were larger for males than females.
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Stroke mortality rates by race and region are tabulated for immigrants and US-born population groups in Table 2. For US-born whites and blacks, resident and native rates were highest in the South; in contrast, interregional migrant rates were highest in the Northeast for whites and in the West for blacks, and immigrant rates were highest in the West for whites and the Midwest for blacks. With few exceptions, region-specific immigrant rates for whites and blacks were significantly lower than rates for either US-born regional residents, US-born migrants to the regions, or US-born natives of the regions. The only clear departure from this pattern is for white immigrants to the West, where immigrant rates were significantly higher than rates for US-born population groups. The absolute and relative differences between immigrant and US-born rates were larger for blacks than whites. The pattern of differences between immigrant rates and US-born rates was consistent for males and females of each racial group (not shown).
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Discussion |
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Many factors influence morbidity and mortality rates among persons who migrate from one place to another, including selection factors for migration and risk-modifying influences at origin and destination. Selection effects on migrant mortality rates occur when out-migrants are differentially selected from among all natives at the place of origin on some basis related to health, producing rates that are either lower or higher than for nonmigrants, independent of the destination. In consideration of the diverse origins of immigrants to the United States, selection factors for immigration probably operate in both positive and negative directions, depending on the individual immigrant's country of origin and individual circumstances. Overall, though, the selection is positive, because the personal and financial burdens associated with international migration and the impact of restrictive immigration laws collectively tend to select relatively healthy populations. Specific circumstances may significantly modify this general pattern, however, if the hurdles to immigration are lessened, as for example with unauthorized immigration to the West from Mexico across a shared border, or with refugee populations.
In the present study, selection effects for migration, rather than origin or destination effects, appear to have a much greater role in determining the generally low stroke rates among immigrants and the differing spatial distribution of rates. Selection effects are also apparent among intranational (interregional) migrants, as demonstrated by the relatively lower stroke mortality rates among US-born interregional migrants than among all US-born residents. Given the lesser barriers (eg, physical, financial, distance) to interregional migration as opposed to international migration, it is not surprising that the rates for interregional migrants are intermediate between those of immigrants and those of all US-born residents.
The apparent selectivity of migration may be enhanced to some degree by return migration. That is, some migrants suffering from cerebrovascular disease might return to their place of origin,27 28 29 thus lowering apparent stroke mortality rates among the remaining migrants. Indeed, relative to other migrants, return migrants tend to be negatively selected on socioeconomic characteristics and are more likely to be physically and socially dependent.30 Particularly among the elderly, return migrations may be precipitated by life transitions that increase the need for social service support, including widowhood, diminished financial circumstances, and deteriorations in health.27 28 29 For international migration, the effect of return migration on US immigrant stroke mortality rates is difficult to gauge, since there are insufficient data on the magnitude and causes of return (counterstream) international migration flows. However, international return migration is unlikely to alter seriously the results reported here for several reasons. First, while return migration propensities vary with age, region, and place of origin,31 32 return interstate migration among those at greatest risk of stroke is of relatively small magnitude: overall return interstate migration accounts for approximately one fifth of all interstate migration, but only 5% of these are of retirement age.33 The elderly are in fact less likely to undergo return migrations than younger persons.31 Second, international migrants have greater barriers to migration, including return migration, than interstate migrants. Therefore, the counterstream of return migration is probably smaller for immigrants than for intranational migrants. Third, elderly immigrants' informal support systems, composed of family and close friends, are more often located in the country of residence than the country of birth, making return international migration less likely with negative life transitions.
Another factor that could distort the present results is a bias introduced from differences in census coverage of the various population groups. While deaths are likely to be certified regardless of immigrant or US-born status, census coverage of immigrant populations may be somewhat lower than for US-born residents because of language barriers, unstable or nonhousehold living arrangements, and fear of being identified if in the United States illegally. Relatively greater census undercounts among immigrants than US-born individuals would not change the finding that immigrant stroke mortality rates are generally significantly less than stroke mortality rates for US-born populations; instead, census undercounts among immigrants would tend to accentuate the differences between immigrant and US-born rates. The only exception is for white immigrants to the West, where census undercounts may be particularly likely for Hispanic immigrants who are concentrated there5 34 and where the estimated stroke mortality rates among white immigrants to the region are higher than for US-born residents of the West. At the time of this study, there were probably between 200 000 and 700 000 undocumented unauthorized immigrants in the West, based on Census Bureau estimates of the total number of undocumented unauthorized immigrants in the country and the distribution of documented unauthorized immigrants.34 Such population undercounts could, if approximately accurate, seriously distort the estimated stroke mortality rates for this region. In particular, since the vast majority of these unauthorized immigrants were white immigrants from Mexico,34 the estimated white immigrant population in the West could have been underestimated by as much as 7% to 20%: a census undercount of 7% among white immigrants to the West would bring the high immigrant stroke mortality rate down to the level of the rate for resident whites in the West, and a census undercount of 20% or so among white immigrants would bring the immigrant stroke mortality rate down to the level of the immigrant stroke mortality rates for other regions. Therefore, it seems likely that the aberrantly high stroke mortality rates among white immigrants to the West are due, at least in part, to a bias resulting from large census undercounts in this population.
Although the present study did not analyze immigrant rates by country of origin because of limited data on this in the mortality files, an "origin effect" is unlikely to explain the significantly lower stroke mortality rates among immigrants than among US-born population groups. Origin or "carry-over"35 effects occur when out-migrants carry with them some of the risk of their place of birth, as may occur if the genetic makeup of the migrants or early-life (before migration) environmental exposures influence outcome, or if important lifestyle factors are carried with the migrants and maintained at their destination. Since US stroke mortality rates overall, and among whites particularly, are lower than those of most other countries,36 37 38 39 40 41 the lower stroke mortality rates among immigrants cannot readily be accounted for by inherently lower risk in the countries of origin.
Destination effects are also unlikely to account for the results observed in the present study. Destination effects on migrant mortality rates occur when individuals moving into an area change their risk because of the new location. Such effects may be spurious if healthcare systems in the origin and destination areas have different thresholds and accuracies for recognition and reporting of disease. Such effects may also reflect important late-life influences on outcome due to such factors as differing management practices among healthcare providers, acculturation and modification of lifelong habits and lifestyle, and pervasive environmental factors. If destination factors were stronger determinants of immigrant stroke mortality rates than selection factors, the spatial distribution of immigrant rates would presumably parallel that of the US-born population. The fact that the spatial patterns of stroke mortality among immigrants and native-born population groups differ markedly suggests that destination effects, if present, are less important than selection factors in determining stroke mortality rates among immigrants to the United States.
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Acknowledgments |
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This study was supported in part by a Clinical Investigator Development Award from the National Institutes of Health (K08-NS01549) and by Research Advisory Group funding from the Office of Research and Development of the Department of Veterans Affairs. Patrick Peterson, PhD, provided assistance with computer programming.
Received September 6, 1996; revision received October 14, 1996; accepted October 14, 1996.
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