Ethnic Differences in Self-Rated and Functional Health: Does Immigrant Status Matter?



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Ethnic Differences in Self-Rated and Functional Health:

Does Immigrant Status Matter?



(Abbreviated title: Ethnicity, Immigrant Status, and Health)
Karen M. Kobayashi,1 Steven Prus, 2 and Zhiqiu Lin 3

1 Karen M. Kobayashi, Ph.D. (corresponding author)

Department of Sociology

University of Victoria

PO Box 3050, Victoria, BC V8W 3P5

email: kmkobay@uvic.ca

phone: 250-721-7574


2 Steven Prus, Ph.D.

Department of Sociology

Carleton University

D795 LA, 1125 Colonel By Drive, Ottawa, Ontario, K1S 5B6 Canada

email: steven_prus@carleton.ca

phone: 613-520-2600 ext 3760


3 Zhiqiu Lin, Ph.D.

Department of Sociology

Carleton University,

D792 LA, 1125 Colonel By Drive, Ottawa, Ontario, K1S 5B6 Canada

email: zhiqiu_lin@carleton.ca

phone: 613-520-2600 ext 1099




ABSTRACT
The current study examines self-rated health status and functional health differences between first-generation immigrant and Canadian-born persons who share the same the ethnocultural origin, and the extent to which such differences reflect social structural and health-related behavioural contexts. Multivariate analyses of data from the 2000/2001 Canadian Community Health Survey indicate that first generation immigrants of Black and French ethnicity tend to have better health than their Canadian-born counterparts, while the opposite is true for those of South Asian and Chinese origins, providing evidence that for these groups, immigrant status matters. West Asians and Arabs and other Asian groups are advantaged in health regardless of country of birth. Health differences between ethnic foreign- and Canadian-born persons generally converge after controlling for socio-demographic, SES, and lifestyle factors. Analysis of the data does however reveal extensive ethnocultural disparities in self-rated and functional health within both the immigrant and Canadian-born populations. Implications for health care policy and program development are discussed.

Keywords: self-rated health; functional health; ethnicity; immigrant status; Canada.


Abstract word count: 137
Text word count: 5,965

INTRODUCTION

Canada, like the United States, the United Kingdom, and Australia, is a multiethnic society with a global reputation for recognizing the ethnocultural diversity of its populace through celebrated federal policies and programs like the 1985 Multiculturalism Act. Despite the existence of such progressive legislation however, ethnic inequalities in a number of key domains continue to exist. In particular, population health and health care are two domains in which differences across and within ethnic groups have been noted, observations that are, as Nazroo (2006) points out, also “relevant in other country contexts” (p. 16) like the UK and the US.

Although research into the health of Canadians has grown considerably over the past few decades, the study of health differences across a wide spectrum of ethnocultural groups has, surprisingly, received little attention (Gee et al 2006). A recent exception to this is Wu and Schimmele’s (2005) study examining health disparities across eleven ethnic groups. Using data from the 1996-97 National Population Health Survey their findings interestingly provide no clear evidence of a relationship between behavioural or socioeconomic differences and ethnic health disparities, nor do the authors find a definitive pattern between ethnicity and functional and self-reported health in their analysis. This, they point out, is in contrast to U.S. studies which have consistently demonstrated such health disparities between whites and non-Hispanic Blacks due, in large part, to variations in “exposure” to health risks (Williams & Collins 1995, Davey Smith et al 1998, Williams, 2001). Similar disparities have been found among ethnic minority groups in the UK (Marmot et al 1984, Nazroo 2003) and Australia (McLennan & Madden 1999) as well.

Wu and his colleagues (2003), using the same data, did however observe differences in mental health by ethnicity. Of particular interest is the finding that two of the largest visible minority groups (defined as persons, other than Aboriginal peoples, who are non-Caucasian in race or non-white in colour), the Chinese and the South Asians, report better mental health than English Canadians, and that Jewish Canadians have comparatively poorer mental health. Such results provide counter evidence to the long-held assumption that being a member of a visible minority group inevitably translates into having poorer mental health (Neighbors & Williams 2001). A further contribution of this paper is the recognition that SES and social support are the main factors in explaining ethnocultural differences in mental health. SES is important, the authors maintain, since it influences well-known determinants of mental health such as access/utilization of healthcare services, physical environment, and the experience of chronic stress. Some ethnic cultures, such as Asian and South Asian, also place greater emphasis on the role of family and/or “community” as key sources of social support, which may provide a buffer against mental health problems. Given the different conclusions drawn from the Wu et al (2003) and Wu and Schimmele (2005) studies in Canada, albeit using different measures of health, it is important to further examine the nature of health differences between ethnocultural groups.

