Word count: 1987

Literature review
In the United States, one-in-four children have an immigrant parent (KFF, 2023). Second-generation
immigrants are a growing segment of the US population, drawing attention to the importance of their
successful integration into society, as they face challenges unique to their native peers or their own
parents. Different patterns can thus arise in many socioeconomic factors. Namely, the health of
second-generation immigrants is an important concern for both their wellbeing and assimilation
process. Studies have dissected differences in the health outcomes in contrast to native children,
finding diverging trends. Research into potential causes of health outcomes is hence crucial for
allowing policymakers to support the wellbeing and process of assimilation.

Education has been studied for its potential causal effect on health, coined the health education
correlation or health gradient. The concept, falling within the wider body of research into
socioeconomic status gradients, has been widely researched globally due to its implications for
education systems and policy reforms. The concept was first studied by Kitagawa and Hauser (1973)
in the US using the 1960 Matched Records Study. The data was first of its kind, allowing the
researchers to match education and mortality data, among other variables. Kitagawa and Hauser
demonstrated an overall inverse correlation between education and mortality, suggesting that higher
levels of education were associated with lower levels of mortality in the adult population. The study
pioneered the concept of education as a primary indicator of mortality, and has since inspired further
research into the concept. Despite the established correlation, identifying causal effects is more
challenging. Typically, three potential hypotheses are explored: education impacts health; health
impacts education; or a third variable drives both.

The first hypothesis involves different theories on the impact of education on health. Among them,
one argument centers on the role of education in forming knowledgeable individuals, who can process
information regarding health and thus have healthy habits. For example, Grossman’s (1976) paper on
the household production function and consumer demand develops models of decision making, tied to
health and education. A strong correlation between health and education was discovered, after
controlling for socioeconomic factors. According to the paper, educated individuals make both
healthy and productive choices, increasing longevity. The hypothesis is also supported by the
correlation between preventable diseases and education, as in the paper by Masters, Link and Phelan
(2015). Their paper discusses fundamental cause theory as a potential explanation, where personal
resources, including knowledge through education, influence health outcomes by helping individuals
to engage in health-inducing behaviors. Moreover, a more specific example by De Walque (2007)
draws a link between college education and smoking, finding that education decreased the incidence
of smoking and increased the likelihood of quitting. De Walque has also studied the theory from a
different perspective. In his 2007 paper on the education HIV/AIDS gradient, De Walque measures
the effect of education on the responsiveness to HIV/AIDS campaigns. A correlation was again
established, although no causal relationship was explicitly argued. Another study on education and
smoking, by Farrell and Fuchs (1982), also found a correlation but did not conclude any causal
relationship, since differences in smoking behavior later in life were accounted for by behavior
already at school age. Overall, despite a strong correlation, evidence of a causal relationship through
health-conscious behavior remains inconclusive. Nevetheless, potential education inequalities
affecting second-generation immigrants could be studied in connection to healthy habits, especially
considering the different epidemiological transition phases across countries of emigration.
Second, education may also causally impact health in the chosen approach to treatment. For example,
Glied and Lleras-Muney (2008) studied the correlation between education and disease-specific
mortality rates. Higher levels of education were associated with higher survival rates from diseases
with the most innovation, stemming from faster adoption of new technical advancements in personal
treatment by the most educated. This correlation was deemed causal and indicates medical
advancements as being tied to health inequality. Delayed adoption of health-related innovation in
treatment opens another avenue through which education can impact health, although access issues
must be considered. Moreover, the findings demonstrates the health gradient to be significant across
the spectrum with wide applicability, from healthy behaviors to the treatment of diseases.

