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Glossary: migration and health
  1. Marcelo L Urquia1,
  2. Anita J Gagnon2
  1. 1Centre for Research on Inner City Health, St Michael's Hospital, Toronto, Ontario, Canada
  2. 2McGill University/MUHC, Montreal, Canada
  1. Correspondence to Dr Marcelo Luis Urquia, Centre for Research on Inner City Health, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8 Canada; marcelo.urquia{at}utoronto.ca

Abstract

The literature on migration and health is quite heterogeneous in how migrants are labelled and how the relation between migration and health is conceptualised. A narrative review has been carried out. This glossary presents the most commonly used terms in the field of migration and health, along with synonyms and related concepts, and discusses the suitability of their use in epidemiological studies. The terminology used in migrant health is ambiguous in many cases. Studies on migrant health should avoid layman terms and strive to use internationally defined concepts.

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Introduction

International migration is a growing phenomenon, recently fuelled by globalisation. The number of international migrants has been estimated to increase from 155 million in 1990 to 213 million in 2010.1 The literature on migration and health is quite heterogeneous in how migrants are labelled and migration-related concepts are defined,2–6 even in the social science literature.7 Some of this heterogeneity may be explained by the fact that many terms were coined in particular historical and geographic settings. Diversity of terminology also may result from nation-state-derived theories and ideologies, and compartmentalisation of academic disciplines.7 We therefore aim to present the most commonly used terminology and discuss the suitability of its use in epidemiological studies to help researchers navigate this complex field and add scientific rigour to migrant studies.

Methods

We conducted a narrative review of the literature based on authors' knowledge of the field, which draws on existing glossaries developed by international migration agencies,8–11 on previous systematic reviews,3 6 and on an expert Delphi consensus of key health migration indicators.12 To ensure that no terms or synonyms in use in the recent health literature were missing, the review was complemented by a PubMed search restricted to meta-analyses or review articles published in English from 2000 to 2009 and containing the words ‘migrant’ or ‘immigrant’ in the title or abstract. This search yielded 103 studies. Articles were retrieved if the abstract indicated discussion of mechanisms linking migration and health or contained terms not already mapped by the authors.2 5 13–28 No quality criteria were used in the article selection.

Glossary

Acculturation

This controversial term is ideologically affiliated with the assimilation policies of the early 20th century. In its earlier formulation, it denotes the process by which immigrants progressively behave according to the social and cultural expectations of the mainstream society, leaving their own distinctive culture behind. Early formulations conceived it positively, particularly in the USA, where the idea of becoming American was tied to the accomplishment of the ‘American Dream.’ Empirical research severely challenged such views.29 30 Acculturation has been traditionally measured by proxies, such as nativity, generational status, length of residence and language spoken at home, each of which used alone is ill suited to capture the complexity of the underlying concept. Some studies tried to overcome this limitation by constructing acculturation scales.26 31 32 Despite the limitations of its use in epidemiological studies, the term was not abandoned, and non-linear and multidimensional uses of the concept have been proposed in recent decades.33

Alien

See Foreign-born.

Assimilation

A policy of incorporating migrants into the host society through a one-sided process of adaptation by which migrants are supposed to give up their distinctive culture and absorb some or all aspects of the dominant culture (eg, language, norms, religion) and therefore become indistinguishable from the majority population.7 Assimilationist approaches can be found in the early 20th century in the USA, and in nations such as France, Britain and The Netherlands, which combine ideas of racial superiority resulting from a colonial history and ideas on citizenship, civil rights, and political participation resulting from democratic-nationalist movements. The term has also been used in the epidemiological literature as a synonym of acculturation and integration.

Asylum seeker

Asylum seeker (also refugee claimant): any person who has applied to the immigration authorities of the receiving country for protection (see refugee) and is awaiting a determination of their status.

Citizenship

Citizenship (also nationality): the status by which a person has full rights and responsibilities in a country, either as a result of being born there or by having acquired it through the legal immigration and citizenship process (ie, naturalisation). International migrants who became naturalised and did not give up their former citizenship are said to have ‘dual citizenship’ and frequently hold two passports.

