European cross-country comparisons of immigrants’ health and mortality. Do different integration policy models play a role?

1. European cross-country comparisons of
immigrants’ health and mortality.
Do different integration policy models
play a role?
Davide Malmusi
Agència de Salut Pública de Barcelona
NORDURM workshop, Stockholm, 5 December 2014

2. Background
SOPHIE project
Acronym for “Structural Policies and Health Inequalities Evaluation”
Funded by EU FP7 (Nov. 2011 - Oct. 2015)
SOPHIE aims to generate new evidence on the health equity impact
of social and economic policies and to develop innovative
methodologies for the evaluation of these policies in Europe

3. Background
SOPHIE project - Migration
SOPHIE aims to generate new evidence on the relationship between
the orientation of immigrant integration policies and migration-related
inequalities in health

4. Background
Immigrants’ health (in one slide)
Immigrants from less to more advanced countries:
• poorer socio-economic conditions
• “healthy immigrant effect” vanishing over time1, 2
Uretsky, Mathiesen. The effect of
years lived in the United States…
J Immigr Minor Health 2007
1 Fernando G De Maio. Immigration as pathogenic… Int J Equity Health 2010
2 Marie Norredam et al. Duration of residence and disease occurrence… Trop Med Int’l Health 2014

5. Background
Immigrants’ health
and immigration policies
>25,000 deaths of migrants in their way to Europe since 2000
according to «The Migrants’ Files» collaborative journalism project

6. Background
Immigrants’ health
and immigration policies
Immigration policies include control and integration policies1
Few studies on their health impact - mostly from the US, on control
policies, on undocumented migrants, single policy cases2
• "Immigration and Customs Enforcement": Fear of deportation impacts mental
health and access to healthcare3, large impact on children4
• Drop in autism diagnoses for Hispanic children after Proposition 1875
• Mental health impacts of passing through detention centres6,7
• Intimate partner violence, higher risk for women on spousal dependent visas8
1 Jennifer L Hochschild et al. Immigration regimes and schooling regimes… Theory Res Educ 2010.
2 Omar Martinez et al. Evaluating the impact of immigration policies… J Immigr Minor Health 2013
3 Karen Hacker et al. The impact of Immigration and Customs Enforcement… Soc Sci Med 2011.
4 Randy Capps et al. Paying the price: The impact of immigration raids… NCLR 2007.
5 Christine Fountain et al. Risk as social context: immigration policy and autism… Sociol Forum 2011.
6 Zachary Steel et al. Two year psychosocial and mental health outcomes for refugees… Soc Sci Med 2011.
7 Ann Lorek et al. The mental and physical health difficulties of children held… Child Abuse Neglect 2009.
8 A Raj et al. Immigration policies increase south Asian immigrant women’s… J Am Med Womens Assoc 2005.

7. Background
Immigrants’ health.
Cross-country comparisons
Emerging cross-country analyses1,2,3 describe variations in the
mortality of immigrants with similar origins…
… but have not yet been linked to immigration policy context
Exceptions in maternal4 and perinatal5 health
“Migrant Integration Policy Index” (MIPEX) overall score not
associated with depression (controlling for individual variables)6
1 Raj S Bhopal et al. Mortality from circulatory diseases by specific country of birth… Eur J Public Health 2012
2 Jacob Spallek et al. Cancer mortality patterns among Turkish immigrants… Eur J Epidemiol 2012
3 Snorri B Rafnsson et al. Sizable variations in circulatory disease mortality… Eur J Public Health 2013
4 Paola Bollini et al. Pregnancy outcome of migrant women and integration policy… Soc Sci Med 2009
5 Sarah F Villadsen et al. Cross-country variation in stillbirth and neonatal mortality… Eur J Public Health 2010
6 Katia Levecque et al. Depression in Europe: does migrant integration have mental health … Ethn Health 2015

8. Do current scores reflect policies that settled immigrants have
experienced? Are all dimensions equally relevant for health?

