Discrimination and mental health in Ecuadorian immigrants in Spain

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1 Researh report 1 Instituto de Salud Carlos III, Madrid, Spain; 2 Ciber de Epidemiología y Salud Públia (CIBERESP), Spain; 3 Consejería de Sanidad de Muria, Spain; 4 Serviio Andaluz de Salud, Spain; 5 Universidad de Alalá, Madrid, Spain; 6 Universidad Miguel Hernández, Aliante, Spain; 7 Université de Montréal, Montréal, Québe, Canada Correspondene to: Dr A Lláer, Centro Naional de Epidemiología, /Sinesio Delgado nu 6 (pabellón 12), Instituto de Salud Carlos III, Madrid, Spain; allaer@isiii.es Aepted 13 April 2009 Published Online First 4 May 2009 and mental health in Euadorian immigrants in Spain A Lláer, 1,2 J Del Amo, 1,2 A Garía-Fulgueiras, 2,3 V Ibáñez-Rojo, 4 R Garía-Pino, 2,3 I Jarrín, 1 DDíaz, 4 A Fernández-Liria, 5 V Garía-Ortuzar, 2,3 L Mazarrasa, 1 M A Rodríguez- Arenas, 6 M V Zunzunegui 7 ABSTRACT Bakground: The aim of this study was to examine the effets of ethni disrimination on the mental health of Euadorian immigrants in Spain and to assess the roles of material and soial resoures. Methods: Data were taken from the Neighbourhood harateristis, immigration and mental health survey onduted in 2006 in Spain. Psyhologial distress measured as Possible Psyhiatri Case (PPC) was measured by the GHQ-28. A logisti regression was fitted to assess the assoiation between PPC and disrimination. Interations of disrimination with soial and material resoures were tested using produt terms. Results: Some 28% of the partiipants met our definition of PPC. About 20% of those who reported no disrimination were PPCs, rising to 30% of those who sometimes felt disriminated against and 41% of those who ontinually pereived disrimination. The OR for ontinuous disrimination was 12 (95% CI 3.5 to 40.3) among those with high finanial strain, and 10 (2.4 to 41.7) when there was lak of eonomi support. Emotional support had an independent effet on PPC (OR 1.8, 95% CI 1.0 to 3.6, for those who reported having no friends). Soial integration through a ommunity group or assoiation was positively related to the probability of being a PPC (OR 1.7, 95% CI 1.0 to 2.9). Conlusion: Ethni disrimination is assoiated with psyhologial distress in these Euadorian immigrants in Spain. effets may be exaerbated among those faing eonomi stress and those without eonomi support. These partiularly vulnerable immigrants should be the subjet of soial and health interventions. an be defined as ations from individuals and institutions that negatively and systematially impat soially defined groups with less power. 1 has negative onsequenes on the mental and physial health of those who suffer it. 2 6 Spain has beome one of the most important host ountries in Europe for eonomi immigrants. 7 This has ourred at a rapid pae, largely due to the demand for unskilled labour. 8 The migratory proess in Spain has developed in a soial ontext in whih demorati values of oexistene have been strengthened and in the awareness of Spain s past history as a ountry of politial and eonomi emigration. In the 1990s Spanish attitudes towards immigrants were less raist than those of other Europeans. 9 However, two more reent surveys showed that pereived disrimination was extensive and inreasing in importane. 10 Experienes of disrimination towards minorities are stressful events with potential health onsequenes For minority immigrants, the hardships and problems diretly related to disrimination denial of deent housing, prearious and hazardous employment, delays and barriers to obtaining servies onstitute soures of stress. an at on mental health indiretly, leading to situations of soial exlusion as well as soial and eonomi problems that in turn inrease the probability of health risk exposures, greater suseptibility to diseases, and less aess to healthare servies. 1 Prolonged and systemati disrimination an also at diretly on mental health through psyhosoial mehanisms, suh as loss of self-esteem and identity. 17 The present aim was to examine the effets of disrimination due to ethni origin on the mental health of Euadorian immigrants in Spain, the third largest immigrant group, who omprise 20% of eonomi immigrants. Extending the model of the stress proess, 18 it is argued that the diret effets of disrimination on mental health are independent of the immigrant s individual harateristis (age, sex, eduation, 19 and health status), and that eonomi resoures and soial support an potentially intervene to attenuate the effets of umulative stress on health due to disrimination. 22 An attempt was made to answer the following researh questions: What are the assoiations between disrimination and mental health? Are these assoiations modified by the availability of eonomi resoures and soial support? METHODS The data were taken from the Neighbourhood harateristis, immigration and mental health survey arried out between May and Deember Sampling was onduted in four regions (Aliante, Almeria, Madrid and Muria) seleted due to the high influx of immigrants to these regions in reent years and the large onentration of immigrants from Euador, employed primarily in the servie and agriulture setors. In Madrid, 128 neighbourhoods (barrios) in the ity s 21 distrits were ranked in tertiles aording to soioeonomi status (measured as the mean prie of housing per square metre) and immigrant density. One neighbourhood was seleted in eah of the nine resulting strata. In both Aliante and Muria, nine populations (neighbourhoods and ities) with high and low immigrant density were 766 J Epidemiol Community Health 2009;63: doi: /jeh