Contract labour migration

See Labour migration.

Convergence hypothesis

This hypothesis is ideologically affiliated to assimilation policies (see assimilation). Assuming that the postmigration process consists in a unidirectional adaptation to the new society (ie, the melting pot), the logical consequence is that migrants would become indistinguishable from the majority population with increasing length of stay. The corollary for health outcomes is that whatever the initial differences in the outcomes between immigrants upon arrival and the host population, such differences will tend to disappear over time, and immigrants will reach the rates observed in the majority population.34 Convergence may be falsely attributed when the study is limited to only one outcome, one migrant group and short follow-ups.35 Ideally, testing the convergence hypothesis requires information on different migrant groups, whose respective health outcomes upon arrival are significantly better or worse than those of the receiving-country population, and equalise some years after arrival and remain at that level thereafter.34

Country of birth

A term referring to the countries in which the study subjects were born. This has been recognised as the most essential indicator for migrant health.12 Country of birth should be distinguished from ‘country of origin’ or ‘country of last permanent residence,’ which could be different if the migrant resided in another country before remigrating.

Country of destination

See Receiving country.

Country of origin

See Source country.

Cultural broker

A person with cross-cultural competence who mediates between groups or persons of different cultural backgrounds aiming at reducing or eliminating racial and ethnic disparities in health. Culturally sensitive approaches to healthcare and interventions emphasise the need to consider minorities' attitudes and practices, as part of a client-centred practice.

Differential exclusion

A set of policies characterised by the incorporation of immigrants into certain areas of society (eg, labour market) but not in others (eg, welfare systems, citizenship and political participation). Immigrants become minorities, excluded from full participation in society, and this may extend to their offspring. Differential exclusion is found in countries where belonging to the nation is strongly rooted in membership of a specific ethnic group, and ethnic and cultural diversity are seen as a threat to national culture.7 Receiving countries such as Austria, Switzerland, Germany and Japan fit into this category.

Double leap migration

See Secondary migration.

Duration of residence

See Length of stay in country.

Emigrant

Emigrant (also migrant): a term referring to persons who left their usual place of residence to settle elsewhere. The term ‘emigrant’ describes the move relative to the point of departure.

Epidemiological paradox

Epidemiological paradox (also Hispanic or Mexican paradox): this term arose in the context of attempts to explain the ‘healthy migrant effect’ by comparing risk factors between the immigrant and non-immigrant population. It refers to the finding that some migrant groups tend paradoxically to have substantially better health than the average population, despite their low levels of income, education and healthcare access and utilisation. This paradox has been reported for mortality, low birth weight, and mental health,19 36–39 and has been found to apply to Hispanics in the USA and North Africans in France and Belgium.40–42

Exile

See Expatriate.

Expatriate

Expatriate (also exile): archaic terms referring to any person who lives outside their own country. It is used when the person left the home country voluntarily and also when they were denied re-entry, typically for political reasons. The term ‘emigrant’ is preferable.

Forced migration

Forced migration (also involuntary migration) is a general term referring to people who have been forced to leave their homes and seek refuge elsewhere. The causes of the movement may include natural or man-made environmental disasters, famine, development projects, and people-trafficking and smuggling.

Foreign-born

Foreign-born (also foreigner, alien): this term refers to persons who were born in a country other than the country of actual residence. The use of ‘foreign-born status’ as the only indicator is not recommended for epidemiological research because it mixes heterogeneous migrant subgroups and may lead to incorrect conclusions regarding particular migrant groups.3 6 ‘Nativity’ is a related term, mainly used in the USA, that generally refers to the place, time and circumstances of a birth, although its use in health research has focused on its spatial meaning, denoting ‘place of birth’ (eg, foreign-born versus native-born) (see native).

Foreigner

See Foreign-born.

