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Migrants health and integration:
outcome and process indicators
Giuseppe Costa1,2
, Teresa Spadea2
, Luisa Mondo2
,
Monica...
importation diseases
uprooting
acculturation effects / social inequalities
time since migration
racial discrimination / cu...
Cancer incidence and mortality worldwide, 2008
http://globocan.iarc.fr/
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-incom...
importation diseases
uprooting
acculturation effects / social inequalities
time since migration
racial discrimination / cu...
importation diseases
uprooting
acculturation effects / social inequalities
time since migration
racial discrimination / cu...
Impact of acculturation
Negative effect Mixed or no
effect
Positive effect
Nutrition 9 1 -
Exercise 3 1 1
Smoking 11 7 -
S...
importation diseases
uprooting
acculturation effects / social inequalities
time since migration
racial discrimination / cu...
Self-rated heath by ethnicity and income - England, 1999
Nazroo J, 2003
Self-rated health according to migration type - Spain, 2006
Model 1: Adjusted by age
Model 2: Model 1 + social
class
Model...
Social effects
• descending career
• segregation
Social effects
• descending career
• segregation
Social
consequences
Soci...
Social effects
• descending career
• segregation
Social effects
• descending career
• segregation
Social
consequences
Soci...
Housing: inadequate, overcrowding
Nutrition: not only decrease due to poverty
but also difference in diet from country of ...
Amable’s model (2006)
Precarious employment - Spain, 2006-2007
Porthé V, 2010
Social effects
• descending career
• segregation
Social effects
• descending career
• segregation
Social
consequences
Soci...
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
mos...
 Gender-based violence, sexual abuse and exploitation is a
major concern in the context of female migration; in situation...
Social effects
• descending career
• segregation
Social effects
• descending career
• segregation
Social
consequences
Soci...
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
1...
Social effects
• descending career
• segregation
Social effects
• descending career
• segregation
Social
consequences
Soci...
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 me...
Social effects
• descending career
• segregation
Social effects
• descending career
• segregation
Social
consequences
Soci...
Krause N, 2010
Effort-Reward Imbalance (ERI) among hotel room cleaners -
USA, 2002
Social effects
• descending career
• segregation
Social effects
• descending career
• segregation
Social
consequences
Soci...
• Access to, quality of, and outcomes of health care are a
constant challenge for migrants and refugees.
• Even when acces...
ENTITLEMENT
PERCEPTION
ACCESSIBILITY
QUALITY
OUTCOME
Limitations in health care
Entitlement
FRA - European Agency for Fundamental Rights,
ENTITLEMENT
PERCEPTION
ACCESSIBILITY
QUALITY
OUTCOME
Limitations in health care
% of pregnancy ending with voluntary abortion (15-49 anni), by ethnicity and age in
Piedmont 2010
Hospital admissions, 201...
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 Roma...
ENTITLEMENT
PERCEPTION
ACCESSIBILITY
QUALITY
OUTCOME
Limitations in health care
Urgent hospital admissions by citizenship and legal status
– Marche Region (Italy), 2004-2007
Carletti P, 2009
ENTITLEMENT
PERCEPTION
ACCESSIBILITY
QUALITY
OUTCOME
Limitations in health care
* Belgium, Denmark, Norway, the Netherlands and Sweden
** Austria, France, Germany, Italy, United Kingdom, Spain and Switz...
Social effects
• descending career
• segregation
Social effects
• descending career
• segregation
Social
consequences
Soci...
Vulnerability to health effects: the case of Roma
In the summer of 2009 in Bulgaria, there has been an outbreak of
a measl...
Vulnerability to social effects of disease: the costs for care
FRA - European Agency for Fundamental Rights,
importation diseases
uprooting
acculturation effects / social inequalities
time since migration
racial discrimination / cu...
Healthy migrant effect and/or salmon bias?
The health of returned migrants in Mexico
Ullmann SH, 2011
p-Value
Demographic ...
importation diseases
uprooting
acculturation effects / social inequalities
time since migration
racial discrimination / cu...
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...
importation diseases
uprooting
acculturation effects / social inequalities
time since migration
racial discrimination / cu...
Italian research context
 Statistical data from ISTAT and NHS:
 Health Interview Survey (ethnic minority boost);
 Morta...
Health dimensions Indicators (prevalence) Relevance Availability
Distal
determinants of
health
Labour, housing, security,
...
Health dimensions Indicators (prevalence) Relevance Availability
Vulnerability to the
health effects of
risk: health care
...
Health
dimensions
Indicators (prevalence) Relevance Availability
Health outcomes
Low physical, psychological and
mental he...
Health
dimensions
Indicators (prevalence) Relevance Availability
Social
vulnerability
to disease
Limitations in job search...
Cross sectoral requirements for indicators
 Stratification
 Age: Young/adult and elderly
 Origin: native, poor and high...
Genetic
characteristics
Exposures in the
country of origin
importation diseases
Migration
experience
Exposures in the
host...
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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

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

  1. 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. 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. 3. Cancer incidence and mortality worldwide, 2008 http://globocan.iarc.fr/
  4. 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. 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. 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. 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. 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. 9. Self-rated heath by ethnicity and income - England, 1999 Nazroo J, 2003
  10. 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. 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. 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. 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. 14. Amable’s model (2006) Precarious employment - Spain, 2006-2007 Porthé V, 2010
  15. 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. 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. 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. 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. 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. 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. 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. 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. 23. Krause N, 2010 Effort-Reward Imbalance (ERI) among hotel room cleaners - USA, 2002
  24. 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. 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. 26. ENTITLEMENT PERCEPTION ACCESSIBILITY QUALITY OUTCOME Limitations in health care
  27. 27. Entitlement FRA - European Agency for Fundamental Rights,
  28. 28. ENTITLEMENT PERCEPTION ACCESSIBILITY QUALITY OUTCOME Limitations in health care
  29. 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. 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. 31. ENTITLEMENT PERCEPTION ACCESSIBILITY QUALITY OUTCOME Limitations in health care
  32. 32. Urgent hospital admissions by citizenship and legal status – Marche Region (Italy), 2004-2007 Carletti P, 2009
  33. 33. ENTITLEMENT PERCEPTION ACCESSIBILITY QUALITY OUTCOME Limitations in health care
  34. 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. 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. 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. 37. Vulnerability to social effects of disease: the costs for care FRA - European Agency for Fundamental Rights,
  38. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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