Presentación para la Sociedad Española de Epidemiología en la 5th European Conference on Migrant and Ethnic Minority Health. Granada, 11 de abril 2014

1. Evolution of migrants' health in times of
economic crisis in Spain: evidence from
health surveys in the general population
and in vulnerable groups
Davide Malmusi @dmalmusi, Mercè Gotsens, Ana M Novoa

2. Immigration and economic growth in Spain
Changing pattern in the last decade
Spanish National Health Surveys
N foreign 650* 3605 3022 .
-4
-2
0
2
4
6
8
10
2000 2002 2004 2006 2008 2010 2012
Foreign-born residents (millions) GDP growth rate (%)
2011:
Non-EU foreigners
at-risk-of-poverty
rate: 49%

3. Objective of the presentation
• To describe the health status of immigrants from less
advanced economies before and during the crisis
according to different information sources
• National Health Survey
• Caritas Barcelona users’ survey on housing and health
• “Immigration, work and health” project (ITSAL) follow
up cohort

4. • CIBERESP Immigration and health
program
• Aim: To analyse the health
status, health determinants and
healthcare use of immigrants in
Spain
– according to
sex, birthplace, length of
residence, social class
– compared to the Spanish
population,
– in 2006 and 2012.
Spanish National Health Survey
(SNHS) 2006-2012

5. SNHS 06-12. Methods
Cross-sectional survey of the non-institutionalised population
Multistage sampling with representation by Autonomous Community
Face-to-face interviews at home
Valid sample completing the adult questionnaire (aged 15 or over):
2006, n=29.478; 2012, n=21.007
Age-standardised proportions were calculated by survey year, sex and:
1. birthplace: Spain, high-income countries, low-income countries
2. Low-income countries divided by continents
3. Low-income countries by years of residence in Spain
4. Spain and low-income countries by social class

6. SNHS 06-12. Results
Sample size by birthplace

7. Results
Social determinants of health
% employment status, men% manual social class, women
PRB = Países de renta baja (Low-Income countries). PRA = Países de renta alta (High-Income countries)

8. Results
General health and chronic conditions
% fair/poor self-rated health, men

9. Results
General health and chronic conditions
% fair/poor self-rated health, women

10. Results
Mental health
% poor mental health (Goldberg GHQ-12 score >2), men

11. Results
Mental health
% poor mental health (Goldberg GHQ-12 score >2), men
Also rise of anxiolytics and antidepressants in “PRB” men

12. Results
Mental health
% poor mental health (Goldberg GHQ-12 score >2), men

13. Results
Mental health
% poor mental health (Goldberg GHQ-12 score >2), women

14. SNHS 06-12. Strenghts and limitations
• Wide range of health aspects covered
• Standardised procedures. Repetition over time
• Comparison with Spanish population
• Sample size
• Sample composition. Are responders a representative sample of
the immigrant population?

15. • Baseline survey of a
quasiexperimental study to
evaluate health effects of
Caritas rehousing program, part
of the SOPHIE project
• Published as part of annual
Caritas Barcelona report
• Aim: to describe the health
status and determinants of
Caritas users with housing
problems, compared with
Barcelona general population
Caritas Barcelona users with
housing problems, 2012 survey

16. Rehoused (Caritas social
renting programme)
Waiting list
Families/people attended
by Caritas living in
substandard housing*
Baseline survey
(Sept-Dec 2012)
Follow-up survey
(1 year after)
*Inadequate housing habitability conditions or overcrowding
Caritas 2012. Methods
Study population

17. Rehoused (Caritas social
renting programme)
Waiting list
Families/people attended
by Caritas living in
substandard housing*
n=175
n=145
*Inadequate housing habitability conditions or overcrowding
Follow-up survey
(1 year after)
Baseline survey
(Sept-Dec 2012)
Caritas 2012. Methods
Study population
… or attended by Caritas
Housing Mediation Service (HMS)
(unable to afford rent/mortgage)

18. Families/people attended
by Caritas living in
substandard housing*
n=175 – 164 foreign-born
n=145 – 84 foreign-born
*Inadequate housing habitability conditions or overcrowding
Baseline survey
(Sept-Dec 2012)
Caritas 2012. Methods
Study population
… or attended by Caritas
Housing Mediation Service (HMS)
(unable to afford rent/mortgage)