On the other hand, the relationship may run in the opposite direction, as suggested by the second
hypothesis. For example, Grossman (1976) cautions against inferring a causal relationship from
education to health due to the potential of reverse causality. Health can increase both attendance and
the returns to education, increasing the amount of education and indicating a potential causal
relationship in the opposite direction. In fact, poor health during early years has been shown to
decrease education attainment in the United Kingdom (Case, Fertig & Paxson, 2005). Poor health
during childhood also correlated with poor health later in life, thus resulting in low education
correlating with poor health in adulthood without being causal. The difficulty in disentangling causes
and relationships from personal characteristics demonstrates the challenges with research into the
health gradient. Becker’s (1962) theory of human capital, which outlines education and health as
components of human capital and laid the foundations for Grossman’s model, provides a potential
theoretical grounding for the complexity. Health and education comprise human capital, influencing
the usefulness of one another and incentives to invest in them, easily subjecting them to reverse
causality. Reverse causality, as well as Becker’s theory of human capital, hence highlight the difficulty
in disentangling relationships between individuals’ characteristics, as they are inherently connected.

To continue, Grossman (2008) also highlights the potential for omitted variable bias, where third
variables determine both health and education. One of the potential third variables discussed in
literature is ability bias. Ability bias has been established through measuring schooling achievement
against smoking at school age (Borland & Rudolf, 1975). Ability bias drives both education
attainment, by allowing students to progress their studies, and health, by allowing them to act upon
information regarding health behaviors. Further, Farrell and Fuchs (1982), in their study concerning
smoking, highlight education tenure as possibly being driven by mental ability, which can likewise
influence health behavior. Ability is, however, difficult to identify and measure. Controlling for
parents’ education may nevertheless provide a useful control as ability can be inherited, to limit the
potential impact of ability bias. Intertemporal choice has also been investigated as another potential
third variable. To explain, Fuchs (1982) describes differences in individual time discounts as
variations in the willingness to incur costs in the current moment for future benefit. Such differences
can impact the willingness to invest in education and participate in health-advancing behaviors,
driving the correlation. Alternatively, Fuchs discusses education as a determinant of an individual’s
time preferences, noting that the two explanations are not mutually exclusive and are difficult to
distinguish from each other. More education could induce willingness to invest in health for a lower
return in the current moment, resulting in better long-term health. Fuchs found some evidence of
correlation of time preferences with schooling and, to a lesser extent, health investment and status.
Time preferences are therefore an important consideration when studying the health gradient, both to
challenge causal claims and to inform policies of compulsory schooling.
The above described factors highlight the challenges with empirical research into personal variables.
The inability to organize a controlled environment allows omitted variables to infiltrate the analysis
and reverse causality to confound the results. One solution used in literature is instrumental variables
(IV) regression. IV regression employs an instrument, a variable which affects the dependent variable
only through the independent variable. Importantly, the instrument must meet two conditions:
instrument relevance, meaning sufficient correlation with the endogenous variable, and exclusion
restriction, which states that the instrument cannot be correlated with the error term of the regression.
Educational reforms have been shown to be fruitful instruments, and have thus been studied globally,
such as in the US (Lleras-Muney, 2005), Denmark (Arendt, 2005) and Sweden (Spasojević, 2010), all
concluding a causal relationship. Opposingly, Clark and Royer (2013) and Meghir et al. (2018) in the
UK and Sweden, respectively, found no significant effect on lifespan. Hence, conflicting evidence
exists when using schooling reforms as an instrument. Regardless, educational reforms are a useful
instrument due to their exogeneity with respect to individuals, direct effect on education attainment
and no apparent relationship to health. Prior literature exploring the instrument suggests that studying
reforms specifically addressing immigrants could prove insightful for the health gradient.

