Neighborhood effects on health among migrants and natives in Shanghai, China
Introduction
The relationship between neighborhood contexts and individual well-being has long been recognized in the Western literature (Park et al, 1928; Shaw and McKay, 1969). Recent years have also witnessed a rapidly expanding literature documenting contextual effects of neighborhood characteristics on individual health outcomes using sophisticated multilevel statistical methods (Kawachi and Berkman, 2003). However, studies of neighborhood effects on health are rarely done in developing countries (Pickett and Pearl, 2001). It was predominantly Western settings that provided the ‘field laboratories’ for most of the research on the link between residential neighborhood and health of residents in the neighborhood (Harpham, 2009).
Multiple neighborhood domains have been linked to both physical and mental health outcomes (O'Campo et al., 2009). Neighborhood overall socioeconomic status (SES) influences residents’ health net of the effects of an individual resident's SES because place-based SES, typically measured by concentrated economic and human capital, reflects residents’ exposure to different amounts of health-promoting resources such as social capital and neighborhood amenities and health-detrimental hazards such as crime and disorder (Haan et al., 1987; Robert, 1998; Ross and Mirowsky, 2009; Sampson et al., 1997; Wen et al., 2003). Neighborhood physical and built environments, manifested in variables such as air quality (Geelen et al., 2009; Isakov et al., 2009), spatial proximity to solid waste (Downey, 2006; Yang et al., 2008), and neighborhood noise (Balfour and Kaplan, 2002; Wen et al., 2006) can directly affect residents’ health. The positive sides of physical design of neighborhoods, such as neighborhood aesthetics (e.g., levels of quality of green areas) and amenities (e.g., ease of access to park, library and gym) are often linked to higher levels of physical activity (Patterson and Chapman, 2004; Wen and Zhang, 2009) and mental health (Nielsen and Hansen, 2007), thereby indirectly promoting health. In addition, neighborhood social capital or social cohesion, which refers to social relational resources of a physically bounded area characterized by some degree of homogeneity, typically manifested in community solidarity and norms of reciprocity, seems to improve health by increasing community members’ social contact, support, and psychological well-being (O'Campo et al., 2009) and by promoting healthy lifestyles and health-beneficial innovative information (Kawachi and Berkman, 2000; Wen et al., 2007). Taking various aspects of neighborhood features into account, perceived neighborhood satisfaction is a comprehensive indicator of perceived neighborhood quality, which is found to have a stronger impact on health than objectively measured neighborhood SES (Wen et al., 2006). According to the social cognitive perspectives (Bandura, 2001), one important pathway from neighborhood satisfaction to residents’ health is via personal factors such as enhanced self-efficacy (Morris et al., 2008) and reduced stress (Wen et al., 2006). It is also possible that better neighborhoods are linked to better labor market outcomes such that the neighborhood satisfaction and health link is partly mediated by enhanced individual SES (Robert and House, 2000). Moreover, contextual mechanisms likely also operate for neighborhood effects, since ecological features are typically intertwined and constantly interacting in dynamic and complex ways. It thus follows that neighborhood satisfaction matters to health partly because it enhances individual mental well-being and life circumstances and partly because it reflects perceived quality of neighborhood social, physical and service environments. These theoretical perspectives, albeit primarily originated from Western settings, may also apply to developing settings marked with prominent spatial inequalities in health-related resources and hazards.
China, a rapidly developing country with growing global influence, provides a unique setting to test the empirical association between neighborhood contexts and health and explore the external validity of theoretical perspectives with regard to the health-place link. It is well known that China has experienced sweeping social, economic, and cultural transformations since the beginning of the economic reforms in the late 1970s implemented to restore China's financial status and lift the nation out of destitution (Quach and Anderson, 2008). Concomitant with enormous economic growth and rising political power in the world system during this period, income inequality was intensified (Yang, 1999), spatial inequalities in socioeconomic resources subsequently worsened (Krugman, 1999; Ling, 2009), and health disparities across different strata of the social hierarchy widened in reform-era China (Luo and Wen, 2002; Wen and Wang, 2009). Despite the emergence of empirical work documenting growing health disparities (Chen and Meltzer, 2008; Ling, 2009; Yu, 2008), most studies focus on the individual-level SES and health link, whereas few writers have addressed whether neighborhood contexts constitute an additional key dimension of social contexts contributing to health disparities in China.
Nonetheless, limited evidence points to important neighborhood influences on individual health and mortality in China's urban and rural areas (Ali et al., 2007; Luo and Wen, 2002; Zimmer et al., 2007). These studies share a common emphasis on neighborhood developmental characteristics such as socioeconomic resources, healthcare services, and amenities while omitting local social relational resources and a general extent of neighborhood satisfaction. The body of the extant literature regarding neighborhood effects on health in China, consisting of not more than a dozen or so relevant studies, is far from adequate for gaining a thorough understanding of the health and place link in China.
Parallel to the rapid economic development and dynamic socioeconomic re-stratification processes in the Chinese society is the unprecedented rural-to-urban and, to a lesser extent, urban-to-urban population movement in the last two decades. Through the unique Household Registration System (hukou) in China, passed by the Chinese Congress in 1958, rural-to-urban migration was tightly restricted. Meanwhile, urban-to-urban migration was also difficult and unusual for the subsequent two decades. Starting from the late 1970s, the widespread economic reform, the fruitful market transition, and the growing inequalities across regions and between the rich and the poor in China jointly led to much lessened governmental restrictions on internal population migration and an enormous growth of the size of migrant population in China. According to the 2000 census in China, there were 121.07 million internal migrants and among them, more than 70 percent were rural-to-urban migrants, equivalent to approximately 85 million individuals (Xiang, 2003). Given the sheer size of this population, it is conceivable that migrant health plays an increasingly important role in China's human and economic development.