While between-group comparisons allow us to establish the existence of an association between ethnicity and health, within-group differences have been previously noted and thus, should also be considered. For example, research shows that new and recent immigrants tend to have better than average health. Chen and his colleagues (1996a) find that newer immigrants to Canada are less likely to have chronic conditions and disabilities, and that this effect is strongest for those from non-European countries. Other research using a number of different measures of health such as self-rated health, heart disease, diabetes, cancer, depression and substance abuse, and life expectancy have found similar results (Parakulam et al 1992; Chen et al 1995; Chen et al 1996b; Dunn & Dyck 2000; Hyman 2001; Meadows et al 2001; Ali 2002; Perez 2002; Newbold & Danforth 2003; McDonald & Kennedy 2004). This “healthy immigrant effect” may help to explain some of the ethnic-based differences in health since the vast majority of new/recent immigrants are visible minorities with China (including Hong Kong and Taiwan), India, Pakistan, the Philippines, Korea, Iran, Romania, and Sri Lanka being the leading source countries (Citizenship and Immigration Canada 2002).

Two explanations for the health advantages of new immigrants have been proposed and supported in the literature (Marmot & Syme 1976; Marmot et al 1984). First, the selectivity hypothesis maintains that migration is selective of healthier individuals. Healthier, younger, and better educated individuals self-select into the immigration process and health requirements in the Immigration Act for entrance into Canada tend to disqualify people with serious medical conditions (Trovato 1998; Oxman-Martinez et al 2000). Second, the acculturation hypothesis states that immigrants tend to have more positive health-related beliefs, attitudes, lifestyle behaviours, as well as stronger social support networks; however over time, as length of residence increases, they experience a deterioration in health due to the adoption (i.e., acculturation) of mainstream Canadian beliefs and lifestyle behaviours (Hull 1979; Chen et al. 1996a; Dunn & Dyck 2000; Ali 2002; Perez 2002). More recently, McDonald and Kennedy (2004) have speculated that the increased likelihood that immigrants will be diagnosed with a chronic condition may be related to processes of acculturation and familiarization with the health care system: as immigrants become more experienced and comfortable negotiating the system, they are more likely to interact with health care practitioners and thus the likelihood of illness diagnoses increases.

Comparisons of immigrant health according to country of origin have been studied in both Canada and the UK. Wang and his colleagues (2000), for example, found that the risk of arthritis is significantly lower for Asian immigrants compared to North American-born Canadians, even after controlling for age, gender, SES, and body mass index. Further, Acharya (1998) found differences in the mental health status of Canadian immigrants in Alberta and in its predictors by country of birth. In the UK, Nazroo (2003) has suggested that the intersection of SES, racial discrimination and systemic racism put immigrant populations, particularly South Asians, at a higher risk for both mental and physical illness.
RESEARCH OBJECTIVES AND QUESTIONS
The literature suggests that immigration and ethnicity interact to influence health. Canada is a multicultural country with a high per capita rate of immigration. Standards of living and life expectancy in Canada are among the highest in the world, and universal health care is provided. Yet little is known about how immigration and ethnicity intersect to shape the distribution of health in Canada. To this end, the main research question asks if health differences exist between first-generation immigrants and Canadian-born persons who share the same ethnocultural origin. To the extent that any disparities are observed, we also ask if social structural and behavioural factors explain these differences. A secondary objective of the study is to assess health differences between ethnocultural groups within the Canadian-born and foreign-born populations. Ethnocultural disparities in health, while controlling for immigration, have been described in the literature both in Canada and abroad. Our stratification approach will detect any such disparities that are unique to the Canadian-born and foreign-born populations.
DATA AND METHODS
Data Data come from the master file of the 2000/2001 Canadian Community Health Survey (CCHS). The CCHS is an on-going, cross-sectional survey that collects information on the health status, health care utilization, and health determinants of a representative sample of Canadians aged 12 years or older living in private households. Sample weights are used in all analyses.