Generational status

An ambiguous term usually used to subcategorise individuals in terms of their national origin or race/ethnicity, with the purpose of comparing the health outcomes of the foreign-born and the native-born within the same group of ancestry (eg, Foreign-born Mexicans versus Mexican-Americans). It refers to the distance of a person to an ancestor expressed as single steps in the line of descent. Thus, first generation (also ‘international migrants,’ ‘foreign-born’) refers to the generation to which the referent (ie, ancestor) belongs and by which all subsequent generations are defined. The term ‘second generation’ refers to persons born inside the receiving country with at least one parent born in another country (ie, the offspring of first-generation migrants—eg, ‘second generation Asian’). Higher-order generations express greater distance from the migrant ancestors' generation, although such information is rarely available in epidemiological studies. In fact, only the first generation are migrants. Unfortunately, incorrect use of ‘second generation’ in association with ‘migrant’ is common. If the purpose is to identify subgroups descending from migrants, other concepts such as ethnicity, race, religion, skin colour or language use may be more appropriate.43 The concept of generational status becomes increasingly problematic with marriage admixtures across generations, thus generating more problems than solutions without a detailed measurement of all its dimensions. Without a solid justification, its use should be avoided in migrant studies whenever possible.

Healthy migrant bias

See Healthy migrant hypothesis.

Healthy migrant effect

See Healthy migrant hypothesis.

Healthy migrant hypothesis

Healthy migrant hypothesis (also ‘healthy (im)migrant effect,’ ‘healthy migrant bias’): this refers to the repeatedly observed phenomenon that foreign-born individuals are often healthier than the native-born residents (see migrant). The healthy migrant effect has also been observed among internal migrants.44 It has been noted, however, that some migrant subgroups, such as refugees or immigrants not in compliance with the immigration laws of the receiving country, may not share the alleged protective effects associated with migration.45 It has also been noted that the healthy migrant effect may be outcome-specific and may not apply equally to immigrants from different parts of the world.3 6

Home country

See Source country.

Host country

See Receiving country.

Illegal migrant

See Irregular migrant.

Immigrant

Migrants (see migrant) are referred to as ‘immigrants’ when the speaker positions themself in the place to which migrants are settling. The term ‘immigrant’ thus describes the move relative to the destination. Immigrants can be internal (see internal migration) or international (see international migration).

Immigrant enclave

An enclosed territory that is set off from a larger population by its high concentration of immigrants, who maintain culturally distinct behaviours from the residents of the surrounding areas. The impact of immigrant or ethnic enclaves on health may vary according to the health outcome, ethnic group and receiving environment.

Immigration class

The categorisation of immigrants by the official immigration-regulating agencies of the receiving countries, based on the circumstances of the immigrants' admission to the country. Although there is no universally accepted classification, main immigration classes in several countries include: economic class (working age migrants to be incorporated to the labour force; these may include business persons, entrepreneurs, or skilled workers); family class (dependants of the main applicant—spouse, children, etc—who are allowed to migrate for the sake of family reunification), and refugees (see refugee). Immigration classes may provide some information about health/exposure risk profile and eligibility for services (with asylum-seekers at greatest risk of inadequate access—see asylum seeker).

Immigration status

The situation of a person as regards their rights and privileges within the receiving country at a given time as recognised by the local official migration-regulating agency. These include but are not limited to: receiving-country citizen, foreign-born citizen, documented resident, undocumented resident, refugee, asylum seeker, student and visitor.

Inclusion

A process designed to allow and achieve the full participation of all residents, including immigrants, in economic, social, political and cultural life of a given community or society.10

Integration

The term has been used in the epidemiological studies as a synonym of assimilation and acculturation, although it slightly differs from them in that it leaves room for an open two-way process of cultural exchange, if mutual understanding is explicit,10 rather than a unidirectional process. National policies towards the immigrants have been labelled as integrative if they promote the inclusion of immigrants into society, that is, their full participation across all domains of civic life (see inclusion). Compared with receiving countries with weak integration policies, countries with strong integration policies have been linked with better health outcomes among immigrants in Europe.17

Internally displaced population

Internally displaced population (also persons): a term referring to persons or groups of persons who have been forced to flee their places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, generalised violence, violations of human rights or natural- or human-made disasters, and who have not crossed an internationally recognised State border.46

Interpreter

A person who translates an expression of a source language into an expression with a comparable meaning in a target language. This definition includes body and sign language. ‘Interpreter’ is distinguished from ‘translator’ in that the interpreter performs verbal translations, usually simultaneously or consecutively with the act of speech, while the translator performs written translations.

