Nativity—characterized by place of birth, duration of residence in the host country, citizenship and immigration status—greatly influences the health of foreign-born individuals in the United States (U.S.). Despite this, many national health surveys omit questions about these dimensions of nativity, particularly immigration status. This omission limits the ability to assess health disparities across diverse immigrant subgroups and develop evidence-based policies and targeted interventions.
To navigate this limitation, researchers rely on proxy measures or imputations to determine immigration status. These proxies, including country of birth, occupation and a lack of a social security number, could be inaccurate and lead to biases. For example, some U.S. citizens and permanent residents also do not have social security numbers. Thus, using this as a proxy for identifying undocumented individuals could be misleading.
These challenges could be avoided if questions about immigrant status were asked directly. However, a few concerns persist: stigmatizing questions, lower response rates, invalid responses and deportation or prosecution if data is acquired by law enforcement or immigration authorities.
A research team led by Professor Fatma E. Marouf from Texas A&M University School of Law conducted a study that was published in the American Journal of Public Health on December 4, 2024 to address these complexities. They presented extensive evidence from various sources to corroborate their argument that objections to asking directly about immigration status lack substantiation and can be mitigated.
Highlighting the study's rationale, Prof. Marouf says, "We can no longer rely on conventional assumptions that [asking about] undocumented status is too stigmatizing or that such questions will yield lower response rates or invalid answers. These concerns must be rigorously tested and weighed against the knowledge lost—and poor health policy decisions that may be made—as a result of not asking [these questions]."
The analysis revealed that surveys like the National Agricultural Worker Survey, Kaiser Family Foundation/Los Angeles Times Survey of Immigrants, Hispanic Community Health Study/Study of Latinos (HCHS/SOL) and Los Angeles Family and Neighborhood Survey (L.A.FANS) have successfully extracted detailed responses to classify immigration status. These surveys provide response choices such as citizen, unauthorized, temporary protected status and pending visa applications.
Furthermore, questions about immigration status in the National Agricultural Worker Survey and the US Census Bureau's Survey on Income and Program Participation did not affect response rates. Similarly, only 4.3% of foreign-born respondents in L.A.FANS and less than 3% in HCHS/SOL did not answer immigration-related questions. So, questions about immigration status on health surveys could be less stigmatizing than previously assumed and reduce the dependence on proxies.
Regarding response validity, Prof. Marouf notes, "The Census Bureau analyzed the accuracy of self-reported citizenship on the American Community Survey by comparing responses to administrative records from numerous sources, including [but not limited to] those from the Department of Homeland Security and Social Security. They found that among individuals identified as noncitizens based on the administrative records, 12.21% misreported themselves as citizens." However, this invalidity percentage is still lower than earlier estimates (23.8% to 34.7%) when the Census Bureau used fewer administrative records for analysis.
To prevent deportation or prosecution, participants' immigration status and personally identifiable information like name and location can be anonymized. Since complete anonymization is impossible in longitudinal surveys, privacy and confidentiality laws can safeguard immigration status data. For instance, the Confidential Information Protection and Statistical Efficiency Act prevents the use of data collected by the federal government for non-statistical purposes and data disclosure without consent by punishments such as 5 years in prison and a fine of up to $250,000.
These findings counter the objections and provide a framework for National Health Surveys to include questions about immigration status. Researchers also proposed that oversampling the foreign-born population could effectively increase the statistical power to detect significant differences.
Prof. Marouf concludes that, "National health surveys have evolved over the past decades to include questions about mental health, substance use, sexual orientation, and gender identity—topics once assumed to be too stigmatizing to ask about, with possible negative legal consequences. The time has come to obtain more detailed information about immigration status as well as to consistently include the measures of immigration history mentioned so that we can better evaluate the health consequences of immigrant-related policy choices."