Measures Studies on ethnicity and health tend to use aggregate groupings, in part because of restrictions placed on public-use microdata and/or because of sample size. The CCHS master data allow the construction of a single comprehensive measure of culture, race, and ethnicity. It is based on two questions.

The first question asks, “People living in Canada come from many different cultural and racial backgrounds. Are you: ...white, Black, Korean, Filipino, Japanese, Chinese, Aboriginal, South Asian (e.g., East Indian, Pakistani, Sri Lankan), Southeast Asian (e.g., Cambodian, Indonesian, Laotian, Vietnamese), Arab, West Asian (e.g., Afghan, Iranian), Latin American, other or multiple visible-minority origin?” A substantial majority of respondents are classified as “white,” thus this group is further divided based on ethnic origin (i.e., the ethnic group which the respondent’s ancestors belonged to such as Canadian, French, English). These data are combined into thirteen categories arranged under the two headings -- white: Canadian, French, English, other west European, other (e.g., south European, east European, Jewish), and multiple white (two or more of the above); non-white: Aboriginal, Black, Chinese, South Asian, other Asian (Korean, Filipino, Japanese, South East Asian), West Asian and Arab, and other non-white including multiethnic. Those of multiple white origin are selected as the reference in the analysis as it is the largest group with no single origin designated.

Health is recognized and measured as a multi-dimensional construct. Self-rated health (SRH) is based on the question “In general, would you say your health is: excellent, very good, good, fair, or poor?” It is collapsed into two groups: “positive” health perception (good, very good, or excellent) and “negative” health perception (poor or fair). Functional limitations (Health Utilities Index or HUI) and disabilities (activity restriction or AR) provide a more objective measure of health. The HUI is a weighted index of an individual's overall functional health based on eight self-reported attributes: vision, hearing, speech, mobility, dexterity, cognition, emotion, and pain/discomfort. Values range from about 0 (completely unfunctional) to 1 (perfect functional health) in increments of 0.001. Activity restriction/disability refers to the need for help -- as a result of any health problem/condition, including a disability or handicap, that has lasted 6+ months -- with instrumental activities of daily living such as preparing meals, shopping for groceries or other necessities, doing everyday housework, doing heavy household chores, and personal care.

A full range of social structural and behavioural control variables are considered. Social structural factors consist of both socio-demographic and SES variables. The socio-demographic controls are gender, age (and age-square to control for an accelerated decline in health with age), marital status (married, other), language (English and/or French, neither English or French), and length of time in Canada since immigration (1 year or less, 2-5 years, 6-9 years, 10-19 years, 20+ years). SES is measured with income and education. Income has five discrete categories, developed by Statistics Canada, where respondents are classified as having either low, low-middle, middle, upper-middle, or high income depending on the dollar-distance between their annual household income (before taxes) and the Canadian low-income cutoff lines. Education is collapsed as follows: < high school graduate, high school graduate, and postsecondary graduate.

Health behaviours include: type of alcohol drinker (regular, occasional, former, never); type of cigarette smoker (daily, former daily-now occasional, always occasional, former daily, former occasional, never); average number of times per day fruits and vegetables are consumed (<5 servings per/day, 5-10 servings per/day, 11+ servings per/day); Body Mass Index (BMI) (underweight: BMI <18.5, normal weight: BMI 18.5-24.9, overweight: BMI 25-29.9, obese: BMI 30+); and level of physical activity (inactive, moderately active, active).

Table 1 provides a description, by immigrant status, of the independent, dependent, and control variables used in the analyses. Dummy variables were created for variables with missing cases to maximize sample size. There are 102,221 Canadian-born (CB) and 26,516 foreign-born (FB) individuals in the sample.



(Table 1 about here)

Analysis Linear and logistic regressions were used to estimate health differences within and between Canadian- and foreign-born groups. The regression analysis was conducted in two stages.

First, Canadian-born and foreign-born groups were analyzed separately. These results are shown in the columns labeled CB and FB respectively in Tables 2-4. Specifically, a separate regression model (for every health measure, before and after structural and behavioral controls) was calculated for each group. This model allows us to assess health differences between ethnocultural categories within the Canadian-born and foreign-born groups, a secondary objective of the study.

Second, Canadian-born and foreign-born individuals were combined together, then an overall regression model (one for each health measure, before and after controlling for structural and behavioral factors) was calculated. This model additionally included interaction terms for ethnicity and country of birth to assess health differences between first-generation immigrants and Canadian-born persons of the same ethnocultural origin, the primary objective of the study. These results appear in the column labeled CB-FB in Tables 2-4.