Based on the western migrant health literature, migrants are generally found to be healthier compared to their co-ethnic natives in the receiving society (LaVeist, 2002). The well-known Hispanic epidemiological paradox found in the USA (Franzini et al., 2002), which refers to the phenomenon that mortality rates among Hispanics tend to be lower than those among other racial/ethnic groups despite their lower SES, exemplifies this migrant health pattern. However, the genealizability of this pattern should not be assumed in other settings as how migrants fare in the receiving community is sensitively responsive to the local socioeconomic, political, and cultural contexts. In fact, a global picture of migrant health is more mixed regarding whether migrants have a health advantage or disadvantage compared to natives in the receiving community (McKay et al., 2003). It is conceivable that there are increased health risks related to migration. For example, challenging new socio–cultural–political environment, harsh contexts of reception, truncated social networks and felt loneliness, and institutional barriers to health-protective services including healthcare delivery may all cause psychological distress unique to migrants including internal migrants in China (Li et al., 2006a, Li et al., 2006b; Wen and Wang, 2009; Xiang, 2003). These increased health risks are common across all types of migration given the shared uprooting nature of migration, although cross-national migration may be more challenging compared to internal migrants due to generally greater migration distance and stronger legal, structural and cultural barriers in the receiving community. Hence, from the causation perspective, migration is concomitant with increased health risks. At the same time, self-selection is also likely at work in voluntary migration given that healthier individuals are more likely to migrate and migrants afflicted with debilitating health conditions often return to the home selecting themselves out of the urban resident pool. Therefore, the selection hypothesis predicts that migrants are generally healthier than natives as long as their residential tenure in the receiving community is not too extended.
To the present day, anecdotal accounts of health problems, such as reproductive health and occupational hazards to which migrants in urban China are particularly vulnerable (Xiang, 2003), are abundant; yet scientific investigation comparing migrants with natives in a wide range of health outcomes is lacking. Published studies regarding health status and health-risk behaviors among Chinese internal migrants and urban natives do not provide comprehensive data on health disparities between migrants and natives in urban China. Indeed, health disparity and social determinants of health research in China remains in its nascent stage. Little work has examined how larger social contexts beyond intra-personal social factors may affect migrant health in China. With few exceptions (Wen and Wang, 2009; Xiang, 2005), quantitative and comparative research on neighborhood effects on health among migrants in urban China is virtually non-existent. Hence, there is not much China-based evidence we can draw upon to devise our hypotheses regarding neighborhood effects on health for migrants in urban China. Presumably, neighborhood environment should matter for migrant health in a similar way as for native residents’ health; yet the magnitude of neighborhood effects on health may differ according to the individual's other characteristics.
Given this background, this study has three aims. First, we compare migrants with native residents in Shanghai in terms of their self-rated health, chronic conditions, and mental well-being to get a general picture of how migrants fare. We hypothesize that migrants are generally healthier than natives in Shanghai because internal migrants in China are self-selected into or out of migration based on many considerations including individuals’ baseline health status and also because most of these migrants are first-generation, voluntary, and temporary in the cities, not well assimilated and acculturated to the receiving community. Second, we examine neighborhood effects on individual-level health after SES and psychosocial factors are controlled for. Based on theory and evidence from Western settings, we hypothesize that neighborhood contexts are independently linked to individuals’ health net of other health-related individual characteristics. Third, we explore whether neighborhood effects vary according to an individual's migrant status. Given that migrants, who lack personal resources to garner health benefits, may be more sensitive to public goods than urban natives, we hypothesize that neighborhood effects, if observed, are stronger for migrants than for natives. Fourth, we test whether the link between neighborhood satisfaction and a general index of well-being is mediated by perceived neighborhood physical and social environment and individual factors. Considering previous findings in Western settings, we expect that these hypothesized mediators can explain a portion of the neighborhood satisfaction effect, although the magnitude of this explanatory power cannot be determined a priori.
Section snippets
Data
Data used in this study were from the 2008 Shanghai Health and Migration Study, jointly sponsored by Chinese University of Hong Kong, Fudan University, and University of Utah. The study was approved by the survey and behavioral research ethics committee at the Chinese University of Hong Kong. The study collected information on a range of personal, family, and neighborhood characteristics that potentially impact physical and mental health and health behaviors among young and middle-aged migrants
Results
Table 1 illustrates sample statistics of the dependent and independent variables included in the analysis, stratified by migrant status. These statistics describe the crude patterns without statistically controlling for any confounders. Migrants’ physical health, captured by self-rated health and chronic conditions, is significantly better than that of natives in Shanghai, whereas the native have a slight advantage in psychological well-being compared to migrants. Not surprisingly, natives’
Discussion
Based on recently collected cross-sectional data, this study examines comparative patterns in self-rated health, chronic conditions, and psychological well-being among internal migrants and urban natives in Shanghai and further explores neighborhood effects on these health outcomes after SES and psychosocial factors are controlled for. Three hypotheses guided our empirical work.
The data fully supports our first hypothesis that migrants on average have a health advantage than natives. This
Acknowledgement
This study was jointly sponsored by the University of Utah, Chinese University of Hong Kong, and Fudan University. The authors thank Xiaoxin Su for her valuable research assistance.
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