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The health selection hypotheses relate to the health status of a migrant at the time of migration. Both in-migration to the new country of residence and out-migration from the country of settlement to the country of origin generate health selection hypotheses.

Ethnic inequalities in health are strongly linked to migration processes. The health selection hypotheses by definition focuses only on immigrants as a single homogeneous group rather than their descendants. Although the hypotheses focus on migrants, those processes are likely to differ by ethnic group due to varied cultures and beliefs in the benefits of migration.

Different ethnic groups will also have different reasons for and timings of migration depending on the context in both their country of origin and country of destination. Jasso also outlines that the health selection effect of migrants might differ by the reason for migration (Jasso et al., 2004). For example, those migrating in old age might well do so attracted by access to better health care in the receiving country. Furthermore, refugees might experience bad health due to difficult experiences in their country of origin and during the process of migration. Hence, the relevance of the health selection hypotheses is likely to vary according to the reason for migration.

The first hypothesis focuses on the health status of migrants when moving from the country of origin to a new country of residence. The so-called “healthy migrant effect” (or

“healthy immigrant effect”) proposes that those who move are likely to be healthier than the ones they leave behind, as the process of migration requires a certain level of health and wealth (Jasso et al., 2004, Marmot et al., 1984). Two processes have been distinguished in the health selection of new migrants: individual self-selection and government health screening to enter the new country of residence (Jasso et al., 2004). The individual self-selection process relies on the assumption that “good health fosters mobility; ill health limits mobility” (Wallace and Kulu, 2014b). Hence, good health can encourage the decision to move. This assumption of selectivity can hold for both internal and international migrations and is thought to be positively associated with the distance of migration (Rubalcava et al., 2008). Health screening can happen prior to migration for potential migrants or at the time of entry into the receiving country. Although it might depend on the political context of the receiving country, health screening is likely to account for a very small part of the health selection process (Jasso et al., 2004). It is also worth noting that a receiving country selecting individuals for economic reasons based on qualifications and higher levels of education will indirectly select individuals with better health as higher education levels and socio-economic status are strongly associated with better health status. Those who migrate are more likely to have a set of characteristics that predispose them to better health in the long run including a determination and open mindedness to move beyond their familiar environment. This supports the idea of migrants being healthier than those they leave behind but not necessarily healthier than the population they come to live with in the country of settlement.

However, the concept of the “healthy migrant” has been extended to migrants being healthier generally and healthier than the population of the country they move to. Indeed, it can be argued that if the sending country has worse average health than the receiving country and the migrants have better health than the native population born in the receiving country, then migrants might have better health than those they have left behind in the sending country (Jasso et al., 2004). Wallace and Kulu refer to the health advantage of migrants over both those left behind in their country of origin and the residents of the receiving country as the “true healthy migrant effect” (Wallace and Kulu, 2014b).

Empirical evidence testing the “healthy migrant effect” (better health in migrants compared to their peers in their country of origin) is limited. Using standardised mortality ratios, initial work by Marmot et al. explored the mortality of migrants in England and Wales compared to that of their countries of birth (Marmot et al., 1984). The authors found better outcomes in

migrant men from Italy, Poland, the Indian subcontinent and the Caribbean compared to that of their respective countries of origin. The exception was that Irish migrants had a higher mortality level than those in Ireland. These ethnic differences in the health of different group of migrants and for this particular example of Irish migrants in the UK, was later attributed to a distance explanation arguing that a short migration distance makes the “healthy migrant effect” less likely as the cost of migration between the two countries is low (Jasso et al., 2004). Since Marmot et al., a few research studies have attempted to test the “healthy migrant effect”. Rubalcava et al. found weak support for the hypothesis with better health not necessarily predicting subsequent migration to the US in 15 to 29-year-old Mexican males and females (Rubalcava et al., 2008). Razum et al. found support for the “healthy migrant effect” in that the mortality of Turkish residents in Germany was low compared to that of Turkish residents in Ankara, in Turkey and also lower than that of Germans in Germany (Razum et al., 1998).

In response to the lack of health and migration data at an international level enabling researchers to follow mobile populations and their health status from the country of origin to the receiving country, a body of evidence has emerged testing the “healthy migrant effect”

hypothesis within countries. Once international migration is excluded, the health effect of internal migration can be analysed between two geographical areas of the same country for example between England and Scotland within the UK, between Northern Sweden and Southern Sweden and between rural and urban areas in China and Indonesia (Andersson and Drefahl, 2017, Lu, 2008, Lu and Qin, 2014, Wallace and Kulu, 2014b). Evidence of a “healthy migrant effect” was found in adult migrants (aged 18-64 years) within the UK, both from Scotland to England (compared to those who stayed in Scotland) as well as from England to Scotland (compared to those who stayed in England) (Wallace and Kulu, 2014b). Similarly, in China, evidence showed a “healthy migrant effect” among rural migrants to urban areas compared to those who stayed in rural areas which included a gradient of the effect as distance increased (Lu and Qin, 2014). In the case of Sweden, however, there was no evidence of a “healthy migrant effect” in Northern Swedes of working age who moved to Southern Sweden compared to stayers (Andersson and Drefahl, 2017). Movers from Northern Sweden also showed a higher risk of mortality than stayers once education level was accounted for. Overall, the findings suggest that making a move within countries might require less of an advantage in health, economic status and resourcefulness generally.

