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G. Costa, T. Spadea, L. Mondo, M. Perez, L. Quattrociocchi  - Migrants health and integration: outcome and process indicators
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G. Costa, T. Spadea, L. Mondo, M. Perez, L. Quattrociocchi - Migrants health and integration: outcome and process indicators

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Integration: knowing, measuring, evaluating 17-18 giugno 2013

Integration: knowing, measuring, evaluating 17-18 giugno 2013


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  • Similar variations in affect on health for migrants apply to all aspect of social exclusion …we are all aware of the health consequence on those determinants, we are only highlighting those specific to poverty and migrants
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    • 1. Migrants health and integration: outcome and process indicators Giuseppe Costa1,2 , Teresa Spadea2 , Luisa Mondo2 , Monica Perez3 , Luciana Quattrociocchi3 1. Università di Torino 2. S.C. a D.U. Epidemiologia, ASL TO3 Regione Piemonte 3. Istat International conference Integration: knowing, measuring, evaluating Rome, 17-18 June 2013
    • 2. importation diseases uprooting acculturation effects / social inequalities time since migration racial discrimination / cultural barriers / legal constraints Genetic characteristics Exposures in the country of origin Exposures in the host country Socioeconomic deprivation Migration experience Natural history of migrants health problems IN – selection: healthy migrant effect OUT- selection: salmon bias Migrants’ health profiles reflect their past medical histories and quality of health care
    • 3. Cancer incidence and mortality worldwide, 2008 http://globocan.iarc.fr/
    • 4. PSA 49892 1 PFPM 204 0,55 0,48 0,63 PSA 15050 1 PFPM 50 0,36 0,27 0,47 PSA 1173 1 PFPM 27 1,86 1,26 2,74 * PSA: high-income countries, according to the 2007-08 World Bank classification (inclu (Africa, Asia excluding Israel, South Korea and Japan, Latin America, Central and E PFPM: countries with strong migratory pressure BREAST CERVIX RR 95% CI ALL CANCERS Cancer Site Citizenship status* N Cancer incidence in migrants – The Turin Longitudinal Study, 1985-2006 females
    • 5. importation diseases uprooting acculturation effects / social inequalities time since migration racial discrimination / cultural barriers / legal constraints Genetic characteristics Exposures in the country of origin Exposures in the host country Socioeconomic deprivation Migration experience Natural history of migrants health problems IN – selection: healthy migrant effect OUT- selection: salmon bias Migration involves uprooting, leaving family and social networks behind, and moving into situations of little guaranteed security
    • 6. importation diseases uprooting acculturation effects / social inequalities time since migration racial discrimination / cultural barriers / legal constraints Genetic characteristics Exposures in the country of origin Exposures in the host country Socioeconomic deprivation Migration experience Natural history of migrants health problems IN – selection: healthy migrant effect OUT- selection: salmon bias Migration involves acculturation, i.e. the process of acquisition of/integration with the cultural elements of the dominant society (language, food, behaviours…)
    • 7. Impact of acculturation Negative effect Mixed or no effect Positive effect Nutrition 9 1 - Exercise 3 1 1 Smoking 11 7 - Substance abuse 19 7 - Health care use - 3 7 Vaccination 2 2 - Cancer screening - 3 9 Studies analysing different health outcomes among Latino in USA (1) Lara M, 2005 behaviours access to care
    • 8. importation diseases uprooting acculturation effects / social inequalities time since migration racial discrimination / cultural barriers / legal constraints Genetic characteristics Exposures in the country of origin Exposures in the host country Socioeconomic deprivation Migration experience Natural history of migrants health problems IN – selection: healthy migrant effect OUT- selection: salmon biasMigrants’ health profiles reflect their working and living conditions they move into on arrival in new countries
    • 9. Self-rated heath by ethnicity and income - England, 1999 Nazroo J, 2003
    • 10. Self-rated health according to migration type - Spain, 2006 Model 1: Adjusted by age Model 2: Model 1 + social class Model 3: Model 2 + material index Malmusi D, 2010 Women