19. • 3 questionnaires
(1) Dwelling questionnaire (household composition, housing type and
conditions, housing costs, housing and neighbourhood satisfaction)
(2) Resident questionnaire (demographic and socio-economic characteristics,
and health status of the person interviewed)
(3) Child questionnaire (sociodemographic and health information of one
randomly selected child 4-14 years old; reported by mother/father) N=177
• Performed at Cáritas by a trained interviewer
• Answered by the household head or partner (randomly
selected)
Caritas 2012. Methods
Data collection

20. • Barcelona Health Survey 2011
Adults and children
For comparable indicators (same question)
Prevalences directly standardised by age (reference: Caritas sample)
Comparison groups:
- Whole population
- Manual social class (IV-V)
- Immigrants from low-income countries
Caritas 2012. Methods
Comparison with Barcelona population

21. • Substandard Housing: 74% women. HMS: 50% women
• 89% manual social class
• 77% immigrants
– 58% Latin America; 17% North Africa; 12% Sub-saharian Africa
– undocumented: 44% of substandard housing sample, 2% HMS
• 53% unemployed. Most employed have no contract
• 78% food insecurity
Caritas 2012. Results
Sociodemographic characteristics

22. • 88% overburden of housing costs (>30% income)
• 59% SH, 78% HMS think they’ll lose their house in two years
• 54% SH, 44% HMS hot/cold temperature is a problem
• 58% SH, 44% HMS rats/cockroaches/similar (5% Barcelona)
Caritas 2012. Housing conditions
22,1
3,2 4,7
56,6
0
20
40
60
80
100
Subst Housing HMS BCN BCN SC IV and V
%
Overcrowding

23. • Much worse health status than overall Barcelona population
Caritas 2012. Results
Health status
62,2
75,0
11,5 12,1
66,9
72,6
15,2
17,4
0
20
40
60
80
100
Subst housing HMS BCN BCN SC IV and V
%
Men Women
Poor mental health (GHQ>2)
24,4
45,8
11,2 12,8
53,1
60,3
15,3
20,5
0
20
40
60
80
100
Subst housing HMS BCN BCN SC IV and V
%
Men Women
Fair/poor health status
BCN migrants: 15% men, 18% womenBCN migrants: 16% men, 18% women

24. • Much worse health status than overall Barcelona population
– also for children
Caritas 2012. Results
Health status
28,9
38,9
3,6
62,3
65,8
8,5
0
20
40
60
80
100
Subst housing HMS BCN
%
Boys Girls
Poor mental health (anormal SDQ)
BCN migrants’ children: 8%
20,5 19,0
3,6
31,9
19,5
1,6
0
20
40
60
80
100
Subst housing HMS BCN
%
Boys Girls
Repeat otitis

25. Caritas 2012. Press coverage
PRESS CONFERENCE (18th Des)
• Presentation of the report “Home, house and health. Housing action and prevention”
– Annual evaluation of Caritas’s activity
– Description of baseline analysis results

26. Other studies: ITSAL (quanti)

27. Other studies: ITSAL (quanti)

28. Other studies: ITSAL (quali)
Fri 13.30h, Session A12, Room A6
Abstracts book page 120

29. Other studies: ITSAL (quali)
Fri 13.30h, Session A12, Room A6
Abstracts book page 120

30. Conclusions
• General population surveys show a substantially stable pattern
in migrants’ health, with worsening mental health in men as
sentinel event
• Specific migrant cohorts recruited in community settings show
a much
• The health-damaging consequences of economic
precariousness are especially evident among the most
vulnerable migrants and their children, often
underrepresented in general population surveys.

31. Reports available at:
www.sophie-project.eu/pdf/ens_inmi.pdf
www.sophie-project.eu/pdf/salut_habitatge.pdf

32. Evolution of migrants' health in times of
economic crisis in Spain: evidence from
health surveys in the general population
and in vulnerable groups
Davide Malmusi @dmalmusi, Mercè Gotsens, Ana M Novoa