When it comes to immigrant health across generations, differences to the native population depend on
the marker of health. Despite clear disadvantages in infant health, second-generation immigrants
appear to fare better than their native peers in chronic conditions and health-conscious behavior,
indicated by lower prevalence of smoking, body weight, and addictive substances (Hernandez &
Charney, 1998). The finding has been coined the immigrant paradox (Jackson et al., 2019). An
explanation may stem from intergenerational persistence in health status, although deteriorating with
longevity in the US (Akbulut-Yuksel & Kugler, 2016). Likewise, the decline in health through
acculturation has also been seen globally. For example, Loi et al. (2021) discovered negative
assimilation in both the physical and mental health of second-generation immigrants in Finland.
Crucially, the overall health of second-generation immigrants is ranked lower than native peers in the
US, emphasizing the concern for health inequality (Hernandez & Charney, 1998). The complex health
outcomes suggest that different forces are at play. According to the healthy migrant hypothesis,
selectivity in the immigration process results in above average health status for first-generation
immigrants and a consequent downward trend for their children towards average health in the native
population (Hernandez & Charney, 1998). Alternatively, the unhealthy acculturation hypothesis
suggests that immigrants adopt the behaviors of the native population, leading to the decline in health
(Landale et al., 1999; Antecol & Bedard, 2006). Dissimilar patterns can therefore trace a health
education correlation different to the native population, warranting further research into the
phenomenon.

Indeed, research has attempted to pin down the health gradient for different generations of immigrants
in the US, with mixed results. For example, Ro et al. (2016) studied the health gradient across Asian
American generations using self-rated health, but only found a weak correlation. Likewise, shallow
health gradients, indicated by body mass index, were found among different generations of Hispanic
immigrants in the US (Khan, Sobal & Martorell, 1997). Correlations between Mexican immigrant
mothers’ education and their children’s birth weight also revealed similar results (Acevedo-Garcia,
Soobader & Berkman, 2007). Conversely, Jackson et al. (2016) discovered a significant correlation
when studying the same relationship in the wider US immigrant population, using mothers’
evaluations of childrens’ health over time. The paper also found better health trajectories for
second-generation immigrants compared to native peers, suggesting that some evidence of the
immigrant paradox stands. Current research has not drawn uniform conclusions regarding the health
gradient for second-generation immigrants, partly due to diverging methodologies and variables used
in analysis. Applying some of the features from prior literature on the wider population to
second-generation immigrants could therefore allow deeper insight.

My dissertation will aim to address the gap in the understanding of the determinants of
second-generation immigrants’ long-term health outcomes through the health gradient in the US.
Firstly, an objective measure of health, namely mortality, is important to avoid cultural differences in
health assessment in self-rated evaluations (Hernandez & Charney, 1998). Moreover, children’s own
education will be applied as the independent variable. Immigrant mothers’ education cannot typically
be altered and is determined in the context of the country of emigration, while childrens’ education
can be subject to reforms in the local context. Further, as proven successful in prior research, IV
regression will be used, specifically the 1982 Plyler v. Doe reform, which banned withholding
education from immigrants, as the instrument (American Immigration Council, 2016). Determining
patterns through the health gradient can prove vital for social change, as correcting education
inequalities has been theorized to reduce mortality significantly (Woolf et al., 2007). Thus, objective
research into second-generation immigrants’ health education correlation can provide tools to aid their
assimilation and improve their long-term health outcomes and well-being.
List of References
Acevedo-Garcia, D., Soobader, Mah-J. and Berkman, L.F. (2007). Low birthweight among US
Hispanic/Latino subgroups: The effect of maternal foreign-born status and education. Social Science
& Medicine, 65(12), pp.2503–2516. doi:https://doi.org/10.1016/j.socscimed.2007.06.033.

Akbulut-Yuksel, M. and Kugler, A.D. (2016). Intergenerational persistence of health: Do immigrants

get healthier as they remain in the U.S. for more generations? Economics & Human Biology, 23,
pp.136–148. doi:https://doi.org/10.1016/j.ehb.2016.08.004.

American Immigration Council (2016). Public Education for Immigrant Students: Understanding
Plyler v. Doe. [online] American Immigration Council. Available at:
https://www.americanimmigrationcouncil.org/research/plyler-v-doe-public-education-immigrant-stude
nts.

‌Antecol, H. and Bedard, K. (2006). Unhealthy Assimilation: Why Do Immigrants Converge to

American Health Status Levels? Demography, 43(2), pp.337–360.
doi:https://doi.org/10.1353/dem.2006.0011.

