Do different immigrant integration
policies impact on migrants’ health?
A test with a European general
population survey
Davide Malmusi, Aitor Domínguez-Aguayo, Laia Palència, Carme Borrell

Background
Immigrants from disadvantaged areas:
• poorer socio-economic conditions
• “healthy immigrant effect” vanishing over time1
Little knowledge on the impact of immigration control and
integration policies on immigrants’ health (mostly US,
undocumented, single policy cases)2
Emerging cross-country analyses3 not yet linked to
immigration policy context
1 De Maio, Int J Equity Health 2010
2 Martinez et al, J Immigr Minor Health 2013
3 Rafnsson et al, Eur J Public Health 2013

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.

Conceptual framework: Immigration
policy and migrants’ health

Integration policy typologies
Three models are describedbased on legal and cultural rights:4,5
- 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.6,7
4 Castles, J Ethn Migr Stud 1995
5 Weldon, Am J Pol Sci 2006
6 Mahnig and Wimmer, J Int Migr Integr 2000
7 Heckmann and Schnapper, 2003

MIPEX overall score not associated with depression after
controlling for individual variables. Levecque et al, Ethn Health 2014

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)

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-Reeskens)
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

Country policy typology
MIPEX 2007 Latent Class Analysis. Meuleman and Reeskens 2008

Country policy typology
MIPEX 2007 Latent Class Analysis. Meuleman and Reeskens 2008
Multicultural
Differential exclusionist
Assimilationist

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

Results
Tertiary education (%)
Men Women

Results
Managerial, professional or technical occupation (%)
Men Women

Results
Household in the lowest income quintile (%)
Men Women

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

Results
Poor self-rated health
Predicted prevalence at age 50 via regression (%)
Men Women

Results
Immigrants between country types (ref. multicultural)
Poor self-rated health. Prevalence ratio with 95%CI

Results
Immigrants versus natives
Poor self-rated health. Prevalence ratio with 95%CI

Results
Limiting longstanding illness
Predicted prevalence at age 50 via regression (%)
Men Women

Results
Immigrants between country types (ref. multicultural)
Limiting longstanding illness. Prevalence ratio with 95%CI

Results
Immigrants versus natives
Limiting longstanding illness. Prevalence ratio with 95%CI

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

Discussion. Limitations

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

Conclusions and recommendations
Integration policy models appear to make a
difference on migrants’ health across Europe.
The “exclusionist” model results in larger socioeconomic
segregation for migrants and takes a toll on their health.
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 (including mortality)
Multilevel (MIPEX dimensions scores, GDP, welfare policy…)
Qualitative studies to uncover how policy gets under the skin

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dmalmusi@aspb.cat
Thank you!
Gracias!
Gràcies!
Grazie!
Photos: Roberto Brancolini, Roberto Malaguti