Internal migration

Residence changes within the same country (eg, rural–urban, interstate, intercity).

International migration

A change of residence involving the spatial movement of persons across country borders. The change of residence may result in a new permanent residence (if the person is allowed to reside indefinitely within a country) or a temporary residence, as in the case of international students and contract labour migrant workers, whose visas expire upon the completion of their respective activities.

Involuntary migration

See Forced migration.

Irregular migrant

Irregular migrant (also illegal, undocumented or unauthorised): a migrant whose current residence status is characterised by non-conformity with the immigration laws of the receiving country, regardless of their mode of entry. Irregular migrants constitute a vulnerable subgroup, particularly due to their limited access to healthcare and/or other public services available to legal international migrants.

Labour migration

Labour migration (also contract labour migration): most commonly a temporary migration by which labourers work in a country other than their own, usually under contractual arrangements organised and enforced by employers, governments, or both, that set limits on the period and nature of employment and rights and responsibilities in the host country.

Length of stay

See Length of time in country.

Length of time in country

Length of time in country (also length of stay, duration of residence): amount of time passed from the date of arrival to the date of the event of interest. This has been acknowledged as an important predictor of health-related outcomes.12 47 48 Immigrants are usually subcategorised according to their length of stay, particularly ‘recent immigrants,’ who are supposed to constitute a vulnerable group in terms of healthcare access and utilisation.

Loss of the healthy migrant effect

This refers to the phenomenon that immigrants' health deteriorates with increasing length of residence in the new country. This phenomenon has been attributed to several potential processes. Negative acculturation (ie, the adoption of unhealthy behaviours more prevalent in the receiving society such as smoking or alcohol consumption) has been linked to the loss of the healthy migrant effect. While the evidence regarding the role of some health behaviours (eg, smoking) is mixed,49 50 and may vary by ethnicity and gender,47 the evidence on physical inactivity and weight gain is more consistent.48 50 Psychosocial factors may also play a role in the deterioration of health after migration.50 The mismatch between immigrants' educational credentials and their occupational achievements may constitute a source of stress, as well as the creation of a new social support network.50 51 It has also been suggested that immigrants may experience a form of regression to the mean, by which they ‘regress’ to the level of health that prevails in the countries from which they came,52 after the stamina and motivation accompanying the migration process fades away.50

Migrant

A migrant is a person who has established a (semi-)permanent new residence in a ‘place’ other than that in which they habitually lived. In this general definition, ‘place’ is generally understood as a locality, district or higher administrative area. Persons changing addresses within the same neighbourhood, town or city are generally referred to not as ‘migrants’ but as ‘movers.’

Multiculturalism

Multiculturalism (also pluralism, inclusion): set of policies aimed at the guarantee of civil, religious, cultural and linguistic rights of immigrant minority groups. Multicultural policies therefore need to include a range of measures to counter discrimination, combat racism and ensure equal opportunities in all areas. Multiculturalism is the prevailing model currently found in Australia, Canada and Sweden, characterised by explicit multicultural policies. The USA also adheres to multiculturalism but through a laissez-faire approach by which ethno-cultural differences are tolerated but not actively supported by the State.7

Nationality

See Citizenship.

Native

A term generally applied to a person who was born within the country's territory and has been legally recognised as that country's citizen from birth, irrespective of their parents' citizenship (principle of jus soli, Latin for ‘right of soil’). However, ‘native’ also connotes an indigenous ancestry, as applied to plants and animals. From this perspective, only aboriginal peoples would be strictly natives. Terms such as ‘Australian-born,’ ‘UK-born’ or just ‘non-immigrant’ are preferable to ‘native-born.’

Nativity

See Foreign-born.

Onward migration

See Secondary migration.

Pluralism

See Multiculturalism.