Arendt, J.N. (2005). Does education cause better health? A panel data analysis using school reforms
for identification. Economics of Education Review, 24(2), pp.149–160.
doi:https://doi.org/10.1016/j.econedurev.2004.04.008.

Becker, G.S. (1962). Investment in Human Capital: A Theoretical Analysis. Journal of Political
Economy, 70(5), pp.9–49.

Beltrán-Sánchez, H., Palloni, A., Riosmena, F. and Wong, R. (2016). SES Gradients Among Mexicans
in the United States and in Mexico: A New Twist to the Hispanic Paradox? Demography, 53(5),
pp.1555–1581. doi:https://doi.org/10.1007/s13524-016-0508-4.

Borland, B.L. and Rudolph, J.P. (1975). Relative effects of low socio-economic status, parental
smoking and poor scholastic performance on smoking among high school students. Social Science &
Medicine, 9(1), pp.27–30. doi:https://doi.org/10.1016/0037-7856(75)90155-9.

Case, A., Fertig, A. and Paxson, C. (2005). The lasting impact of childhood health and circumstance.
Journal of Health Economics, 24(2), pp.365–389. doi:https://doi.org/10.1016/j.jhealeco.2004.09.008.

Clark, D. and Royer, H. (2013). The Effect of Education on Adult Mortality and Health: Evidence
from Britain. American Economic Review, [online] 103(6), pp.2087–2120.
doi:https://doi.org/10.1257/aer.103.6.2087.

de Walque, D. (2007a). Does education affect smoking behaviors? Evidence using the Vietnam draft
as an instrument for college education. Journal of Health Economics, 26(5), pp.877–895.
doi:https://doi.org/10.1016/j.jhealeco.2006.12.005.

de Walque, D. (2007b). How does the impact of an HIV/AIDS information campaign vary with
educational attainment? Evidence from rural Uganda. Journal of Development Economics, 84(2),
pp.686–714. doi:https://doi.org/10.1016/j.jdeveco.2006.12.003.

Farrell, P. and Fuchs, V.R. (1982). Schooling and health: the cigarette connection. Journal of Health
Economics, 1(3), pp.217–230. doi:https://doi.org/10.1016/0167-6296(82)90001-7.

Fuchs, V.R. (1982). Time Preference and Health: An Exploratory Study. In: Economic Aspects of
Health. Chicago: University Of Chicago Press.

Glied, S. and Lleras-Muney, A. (2008). Technological Innovation and Inequality in Health.

Demography, 45(3), pp.741–761. doi:https://doi.org/10.1353/dem.0.0017.
Grossman, M. (1976). The Correlation between Health and Schooling. In: Household Production and
Consumption. National Bureau of Economic Research, pp.147–224.

Grossman, M. (2008). The Relationship between Health and Schooling. Eastern Economic Journal,
34(3), pp.281–292.

‌ ernandez, D.J. and Charney, E. (1998). Health Status and Adjustment. In: From Generation to
H
Generation: The Health and Well-Being of Children in Immigrant Families. [online] National
Academies Press (US). Available at: https://www.ncbi.nlm.nih.gov/books/NBK230359/.

Jackson, M.I. and Kihara, T. (2019). The Educational Gradient in Health Among Children in
Immigrant Families. Population Research and Policy Review, 38(6), pp.869–897.

KFF (2023). Key facts on health coverage of immigrants. [online] Available at:
https://www.kff.org/racial-equity-and-health-policy/fact-sheet/key-facts-on-health-coverage-of-immig
rants/.

Khan, L., Sobal, J. and Martorell, R. (1997). Acculturation, socioeconomic status, and obesity in
Mexican Americans, Cuban Americans, and Puerto Ricans. International Journal of Obesity, 21(2),
pp.91–96. doi:https://doi.org/10.1038/sj.ijo.0800367.

Kitagawa, E. and Hauser, P. (1973). Differential Mortality in the United States. Harvard University
Press, 16. doi:https://doi.org/10.4159/harvard.9780674188471.