    • 11. Social effects • descending career • segregation Social effects • descending career • segregation Social consequences Social consequences Policy context Social context Policy context Social context Control over resources • material/education • status • ties/social support Control over resources • material/education • status • ties/social support Social position Social position Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors Risk factors Health outcomes • death/morbidity • hospitalization • injury Health outcomes • death/morbidity • hospitalization • injuryHealth impairment Health impairment Physical vulnerability Social vulnerability SOCIETY Social stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility INDIVIDUAL Exposure Healthy migrant effect and salmon bias
    • 12. Social effects • descending career • segregation Social effects • descending career • segregation Social consequences Social consequences Policy context Social context Policy context Social context Control over resources • material/education • status • ties/social support Control over resources • material/education • status • ties/social support Social position Social position Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors Risk factors Health outcomes • death/morbidity • hospitalization • injury Health outcomes • death/morbidity • hospitalization • injuryHealth impairment Health impairment Physical vulnerability Social vulnerability SOCIETY Social stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility INDIVIDUAL Exposure Healthy migrant effect and salmon bias
    • 13. Housing: inadequate, overcrowding Nutrition: not only decrease due to poverty but also difference in diet from country of origin Education: in migrants’ case, even higher education does not equalize access to health care Isolation and Separation: prolonged separation from loved ones is associated with mental and psychosocial illness as well as risk taking behaviors that have adverse health outcomes. Of note is also the emotional stress, increased work load, lack of parental supervision in families left behind Early life: problems found more frequently among migrant children are parental poverty, frequent moves, low health expectations, interrupted schooling, overcrowded living conditions, and poor sanitation facilities Social determinants of health among migrants
    • 14. Amable’s model (2006) Precarious employment - Spain, 2006-2007 Porthé V, 2010
    • 15. Social effects • descending career • segregation Social effects • descending career • segregation Social consequences Social consequences Policy context Social context Policy context Social context Control over resources • material/education • status • ties/social support Control over resources • material/education • status • ties/social support Social position Social position Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors Risk factors Health outcomes • death/morbidity • hospitalization • injury Health outcomes • death/morbidity • hospitalization • injuryHealth impairment Health impairment Physical vulnerability Social vulnerability SOCIETY Social stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility INDIVIDUAL Exposure Healthy migrant effect and salmon bias
    • 16. Predicted per cent reporting fair or poor health 0 10 20 30 40 50 None Verbal Physical or property No or a few Some or most Non manual Manual Karlsen and Nazroo, 2002 Racial harassment Do employers discriminate? Class Racism, discrimination, occupational class and health
    • 17.  Gender-based violence, sexual abuse and exploitation is a major concern in the context of female migration; in situations in which women lack personal power and self-esteem violence and abuse are common  Arranged or forced marriages can be a major source of psychosocial suffering for girls who grow up seeing their non-migrant peers going through different lifestyles; this may be an important factor for the very high suicide rates reported among adolescent South Asian girls in the UK  Many migrant children usually find difficulties in finding a balance between their cultural identities and face a number of psychological stresses (uprooting, violence, mental health problems) Psychosocial implications: women and children
    • 18. Social effects • descending career • segregation Social effects • descending career • segregation Social consequences Social consequences Policy context Social context Policy context Social context Control over resources • material/education • status • ties/social support Control over resources • material/education • status • ties/social support Social position Social position Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors Risk factors Health outcomes • death/morbidity • hospitalization • injury Health outcomes • death/morbidity • hospitalization • injuryHealth impairment Health impairment Physical vulnerability Social vulnerability SOCIETY Social stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility INDIVIDUAL Exposure Healthy migrant effect and salmon bias