9. Background
Integration policy typologies
Three models are described based on legal and cultural rights:1,2
- Multicultural: facility to acquire citizenship (ius soli), tolerance
of cultural difference. UK, Netherlands, Sweden
- Differential exclusionist: migrants as “guest workers”, low
tolerance, citizenship based on ancestry. Germany
- Assimilationist: facility to acquire citizenship, but cultural
manifestations should be private. France
Increasing policy convergence of EU countries with historically
different approaches.3,4
1 Castles, J Ethn Migr Stud 1995
2Weldon, Am J Pol Sci 2006
3 Mahnig and Wimmer, J Int Migr Integr 2000
4 Heckmann and Schnapper, 2003

10. A “data-driven” policy typology
MIPEX 2007 Latent Class Analysis. Bart Meuleman 2009 (Dissertation)
Multicultural
Assimilationist
Differential exclusionist
Background

11. A “data-driven” policy typology
MIPEX 2007 Latent Class Analysis. Bart Meuleman 2009 (Dissertation)
Multicultural
Differential exclusionist
Assimilationist
Background

12. SOPHIE immigrants’ health
cross-country studies
Status Dec. 2014
• Self-rated health (EU-SILC) Published
• Mortality (MEHO) Presented at conference
• Mental health and discrimination (ESS) Draft
• Medical unmet need (EU-SILC) Started
• Adolescents’ health (HBSC) Planned 2015
• National Health Surveys?

13. Objective: To analyse the differences across European
countries with different integration policies:
• in immigrants’ self-rated health
• in self-rated health inequalities between natives
and immigrants,
and the contribution of socio-economic conditions to
such differences.

14. Immigrants’ health by type of integration policies
Methods. Design and data
Design: Cross-sectional
Data source: European Union Survey on Income and Living
Conditions (EU-SILC) 2011 cross-sectional database
Study population: individuals aged 16 or over
Countries excluded: No 2011 data released, not classified in the
typology, not separating EU and non-EU foreign-born, <0.5%
immigrants, Lithuania (most “foreign-born” from USSR)
Countries included: United Kingdom, the Netherlands, Belgium,
Sweden, Norway, Finland, Italy, Spain, Portugal, Switzerland,
France, Luxembourg, Austria and Denmark
Valid sample: 184,388 subjects (7,088 immigrants)

15. Immigrants’ health by type of integration policies
Methods. Variables
Dependent variables:
• Self-rated health (very good, good / fair, bad, very bad)
• Limiting longstanding illness
• Activity limitation because of health problems
Independent variables:
• Immigrant status: born in country of residence, or born outside
the EU and having resided ten or more years in the country
• Country typology of integration policies (Meuleman 2009)
Explanatory variables:
EU citizenship, Year of immigration, Educational level,
Occupational social class, Economic situation (household income,
material deprivation, ability to make ends meet, overcrowding)
Adjustment by age, stratification by sex

16. Immigrants’ health by type of integration policies
Countries included by policy model
Multicultural
Differential exclusionist
Assimilationist

17. Immigrants’ health by type of integration policies
Methods. Analysis
Description of explanatory variables by country typology, sex and
immigrant status
Description of the sample size and age-adjusted prevalence*
of poor health by country, sex and immigrant status
Using robust Poisson regression models, estimation of prevalence
ratios (PR) of poor self-rated health:
• between migrants living in each country group
• for migrants versus natives within each country group
sequentially adjusting for age and explanatory variables
* Predicted probability post-estimation function of Poisson regression

18. Immigrants’ health by type of integration policies
Results
Tertiary education (%)
Men Women

19. Immigrants’ health by type of integration policies
Managerial, professional or technical occupation (%)
Men Women
Results

20. Immigrants’ health by type of integration policies
Household in the lowest income quintile (%)
Men Women
Results

21. Immigrants’ health by type of integration policies
Results
Poor self-rated health. Country by country
Predicted prevalence at age 50 via regression (%)
Men Women
Numbers indicate immigrants’ weighted sample size

22. Immigrants’ health by type of integration policies
Poor self-rated health
Predicted prevalence at age 50 via regression (%)
Men Women
Results

23. Immigrants’ health by type of integration policies
Immigrants between country types (ref. multicultural)
Poor self-rated health. Prevalence ratio with 95%CI
Results

24. Immigrants’ health by type of integration policies
Immigrants versus natives
Poor self-rated health. Prevalence ratio with 95%CI
Results

25. Immigrants’ health by type of integration policies
Limiting longstanding illness
Predicted prevalence at age 50 via regression (%)
Men Women
Results

26. Immigrants’ health by type of integration policies
Immigrants between country types (ref. multicultural)
Limiting longstanding illness. Prevalence ratio with 95%CI
Results