Statistical significance at the 0.05 level or less was used to test for health differences, with those of “multiple white ethnocultural descent” used as the reference group in all models. Preliminary analysis revealed that some predicted HUI scores fell beyond the range of 0-1. Out-of range scores were relatively few in number and therefore excluded from the final models.



RESULTS

Ethnocultural health differences within Canadian- and foreign-born populations are noted in the CB and FB columns respectively in Tables 2-4. In general, non-whites are healthier than whites, regardless of immigrant status. Persons of Chinese origin are particularly advantaged in health compared to those of multiple white ethnocultural origin while Aboriginal persons on average report poorer health. Social structural and lifestyle factors do appear to account for a considerable amount of the health inequalities of Aboriginals; that is, after introducing structural and lifestyle controls the health gap is notably reduced. These findings overall are consistent with other Canadian research that shows visible minorities tend to have above average health status compared to non-visible minorities and Aboriginal persons.

Statistically significant health differences between Canadian- and foreign-born persons of the same ethnocultural origin are shown in the column labeled CB-FB in Tables 2-4. Looking at the results before social structural and lifestyle controls are introduced, blacks and those of other non-white ethnic origin, especially those who are foreign born, report significantly higher HUI scores and are less likely to have an activity restriction compared to those of multiple white ethnocultural origin. By contrast, South Asians who are Canadian-born are more likely to report positive health and to be free of disability (activity restriction) than their first-generation counterparts. Also, Canadian-born Chinese are also more likely to be disability free than foreign-born Chinese.

Other Asians are advantaged on all three measures of health compared to those of multiple white origin regardless of immigrant status. West Asians and Arabs who are either Canadian- or foreign-born also have a much higher incidence of positive SRH and a lower likelihood of having an activity restriction.

French immigrants have better health compared with Canadian-born French persons. In fact they have one of the highest average functional health (HUI) scores, as well as higher odds of reporting positive SRH and of being free of disability compared to their Canadian-born counterparts. Conversely, foreign-born persons of other white origin have a lower average HUI score and are less likely to report positive SRH, while the Canadian-born report similar levels of health to those of the reference group. Interestingly foreign-born persons who define themselves as Canadian, and to a less extent the native-born, report on average higher HUI scores and have higher odds of being disability free. It is persons of English descent that are most like those of multiple white ethnocultural origin in health regardless of immigrant status.

(Tables 2-4 about here)

Next we examine if these health differences between Canadian- and foreign-born persons of the same ethnocultural origin are explained by their differences in social structural and behavioural environments. Health differences are indeed mediated to some extent by the combined effects of structural and behavioural factors. Comparing the results before to those after controls are introduced in Tables 2-4, we observe that first-generation (immigrant) Blacks and those of other non-white ethnic origin continue to report better health than those of multiple white ethnocultural origin, however those who are Canadian-born are no longer advantaged in health. The advantages reported by persons of Chinese, South Asian, and West Asian and Arab origin, regardless of immigrant status, also tend to be explained by differences in social structural and lifestyle environments. They also help to account for some of the better health of persons of other Asian ethnic origins; however, both the foreign- and Canadian-born populations continue to have a higher average HUI score and odds of being disability free compared to the reference group.

Structural and behavioural factors also explain some of the health advantages of foreign-born persons of French origin, as odds of positive SRH are reduced and odds of being disability free become statistically similar to those of multiple white origin; for those who are Canadian-born, on the other hand, average HUI score increases, the odds of being disability free become statistically significant, and the disadvantage in SRH disappears. Health differences between foreign and Canadian-born persons of French descent are therefore reduced after introducing structural/behavioural controls. This pattern is also generally observed for those of other white origin.

In contrast, the previously suppressed differences in health between foreign- and Canadian-born persons of English descent become statistically significant, with the former reporting higher odds of positive SRH and being disability free relative to the reference group. A similar pattern is observed for those of other west European descent, where differences in average HUI score and the odds of being free of disability are significantly larger for immigrants than their Canadian-born counterparts.