    • 19. Smoking habit by country of origin - Italy, 2005-2006 Gargiulo L, 2008 28 38 42 34 33 29 25 28 24 5 15 13 13 18 20 15 22 14 12 5 4 5 1 0 6 1 4 31 1 4 20 15 0 10 20 30 40 50 Italians Foreigners Romania Albania M orocco Other Europe not EU Other Africa Latin America S m o ke rs _ M S m o ke rs _ W H e a v y s m o ke rs _ M H e a v y s m o ke rs _ W Age-adjusted rates
    • 20. Social effects • descending career • segregation Social effects • descending career • segregation Social consequences Social consequences Policy context Social context Policy context Social context Control over resources • material/education • status • ties/social support Control over resources • material/education • status • ties/social support Social position Social position Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors Risk factors Health outcomes • death/morbidity • hospitalization • injury Health outcomes • death/morbidity • hospitalization • injuryHealth impairment Health impairment Physical vulnerability Social vulnerability SOCIETY Social stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility INDIVIDUAL Exposure Healthy migrant effect and salmon bias
    • 21. Precarious employment and injury risk - Italy, 2000-2005 Bena A, 2012 1.00 1.20 1.40 1.60 1.80 2.00 2.20 < 3 mesi 3 - 6 mesi 7 - 11 mesi 12 - 23 mesi 24 - 35 anni >= 3 anni PFPM PSA 0.97 1.09*** 1.08*** 1.13*** 1.20*** 1.35*** PSA: high-income countries; PFPM: countries with strong migratory pressure § All events that led to death, permanent incapacity or temporary disability with more than 29 days of prognosis Serious injuries§ by length of contract – Risk rates (y-axis) and relative risks (arrows) adjusted for gender, age, skill level, economic activity and year * p<0.10 ** p<0.05 *** p<0.01
    • 22. Social effects • descending career • segregation Social effects • descending career • segregation Social consequences Social consequences Policy context Social context Policy context Social context Control over resources • material/education • status • ties/social support Control over resources • material/education • status • ties/social support Social position Social position Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors Risk factors Health outcomes • death/morbidity • hospitalization • injury Health outcomes • death/morbidity • hospitalization • injuryHealth impairment Health impairment Physical vulnerability Social vulnerability SOCIETY Social stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility INDIVIDUAL Exposure Healthy migrant effect and salmon bias
    • 23. Krause N, 2010 Effort-Reward Imbalance (ERI) among hotel room cleaners - USA, 2002
    • 24. Social effects • descending career • segregation Social effects • descending career • segregation Social consequences Social consequences Policy context Social context Policy context Social context Control over resources • material/education • status • ties/social support Control over resources • material/education • status • ties/social support Social position Social position Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors Risk factors Health outcomes • death/morbidity • hospitalization • injury Health outcomes • death/morbidity • hospitalization • injuryHealth impairment Health impairment Physical vulnerability Social vulnerability SOCIETY Social stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility INDIVIDUAL Exposure Healthy migrant effect and salmon bias
    • 25. • Access to, quality of, and outcomes of health care are a constant challenge for migrants and refugees. • Even when access to healthcare services is possible in principle, other obstacles intervene. • These may include how migrants perceive the health services, unfounded beliefs about what is and is not really available to them, what the healthcare personnel are willing to “share” with them, lack of information about entitlements, cultural barriers, the fear of being denounced, etc. • Many obstacles are to be found in legislation, knowledge and attitudes of health professionals, health care organization and models Access to care
    • 26. ENTITLEMENT PERCEPTION ACCESSIBILITY QUALITY OUTCOME Limitations in health care
    • 27. Entitlement FRA - European Agency for Fundamental Rights,
    • 28. ENTITLEMENT PERCEPTION ACCESSIBILITY QUALITY OUTCOME Limitations in health care
    • 29. % of pregnancy ending with voluntary abortion (15-49 anni), by ethnicity and age in Piedmont 2010 Hospital admissions, 2010 PSA = advanced countries PFPM = countries with high demographic and migration pressure - 20 40 60 80 15-19 20-24 25-29 30-34 35-39 40-44 45-49 PSA PFPM
    • 30. 70 42 49 31 30 57 30 50 73 65 70 47 50 59 38 75 72 53 63 37 34 58 33 61 0 10 20 30 40 50 60 70 80 Italians Foreigners Romania Albania M orocco Other Europe not EU Other Africa Latin America 0-9 years of education 10+ years of education Total Pap-test practice by country of origin and education – Italy, 2005-2006 Gargiulo L, 2008 Age-adjusted rates
