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

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

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

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-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

uprooting
Genetic
characteristics
Exposures in the
host country
Socioeconomic
deprivation
Migration
experience
IN – selection:
OUT- selection:
salmon bias
Migration involves uprooting,
leaving family and social
networks behind, and
moving into situations of little
guaranteed security

uprooting
Genetic
characteristics
Exposures in the
host country
Socioeconomic
deprivation
Migration
experience
IN – selection:
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…)

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

uprooting
Genetic
characteristics
Exposures in the
host country
Socioeconomic
deprivation
Migration
experience
IN – selection:
OUT- selection:
salmon biasMigrants’ health profiles reflect
their working and living
conditions they move into on
arrival in new countries

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 3: Model 2 + material
index
Malmusi D, 2010
Women

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

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

Amable’s model (2006)
Precarious employment - Spain, 2006-2007
Porthé V, 2010

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

 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

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

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

Krause N, 2010
Effort-Reward Imbalance (ERI) among hotel room cleaners -
USA, 2002

• 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

ENTITLEMENT
PERCEPTION
ACCESSIBILITY
QUALITY
OUTCOME
Limitations in health care

Entitlement
FRA - European Agency for Fundamental Rights,

% 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

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

Urgent hospital admissions by citizenship and legal status
– Marche Region (Italy), 2004-2007
Carletti P, 2009

* 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

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

Vulnerability to social effects of disease: the costs for care
FRA - European Agency for Fundamental Rights,

uprooting
Genetic
characteristics
Exposures in the
host country
Socioeconomic
deprivation
Migration
experience
IN – selection:
OUT- selection:
salmon bias
Selection
effects

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

uprooting
Genetic
characteristics
Exposures in the
host country
Socioeconomic
deprivation
Migration
experience
IN – selection:
OUT- selection:
salmon bias
Heterogeneity by
ethnic origin, age
at arrival and time
since migration

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

uprooting
Genetic
characteristics
Exposures in the
host country
Socioeconomic
deprivation
Migration
experience
IN – selection:
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

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)

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
& 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

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

Health
dimensions
Indicators (prevalence) Relevance Availability
Health outcomes
Low physical, psychological and
mental health
Middle
& 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

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

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

Genetic
characteristics
Exposures in the
country of origin
Migration
experience
Exposures in the
host country
acculturation effects
Socioeconomic
deprivation
social inequalities
IN – selection:
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

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

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