DISCUSSION AND CONCLUSIONS
It has long been known that Canadian society is structured along ethnic and racial lines. The ethnic dimension of inequality in Canada was first systemically studied and highlighted by John Porter (1965) in The Vertical Mosaic. Based on national data for the period 1931-1961, he found evidence of an ethnically-ranked system in terms of occupations, income, “ethnic prestige,” and entry into the Canadian elite with those of British origins coming out on top; French Canadians were second; persons of other European origins followed - with western and northern European origins ranking higher than southern and eastern European origins; and Blacks and Aboriginals - very small groups numerically – were at the bottom of the hierarchy.

Many significant events and policy changes have occurred since the publication of Porter’s research. Important among these include: continued non-racist improvements in Canadian immigration policy; the establishment of the Canadian Charter of Rights and Freedoms; the institutionalization of Multiculturalism as a federal policy; the Employment Equity Act (which targets women, visible minorities, Aboriginals, and persons with disabilities); increasing awareness and acknowledgement of the injustices wrought on Aboriginal Canadians and nascent developments aimed at meeting their needs (Frideres 2000); and, last but not least, research revealing that biologically-based race (and racial difference) is not scientifically valid (e.g., Smaje 1996; Stolley 1999). These changes bode well for a multiethnic society in which race and ethnicity are less significant as a principle of social organization and as a determinant of an individual’s life chances. Research, although not consistent across all studies, does continue to show however, that ethnocultural differences exist in and across social domains.

Studies that provide health comparisons between aggregate groups of race, ethnicity, and culture such as Aboriginal and visible minority versus non-visibility minority, foreign-born versus Canadian-born, and Anglophone and Francophone versus Allophone (e.g., Young et al 1999; Dunn & Dyck 2000; Trovato 2001; McDonald & Kennedy 2004; Gee et al 2006; Newbold and Filice 2006) indicate that disparities do exist across groups. This study, which moves beyond the individual identity markers of ethnicity and immigrant status to their intersection, further reveals health disparities within ethnocultural groups according to country of birth.

Visible minority persons (e.g., Blacks, other Asians), with the exception of Aboriginals, are advantaged in health, results that support Wu et al’s (2003) finding that visible minority status does not automatically translate into poorer health status in all domains. In answer to the question, “does immigrant status matter,” the findings indicate that for certain groups, it does. While the within-group examinations show that some visible minority immigrants as well as the foreign-born French are more likely to have better health than their Canadian-born counterparts, for the two largest ethnocultural minorities, the Chinese and South Asians, the Canadian-born actually have better health. This finding is interesting in that it stands in contrast to results from previous studies on the “healthy immigrant effect” that show the foreign-born are healthier than their Canadian-born counterparts, at least in the early years of immigration (i.e., the first 10 years) (Ali 2002, McDonald & Kennedy 2004). The fact that first generation (foreign-born) South Asians and Chinese are more likely to report a disability, may, in part, reflect changes to health screening procedures for immigrants in the recent past and/or deteriorations in health due to difficulties in transitioning to new cultural and/or physical environments, the latter possibly having an impact on both physical and mental/emotional health status. It should also be noted here that the response categories for the health variables used in this study may have limited utility for fully exploring ethnic inequalities in health due to the subjective nature of key concepts such as “good health” or “need for assistance,” concepts that are best examined in relationship to factors like ethnic identification, cultural perceptions of health, and the quality of social supports. Unfortunately, the CCHS did not include questions probing these important areas.

Interestingly, the health advantages of the Chinese and South Asians, regardless of immigrant status, are explained away by differences in social structural and lifestyle environments. Although Aboriginal Canadians are under-represented in the CCHS due to the inclusion of only non-reserve-dwelling Aboriginals (approximately 69% of the total Aboriginal population), it is important to highlight the finding that structural and behavioural factors account for a significant amount of the health disparities in this population. This is, of course, not surprising given that off-reserve Aboriginals are more likely to live in poverty, to have low educational attainment, to engage in negative lifestyle behaviours like smoking and drinking alcohol, and to have poor nutritional habits (Young et al 1999).

These findings demonstrate that when the combined effects of key factors like SES and lifestyle are taken into account, the health of Aboriginal and visible minority Canadians converges to resemble that of non-visible minorities. These results lend support to the argument that health disparities between ethnocultural groups are at least partly attributable to structural and behavioural environments. The extent to which this is true, however, varies across and within groups; that is, the mediating effects of these control variables varies according to ethnicity and immigrant status.