27. Immigrants’ health by type of integration policies
Immigrants versus natives
Limiting longstanding illness. Prevalence ratio with 95%CI
Results

28. Immigrants’ health by type of integration policies
Discussion. Main results
First cross-country comparative study that tests the influence
of integration policy models on migrants’ health
Immigrants in all typologies experience poorer health than
natives, fully or partly explained by socioeconomic conditions
Immigrants in countries with an “exclusionist” model experience
worse health and more health inequality than in other countries,
beyond what expected for their poorer socioeconomic conditions
Less conclusive* tendency to better migrants’ health in
multicultural compared to assimilationist countries
* Differences reduced when adjusting for education,
when omitting recent immigration countries,
with other health indicators

29. Immigrants’ health by type of integration policies
Discussion. Limitations
EU-SILC: Country-level heterogeneities in sampling, data
collection and response rates
Mixing together all non-EU migrants (or all foreign-born)
Limited participation/representativeness of immigrants
Comparability of self-rated health across countries and origins
Typology analysis: single big countries driving results
Use of a ‘history-blind’ empirical typology based on MIPEX 2007

30. Immigrants’ health by type of integration policies
Discussion. Limitations

31. Integration policies and immigrants’ mortality:
an explorative European study
Umar Ikram1, Davide Malmusi2, Knud Juel3, Gregoire Rey4, Anton Kunst1
1Department of Public Health, Academic Medical Center, Amsterdam; 2Agència de Salut Pública de Barcelona; 3National Institute of Public Health, University of
Southern Denmark, Copenhagen; 4INSERM, CépiDc, Le Kremlin-Bicêtre, France
Poster presented at European Public Health Conference 2014
Objective
To assess mortality differences among Turkish- and Moroccan-born immigrants
living in three European countries with distinct types of integration policies
• Netherlands  multiculturalist
• France  assimilationist
• Denmark  exclusionist

32. Integration policies and immigrants’ mortality:
an explorative European study
Umar Ikram1, Davide Malmusi2, Knud Juel3, Gregoire Rey4, Anton Kunst1
1Department of Public Health, Academic Medical Center, Amsterdam; 2Agència de Salut Pública de Barcelona; 3National Institute of Public Health, University of
Southern Denmark, Copenhagen; 4INSERM, CépiDc, Le Kremlin-Bicêtre, France
Methods
Mortality and population data from the Migrant Ethnic Health Observatory project
(Netherlands 1996-2006 open cohort; Denmark 1992-2001 open cohort; France
2005-07 unlinked mortality register and census data)
Immigrants from Turkey and Morocco, and local-born
populations aged 20-69 years
Age-standardised mortality rates by sex, country of residence and country of birth
Mortality rate ratios calculated using Poisson regression

33. Integration policies and immigrants’ mortality:
an explorative European study
Umar Ikram1, Davide Malmusi2, Knud Juel3, Gregoire Rey4, Anton Kunst1
1Department of Public Health, Academic Medical Center, Amsterdam; 2Agència de Salut Pública de Barcelona; 3National Institute of Public Health, University of Southern
Denmark, Copenhagen; 4INSERM, CépiDc, Le Kremlin-Bicêtre, France
Results
Compared with their peers in the Netherlands, Turkish-born had higher mortality
in Denmark but lower in France. The mortality differences between immigrants
and local-born population were largest in Denmark and lowest in France.

34. Conclusions and recommendations
Integration policy models appear to make a
difference on migrants’ health across Europe.
The “exclusionist” model is associated with larger socioeconomic
segregation and poorer health for migrants.
Inclusive social policies and reduced barriers to full
citizenship may have health benefits.
Future studies
Adequate cross-country samples of migrants with similar origins
Other health indicators and populations
Multilevel (MIPEX dimensions scores, GDP, welfare policy…)
Qualitative studies to uncover how policy gets under the skin

35. sophie-project.eu
@sophieproject
info@sophie-project.eu
dmalmusi@aspb.cat
Thank you!
Gracias!
Gràcies!
Grazie!
Photos: Roberto Brancolini, Roberto Malaguti

36. sophie-project.eu
@sophieproject

37. Framework Spanish Commission

38. Conceptual framework: Immigration
policy and migrants’ health