The second theory relates to return migration in an unhealthy state. The “salmon bias”

hypothesis is a key element of the unhealthy return migration theory. It proposes that ill health precipitates return migration to the country of origin with the idea of a wish to die at home or, if ill, a preference to be “at home”. The “salmon bias” terminology was proposed by Pablos-Mendez in 1994 based on the idea of the salmon run and the compulsion to go back to their birthplace and die (Pablos-Mendez, 1994). However, reasons other than ill health in older age can lead to unhealthy return migration. An unhealthier individual more generally might experience more difficulties in securing a job and the stability necessary to settle in the receiving country and could engage in return migration to find support and security back home. Health might not be the only reason for the inability to settle in the receiving country. An “unsuccessful migration” or negative experience of migration can leave scars. A negative experience of migration can be due to many factors such as language difficulties, culture and norm differences, a lack of transferability or recognition of skills, unemployment, and experiences of deprivation, discrimination, and racism. Those who engage in return migration due to unsuccessful settlement in the receiving country are likely to come back disillusioned, scarred and in worse health compared to the successful migrants who settled.

A few studies have tested the “salmon bias” hypothesis whereby ill health precipitates return migration to the country of origin when death is imminent. Turra and Elo tested this hypothesis using beneficiary data in the US (population aged 65 years and above) (Turra and Elo, 2008). The key advantage of beneficiary data is that individuals’ migration and health status can be tracked to the country people move to outside the US and the mortality outcome of migrants who engaged in return migration can be compared to those who remained in the US. The authors found a higher mortality in those who returned from the US compared to those who stayed in the US, in both foreign-born Hispanic Whites and, to a lesser extent, in foreign-born non-Hispanic Whites. Higher mortality was also found among recent returnees to their country of origin i.e. within a year of return migration, in line with the hypothesis of precipitated return migration due to deteriorating health. This supports the hypothesis of a “salmon bias”

phenomenon in foreign-born elders.

Another US study aimed to test the “salmon bias” hypothesis in relation to morbidity.

Ullmann et al. focused on the health of returnees from the US to Mexico and found a higher prevalence of mental health disorder, smoking and heart disease in returnees compared to stayers in the US. However, the authors could not distinguish whether the results were

attributable to the health effect of residing in the US (acculturation effect) or a negative health selection of Mexican migrants (salmon bias) who then returned to Mexico (Ullmann et al., 2011).

This highlights the need to develop longitudinal studies in both sending and recipient countries.

Further evidence on European Turkish migrants in the European context does not provide support for a “salmon bias” phenomenon. For example, Baykara-Krumme examined whether elderly Turkish migrants to Europe decide to live in Turkey (remigrants), stay in their European receiving country (immigrants) or both (transmigrants) (Baykara-Krumme, 2013). She found no evidence of a health selection process in the decision to stay, return or both for Turkish migrants aged 65 years and above. Similarly, Razum et al. conducted focus group sessions with returnees, Turkish male migrants from Germany to Turkey, and found varied reasons for return migration such as lack of economic success, emotional and value-oriented reasons. There was no indication of a return due to the desire to die at home although the returnees who did not

‘succeed’ in Germany were likely to be at higher risk of unhealthy return migration (Razum et al., 2005).

Due to limited international data to test health selection processes, a few studies have also tested the “salmon bias” in an internal migration context (Andersson and Drefahl, 2017, Lu, 2008, Lu and Qin, 2014, Wallace and Kulu, 2014b). Based on self-assessed health, Wallace and Kulu found no evidence of a “salmon bias” between Scotland and England which they attributed to possible similarities of language, culture and government as well as short distance of migration (Wallace and Kulu, 2014b). In contrast, studies in the Chinese context using self-reported health and in the Swedish context using mortality found evidence of an unhealthy return migration to the birth place (Andersson and Drefahl, 2017, Lu and Qin, 2014).

Under the “salmon bias” hypothesis, unhealthy people would emigrate and die abroad soon after. If emigrations and deaths abroad are not recorded in the receiving country, this creates a sample of “statistically immortal” migrants thus resulting in numerator and denominator biases and consequently, in an artificial mortality advantage in migrant populations. In an attempt to test whether the “salmon bias” could explain out the mortality advantage in Hispanics, Turra and Elo added the death data for both US residents and foreign-residents into a sensitivity analysis of ethnic differences in mortality (Turra and Elo, 2008). The mortality advantage of foreign-born Hispanics in the US was not explained when deaths abroad where included in the analysis. Some studies have also attempted to indirectly test the “salmon bias” effect by comparing ethnic groups to the native population within the receiving country

(Abraido-Lanza et al., 1999, Vandenheede et al., 2015). Although not assessing the health status of return migrants in their country of origin, this research provided indications that the mortality advantage seen in minorities was not or not fully the result of a salmon bias effect (Abraido-Lanza et al., 1999, Vandenheede et al., 2015). So far, the evidence of a “salmon bias”

phenomenon that could explain a migrant mortality advantage is weak and requires further investigation.

In summary, both the “healthy migrant effect” and the unhealthy return migration including the “salmon bias” in later life have been offered as explanation for a migrant mortality advantage as it is expected that the healthiest come and the healthiest of the healthiest remain.

However, current empirical evidence remains limited to conclude on the contribution of the health selection hypotheses in explaining the mortality patterns observed.

Finally, a few studies have ventured a third health selection hypothesis of migrants which cannot be offered as an explanation for the mortality advantage in migrants: a healthy return migration to the country of origin (Razum et al., 2005, Sander, 2007). This alternative theory proposes that ill and more frail migrants are less likely to engage in return migration due to their bad health restricting mobility and the availability and access to a good health care system in the receiving country (Razum et al., 2005). In this hypothesis, only the healthier and wealthier can afford the luxury to move back to their country of origin in later life and after a successful economic gain while in the receiving country. This supports that the “healthy migrant effect” holds whatever the direction of migration (from the country of origin to the receiving country or back to the country of origin) in line with the idea that healthiness fosters mobility.