Given that ethnicity and immigrant status mediate the effects of SES and lifestyle on health in these groups, it is important to explore how these identity markers give rise to and/or shape inequalities in health between and within Aboriginal and visible minority populations. Groups like the Chinese and South Asians, populations that are largely foreign-born, for example, may experience racism or racial discrimination in a number of different social contexts from the workplace to residential settings to health care services due to cultural and/or language incongruence with non-visible minorities or even their own Canadian-born counterparts. Nazroo (2003) points out that it is important to acknowledge that “racism can be fundamentally involved in the structuring of economic, social, and health opportunities for ethnic minority peoples” (p. 283), however it is also important to note that discrimination can be directed at individuals from sources within (insiders) as well as outside ethnic groups also structuring opportunities. It should be acknowledged then that health inequities can be derived from “unlikely” sources (from within) as they may be rooted in classist or gendered attitudes and/or religious intolerance as much as in targeted racism from outside a group.

A number of policy implications can be drawn from of these findings. The first, given that health disparities between ethnic and immigrant groups are tied to structural inequities and lifestyles, it is important that health care policies and programs address these issues as key determinants of health in these groups. Second, since the identity markers of ethnicity and immigrant status have been recognized alone and in intersection as salient factors affecting the health and well-being of Canadians, these markers should be included in any and all policy discussions on the restructuring of the health care system and related social welfare programs (i.e., housing, employment) in Canada. Finally, armed with the knowledge that 18.5 percent of the current Canadian population (Statistics Canada 2004) is foreign-born (and on the rise), and that this population is incredibly ethnoculturally diverse, it is imperative that health care policymakers at all levels of government acknowledge and address this diversity through culturally- and linguistically-relevant policies and programs, particularly in large urban centres (i.e., Toronto, Montreal and Vancouver) where the vast majority of visible minorities and immigrants choose to settle.

In addition, and certainly related to the policy implications above, recognition of the health care needs – high versus low – of different ethnocultural and immigrant groups by, for example, gender, marital status, time since immigration and/or and place of residence, and the extent to which these needs are shaped by structural inequities like economic position and/or experiences of racism and racial discrimination is necessary if we are to move towards the creation of an equitable and just society for all Canadians. This requires moving beyond simply acknowledging that the health disparities between and within groups may be the result of socioeconomic processes and inequities faced by only particular groups, to trying to understand how these processes take hold and in what contexts they operate in Canadian society with the intention of developing specific interventions (both through research and policy/program planning) to address differential need over time.

While this study provides much-needed insights into the relationship between ethnicity, immigrant status, and health in Canada, the research objectives are limited by the variables that were available from the CCHS dataset, including ethnic identity, self-control/mastery, religion, and social support (Noh et al 1999; Wu et al 2003). No data were available to examine ethnocultural patterns in health by generational status of persons (first, second, third, or later generation immigrants) or by immigration class (those who came to Canada voluntarily under business or family classifications, as refugees, etc.), for example, thereby limiting what the study is able to say about within group differences. Further, cultural perceptions as they are shaped by adherence to traditional values and belief systems may also influence both an individual’s willingness to report and/or how they report health problems (Kopec et al 2001; Ali 2002; Kobayashi 2003), as there may be fundamental differences in his/her understanding of health and illness (e.g., what constitutes ‘good health’) (Saldov 1991) and/or experiences of subtle or overt discrimination from formal or informal sources with respect to help-seeking behaviour (Nazroo 2003). The CCHS did not ask questions probing levels of adherence, questions that would assist in the gathering of information on the extent to which cultural and linguistic (both language and dialect) (in)congruence influence the reporting and interpretation (by practitioners of the same ethnic origin for example) of health problems, nor did it make inquiries into the experience of racism or racial discrimination as a barrier to reporting health care issues or access to care. This is a salient issue with respect to understanding not only between-group differences but within-group variations in health as well.

Future research examining dimensions of inequality in the health domain should consider the collection of primary data with a random, representative sample of Canadians from various ethnic groups, both foreign- and native-born. Questions probing such key factors as immigrant class (i.e., reason for immigration), generational status, religion, and cultural beliefs and value systems are important to include as both close- and open-ended items in a semi-structured interview schedule/survey instrument. Such data collection would require knowledge of and an appreciation for both quantitative and qualitative research strategies, approaches that, given the complex nature of the relationship between ethnicity, immigrant status, and health, would work best in combination to further research in this emergent area of study.

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