    • 31. ENTITLEMENT PERCEPTION ACCESSIBILITY QUALITY OUTCOME Limitations in health care
    • 32. Urgent hospital admissions by citizenship and legal status – Marche Region (Italy), 2004-2007 Carletti P, 2009
    • 33. ENTITLEMENT PERCEPTION ACCESSIBILITY QUALITY OUTCOME Limitations in health care
    • 34. * Belgium, Denmark, Norway, the Netherlands and Sweden ** Austria, France, Germany, Italy, United Kingdom, Spain and Switzerland   Relative risks of immigrants vs. natives in different EU countries   Total Countries with strong integration* Countries with light integration** Birthweight <2500 gr 1.43 (1.42-1.44) 0.98 (0.96-1.01) 1.54 (1.52-1.55) Gestational age < 37 weeks 1.24 (1.22-1.26) 1.16 (1.14-1.18) 1.47 (1.43-1.52) Early Mortality 1.50 (1.47-1.53) 1.41 (1.37-1.46) 1.56 (1.52-1.60) Congenital malformations 1.61 (1.57-1.65) 0.94 (0.87-1.00) 1.78 (1.74-1.84) Bollini P, 2009 Birth outcomes – Italy, 2005-2006
    • 35. Social effects • descending career • segregation Social effects • descending career • segregation Social consequences Social consequences Policy context Social context Policy context Social context Control over resources • material/education • status • ties/social support Control over resources • material/education • status • ties/social support Social position Social position Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors • psycho-social • behavioural • environmental/occupational • health care accessibility Risk factors Risk factors Health outcomes • death/morbidity • hospitalization • injury Health outcomes • death/morbidity • hospitalization • injuryHealth impairment Health impairment Physical vulnerability Social vulnerability SOCIETY Social stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility INDIVIDUAL Exposure Healthy migrant effect and salmon bias
    • 36. Vulnerability to health effects: the case of Roma In the summer of 2009 in Bulgaria, there has been an outbreak of a measles epidemic, starting from an unrecognized case in the Roma community, with about 24,000 cases and 24 deaths, mostly among Roma: - not recorded in health registries (no GP) - low vaccine coverage and no official data - delayed access to care
    • 37. Vulnerability to social effects of disease: the costs for care FRA - European Agency for Fundamental Rights,
    • 38. importation diseases uprooting acculturation effects / social inequalities time since migration racial discrimination / cultural barriers / legal constraints Genetic characteristics Exposures in the country of origin Exposures in the host country Socioeconomic deprivation Migration experience Natural history of migrants health problems IN – selection: healthy migrant effect OUT- selection: salmon bias Selection effects
    • 39. Healthy migrant effect and/or salmon bias? The health of returned migrants in Mexico Ullmann SH, 2011 p-Value Demographic characteristics Age 48.4 46.4 48.9 <0.01 Urban 40.5% 30.7% 43.4% <0.001 Married 96.8% 95.9% 97.1% -- Anthropometric characteristics Height (m) 1.66 1.67 1.65 <0.05 Weight (kg) 75.3 77.1 74.8 <0.001 Health behaviors Ever smoking 34.5% 41.2% 32.7% <0.01 Current smoking 23.6% 28.5% 22.2% <0.05 Health at age 14 (before migration) Excellent 23.6% 37.6% 19.7 <0.001 Good 73.9% 60.1% 77.6% <0.001 Fair/Poor 2.5% 2.2% 2.6% -- Health at the time of survey Excellent 5.9% 9.6% 4.8% <0.01 Good 60.2% 56.4% 61.2% -- Fair 30.1% 28.8% 30.4% -- Poor 3.8% 5.1% 3.5% -- Health conditions and diseases Obesity 19.8% 22.8% 19.0% -- Hypertension 14.0% 17.3% 13.1% <0.05 Diabetes/high blood sugar 10.4% 12.0% 9.9% -- Emotional/psychiatric 7.4% 13.1% 5.9% <0.001 disorders Heart attack/heart disease 4.3% 6.9% 3.6% <0.05 With migration experience Without migration experience Total sample Early life health Adult health
    • 40. importation diseases uprooting acculturation effects / social inequalities time since migration racial discrimination / cultural barriers / legal constraints Genetic characteristics Exposures in the country of origin Exposures in the host country Socioeconomic deprivation Migration experience Natural history of migrants health problems IN – selection: healthy migrant effect OUT- selection: salmon bias Heterogeneity by ethnic origin, age at arrival and time since migration
    • 41. 75.0 83.9 89.0 84.7 75.7 84.9 88.7 95.2 67.9 76.0 77.4 77.2 54.8 82.2 76.2 71.5 35.7 21.8 21.1 17.5 29.9 18.8 15.5 19.7 43.0 29.3 33.5 32.1 40.7 29.0 17.1 32.9 0 10 20 30 40 50 60 70 80 90 100 Ita lia ns F o re igne rs R o m a nia A lba nia M o ro c c o O the r Euro pe no t EU O the r A fric a La tin A m e ric a Good/very good _M Good/very good _F At least one chronic disease _M At least one chronic disease _F Health indicators by country of origin - Italy, 2005-2006 Gargiulo L, 2008