Refugee

The term refers to any person who, owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of their nationality and is unable or, owing to such fear, is unwilling to avail themself of the protection of that country; or who, not having a nationality and being outside the country of their former habitual residence as a result of such events, is unable or, owing to such fear, unwilling to return to it.53

Receiving country

Receiving country (also country of destination, host country): the country in which the migrants are located after having crossed international borders.

Refugee claimant

See Asylum seeker.

Re-migration

See Secondary migration.

Repatriation

See Return migration.

Return migration

Return migration (also repatriation): the event in which persons return to their place (or country) of last permanent residence (or citizenship) before migration.

Salmon bias hypothesis

This alternative explanation to the healthy migrant hypothesis states that the low mortalities of migrants may be an artefact resulting from return migration. Migrants who return to their country of origin (and probably die there) frequently remain registered on national population registries for a long time, thus inflating the denominator and leading to an underestimation of their mortality.36 54

Secondary migration

Secondary migration (also double leap, two-step, onward migration, remigration): migration to another place after initially migrating. This type of migration can be national (eg, interurban mobility) or international. When the process involves more than two destination countries, it is known as ‘serial migration.’

Segmented assimilation hypothesis

The unidirectional assimilation view and therefore the convergence hypothesis may be challenged by the segmented assimilation hypothesis, which in the social sciences literature states that rather than a one-way assimilation of immigrants into the mainstream society, immigrants are differentially assimilated into the system of stratification of the host society.55 The implications for health research are that health outcomes are no longer expected to converge towards the level observed in the majority population but rather expected to split according to the levels observed in the ethnic minorities to which immigrants become assimilated based on their socio-economic, racial or cultural belonging.6

Selective migration hypothesis

Since the healthy migrant effect could not be fully explained by demographic and socio-economic characteristics, thus leading to the ‘epidemiological paradox,’ researchers suggested that the favourable outcomes of the foreign-born may result from selective migration. The idea is that good health status positively influences a person's propensity to emigrate. International migrants are thus seen as a group selected (or self-selected) on the basis of characteristics correlated with good health status and therefore healthier than those who remained in their countries of origin,52 56 although this assumption is rarely subject to empirical scrutiny. A few studies found little, if any, evidence in favour of this hypothesis,56–58 while others did support it.40 59 The selective migration hypothesis differs from the healthy migrant effect in that it compares the outcomes of migrants with those who did not migrate, while in the healthy migrant hypothesis, the reference group is composed of the native-born population of the receiving country.56

Sending country

See Source country.

Source country

Source country (also country of birth, country of origin, sending country, home country): this refers to the country migrants come from. Unfortunately, the use of this term does not allow distinguishing between migrants' country of birth and country of last permanent residence, which may differ in the case of secondary or serial migrants (see secondary migration).

Transnational communities

Transnational communities (also transnational networks) are groups of people who maintain family, social and economic links across borders, and have multiple identities and competencies in more than one culture. The development of transnational communities has been fuelled by globalisation, and it has been linked with the spread of tuberculosis and sexually transmitted diseases.14 20

Two-step migration

See Secondary migration.

Unauthorised migrant

See Irregular migrant.

Undocumented migrant

See Irregular migrant.

Xenophobia

Xenophobia refers to an attitude characterised by fear, dislike, mistrust and even hate towards strangers, foreigners or people different from oneself.

Conclusion

The terminology used in migrant health is ambiguous in many cases. Epidemiological studies on migrant health should use internationally defined concepts and avoid layman terms. Epidemiological studies would also benefit from a critical examination of the measurement properties of the migration-related variables and their potential to accurately inform public health policies.

What is already known

  • The literature on migration and health is characterised by a diverse terminology, resulting from historical nation-state policies and compartmentalisation of academic disciplines.

What this study adds

  • This glossary defines the most commonly used terms and concepts in the field of migration and health, and examines the appropriateness of their use in epidemiological studies.

Acknowledgments

The authors thank R Glazier, for his encouragement and helpful comments on an earlier version of the manuscript, and the reviewers, for their suggestions to improve the glossary.

References

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Footnotes

  • Funding MLU was supported by a personal research grant (CIHR IOP-44972) of Dr John Frank, Canadian Institutes of Health Research.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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