APH 2002, 60, 23-25:

Commentary about: immigrant mortality in Belgium: the person and the place.

J. Hussey


Heallth disparities and community effects on health are attracting increasing attention. In the case of health disparities, there is particular interest in understanding why, in some populations, socio-economically disadvantaged immigrants have better health outcomes than more advan­taged native-born residents (1). Possible explanations for this paradox include theories of acculturation and selective migration (the “healthy migrant effect”) (2). At the same time, there is growing evidence that com­munity characteristics influence individual outcomes (3). However, despite knowledge that immigrants are more often exposed to different commu­nity environments than native-born residents (4-5), surprisingly little is known about the influence of community characteristics on immigrant health. The paper by Anson J. in this issue addresses this important gap in the literature.

Consistent with studies on other populations (6), Anson J. find that foreign-nationals and foreign-born residents of Belgium enjoy lower mor­tality risks than Belgian nationals and native-born Belgians. Having estab­lished that a mortality advantage exists, the authors attempt to explain it. This stage of their analysis begins by estimating separate Cox proportional hazards models for each of 588 Belgian communes. Goodness of fit sta­tistics and hazard coefficients from each of these 588 models become the dependent variables in the final stage of analysis. In the final stage, the authors examine the ability of regional and commune-level characteristics to explain between-commune variation in the importance of nativity and nationality on mortality risk. For example, how much variation, across com­munes, in mortality risk by nationality is explained by the level of immigrant concentration in those communes?

This ambitious and complex analysis raises a number of questions that merit further investigation. Why, in the final models, do the community characteristics do a much better job of explaining variation in mortality risk by nationality than by nativity? What is the meaning of nationality in the context of Belgium where, as the authors report, approximately one-third of foreign nationals are Belgian-born? Why do females appear to be more sensitive to community conditions than males? Finally, is the commune the most appropriate level of aggregation for examining “community” effects?

With continued growth in international migration projected (7), research on immigrant health will only increase in the future. This trend is welcome because these studies have great potential to reveal how community and other contextual influences interact with individual behaviors to shape health outcomes. Hopefully, as theories of migration and health are refined and tested, better data become available, and techniques of analysis are improved, our understanding of the association between immigrant status and health will also grow.