    • 42. importation diseases uprooting acculturation effects / social inequalities time since migration racial discrimination / cultural barriers / legal constraints Genetic characteristics Exposures in the country of origin Exposures in the host country Socioeconomic deprivation Migration experience IN – selection: healthy migrant effect OUT- selection: salmon bias Conclusions on relative health impact of each mechanism Low, negative, long High, negative/positive, long Low, negative, short High, negative, long
    • 43. Italian research context  Statistical data from ISTAT and NHS:  Health Interview Survey (ethnic minority boost);  Mortality statistics  Administrative data from NHS utilization  Hospital admission  Outpatient visit and examination  Prescribed medication  Pregnancy and children care  Occupational injury (INAIL)
    • 44. Health dimensions Indicators (prevalence) Relevance Availability Distal determinants of health Labour, housing, security, rights… High See other chapters Proximate determinants of health (risk factors that intermediate the health impact of distal determinants) Smoking High Health interview Survey & HIS migrants wave Alcohol abuse High Household Living Condition Interview Survey Overweight / Obesity Middle Health interview Survey & HIS migrants wave Sedentariness Middle Health interview Survey Contraceptive use High HIS migrants wave Working conditions at risk for safety and hygiene High HIS migrants wave & WHIP-Health longitudinal panel Housing conditions at risk for safety and hygiene Low Census Racial discrimination and harassment Middle HIS migrants wave
    • 45. Health dimensions Indicators (prevalence) Relevance Availability Vulnerability to the health effects of risk: health care utilization Periodic examination Middle Health interview Survey Female cancer screening High Recommended paediatric vaccinations High At least one GP / paediatrician consultation High Health interview Survey & HIS migrants wave At least one specialist consultation Middle At least one diagnostic test Middle % out-of-pocket health care utilization Middle Unconventional medicine Middle Use of drugs Low Hospitalization Low Inappropriate hospitalization High NHS hospital discharges Emergency care Middle Health interview Survey & HIS migrants waveUse of family counselling High
    • 46. Health dimensions Indicators (prevalence) Relevance Availability Health outcomes Low physical, psychological and mental health Middle Health interview Survey & HIS migrants wave Trauma from accidents (occupation, transport, housing) High HIS migrants wave Trauma from violence High Hospitalization from trauma High NHS hospital discharges Time of first visit during pregnancy Middle NHS birth certificates Low gestational age at birth Middle Low birth weight Middle Neonatal mortality Middle Voluntary abortion Low NHS discharges & abortion certificates Infectious diseases Low NHS infectious disease & hospital discharges Hospitalization for mental health diseases High NHS hospital discharges Antidepressant medication Middle NHS drug prescriptions
    • 47. Health dimensions Indicators (prevalence) Relevance Availability Social vulnerability to disease Limitations in job search due to disease High HIS migrants wave Poverty due to health care costs High Survey of consumes Entitlement and fruition of health care rights Registration to NHS of children belonging to undocumented parents High Survey of the Italian Society of Medicine for Migration Mandatory registration to NHS of migrants waiting for final documents High Mandatory registration to NHS of migrants waiting for the first document High Voluntary registration to NHS over 65 High Emergency and continuity of care for temporary present undocumented migrants (STP) High Registration of temporary present undocumented migrants (STP) High Definition of exemption code X01 High Mandatory registration to NHS of undocumented parents of Italian children High Voluntary registration to NHS of migrants from EU countries High Equal access to guaranteed care for undocumented STP and refugees ENI High
    • 48. Cross sectoral requirements for indicators  Stratification  Age: Young/adult and elderly  Origin: native, poor and high pressure countries, the rest  Duration since migration  Drivers of migration: voluntary, forced, family reunification   Age adjustement  Focus on social inequalities
    • 49. Genetic characteristics Exposures in the country of origin importation diseases Migration experience Exposures in the host country acculturation effects Socioeconomic deprivation social inequalities time since migration racial discrimination / cultural barriers / legal constraints IN – selection: healthy migrant effect OUT- selection: salmon bias mechanisms entry points for interventions EQUITY AUDIT (EX ANTE – EX POST) OF STRATEGIES PROGRAMS INTERVENTIONS TIME FOR ACTION: INDICATORS MAY HELP