Landale, N.S., Oropesa, R.S., Llanes, D. and Gorman, B.K. (1999). Does Americanization Have
Adverse Effects on Health?: Stress, Health Habits, and Infant Health Outcomes among Puerto Ricans.
Social Forces, 78(2), pp.613–641. doi:https://doi.org/10.1093/sf/78.2.613.

Lleras-Muney, A. (2005). The Relationship Between Education and Adult Mortality in the United
States. Review of Economic Studies, 72(1), pp.189–221. doi:https://doi.org/10.1111/0034-6527.00329.

Loi, S., Pitkänen, J., Moustgaard, H., Myrskylä, M. and Martikainen, P. (2021). Health of Immigrant
Children: The Role of Immigrant Generation, Exogamous Family Setting, and Family Material and
Social Resources. Demography, 58(5), pp.1655–1685. doi:https://doi.org/10.1215/00703370-9411326.

Masters, R.K., Link, B.G. and Phelan, J.C. (2015). Trends in education gradients of ‘preventable’
mortality: A test of fundamental cause theory. Social Science & Medicine, 127, pp.19–28.
doi:https://doi.org/10.1016/j.socscimed.2014.10.023.

Meghir, C., Palme, M. and Simeonova, E. (2018). Education and Mortality: Evidence from a Social
Experiment. American Economic Journal: Applied Economics, 10(2), pp.234–256.
doi:https://doi.org/10.1257/app.20150365.

Ro, A., Geronimus, A., Bound, J., Griffith, D. and Gee, G. (2016). Educational gradients in five Asian
immigrant populations: Do country of origin, duration and generational status moderate the
education-health relationship? Preventive Medicine Reports, 4, pp.338–343.
doi:https://doi.org/10.1016/j.pmedr.2016.07.001.

Spasojević, J. (2010). Effects of Education on Adult Health in Sweden: Results from a Natural
Experiment. In: Current Issues in Health Economics. Emerald Publishing Limited.

Woolf, S.H., Johnson, R.E., Phillips, R.L. and Philipsen, M. (2007). Giving Everyone the Health of
the Educated: An Examination of Whether Social Change Would Save More Lives Than Medical
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doi:https://doi.org/10.2105/ajph.2005.084848.
Planned timeline
November - December
1. Implement comments on the literature survey to my approach
a. Direction of research
b. Depth and breadth of my survey considering the literature survey that will be written
for the dissertation
c. Redefining sample/methodology
d. Identify new areas of literature to look at more deeply
2. Obtain data from a suitable source and begin cleaning it
a. Using IPUMS / NSLY as per prior research
b. Compare the variables available in each source
c. Find the data source that allows for the best date range
3. Scrutinize the variables and see the impact of the 1982 Plyler v. Doe reform
a. Availability of mortality data with education for the relevant years
b. If reform proves immaterial, consider other reforms
4. Run preliminary regressions to see outcomes
a. Allow time to test different variables for health (depression, smoking) indicating for
different aspects of health
- Decide on the direction of research based on availability and findings
b. Test different variables of education (college attendance, total education attainment)
c. Leave time for problems to arise (data, methodology, results)
5. Contemplate different controls and their effects
a. Tie to literature
6. Begin formulating an introduction

January
1. Dissect results into writing
a. Leave time for issues to arise with outcomes
b. Reformulating question/data/methodology
c. Identify potential conclusions from the data to analyze in the later sections
2. Write methodology section
3. Outline the rest of the dissertation once satisfied with the data
4. Work on the literature survey/background section
a. Using previous survey, feedback on it and any new findings along the way

February
1. Finish the literature survey
2. Dissect results section into discussion and conclusion
a. Identify ties to past literature
b. Think of implications for further research

March
1. Tie introduction to the rest of the dissertation
a. Making sure the motivation is clearly stated as well as connection to past literature
2. Leave time to critically analyze my work and findings
a. Rewriting parts of the dissertation
b. Finding potential ideas for new areas to research based on findings

April
1. Final edits and changes