2 seleted, and in Almeria, only six ities were seleted. A list of residents was available from ensus rolls in eah ity with plae of birth, age and sex. A sex-speifi stratified random sample of Euadorian residents aged years was seleted to obtain nine men and nine women at eah loation. The final sample had 570 subjets from 33 areas stratified by mean housing pries and immigrant density (Madrid sample) or only by immigrant density (Almeria, Aliante and Muria). Assuming only two-thirds of addresses would atually be valid (estimated by a pilot study), a seond sample of five men and five women was seleted to replae those whom were not loated during field work. A letter of invitation was sent to eah potential partiipant followed by a home visit from trained interviewers. Response rates [ompleted interviews/(ompleted +refused interviews)] varied by loation: 42.9% in Madrid, 79.5% in Aliante, 96.4% in Muria and 89.6% in Almeria, giving an overall response rate of 69%. The questionnaire and the measurement sales used were tested in the pilot study. The dependent variable was psyhologial distress measured by the General Health Questionnaire GHQ-28, 23 a sreening instrument onsisting of four subsales (somati symptoms, anxiety and insomnia, soial dysfuntion and depression). The response ategories refer to the person s experiene in the last 4 weeks ompared to their usual state (better/same/worse/ muh worse than usual). The oding sheme that assigns values of 0,0,1,1 to these responses was used and the summary sore of the 28 items were alulated, the so-alled GHQ sore. 24 A 4/5 ut-off point as a marker of aseness was adopted, meaning that those individuals with sores higher than four are onsidered as having a high probability of being a possible psyhiatri ase (PPC). 25 The Spanish translation of the GHQ has been validated. 26 To measure disrimination, we onstruted a five-item sale based on the works of Finh and Noh Respondents indiated how often they had felt treated as desribed in eah of five sentenes due to their Latin Amerian origin (table 1). Fator analysis using the data from the pilot study revealed a single fator. In the final sample, this fator explained 67% of the variane. Internal onsisteny measured with Cronbah s alpha was The total possible sore on the disrimination sale ranged from 0 (reply of never to all five questions) to 20 (reply of always to all five questions). As a onsiderable proportion of respondents (37.7%) said they had never felt treated in any of these ways, a ategorial variable was reated to identify those who had never felt disriminated against for ethni reasons, those whose umulative sore was in the upper tertile of the distribution, and those in intermediate situations. The ategories were labelled: (0) never, (1) sometimes and (2) always or nearly always. Finanial strain was assessed by the following question: How would you rate your diffiulty in making ends meet eah month using your net monthly inome? Responses were: a lot, quite a lot, neither a lot not a little, little and none. 29 As responses in the two extreme ategories were infrequent, they were ollapsed with the adjaent ategories. Categories for analysis were: a lot, some and little diffiulty. Two kinds of soial support were assessed. Eonomi support was assessed by the following question: In ase of need, do you have anybody from whom to borrow 100 euros? (yes/no). Emotional support was assessed by the following question: How many friends do you have? I mean people who make you feel good, who you an talk to about personal matters and an ask for help when you need it? For the analysis the answer was dihotomised to none and one or more. Researh report Soial integration was assessed by partiipation in ommunity assoiations. A list of different groups was read by the interviewer: sports, neighbourhood, parents of shool hildren, housewives, volunteers, immigrants, trade unions, dane groups, religious assoiations and others. As most partiipants did not partiipate in any ativity, and those who did tended to belong to just one group, the variable was dihotomised. Potential onfounders were age, sex, area of residene, eduation, and self-rated health, measured by the general question: How would you rate your health?. Data analysis was desribed aording to age, sex, area of residene, eduation and self-rated health. Bivariate assoiations between aseness and disrimination were estimated using a x 2 statisti. A multivariate logisti regression analysis of the assoiation ontrolling for the possible onfounding effets of age, sex and self-rated health was performed (p,0.05). The possible modifying effets of eonomi and soial resoures were evaluated on the assoiation between disrimination and aseness by a desriptive stratified analysis and by testing the interation terms (the produt terms of finanial strain, eonomi and emotional support, and soial integration with disrimination) in the logisti regression. Lastly, 95% onfidene intervals for the odds ratio of aseness for disrimination ompared to the absene of disrimination were estimated. The statistial software used was SPSS version RESULTS Depending on the sale item onsidered, these Euadorian immigrants aknowledge ethni disrimination as a relatively onstant experiene in their lives, and a sizeable proportion reported feeling disriminated against as a somewhat frequent experiene (sometimes) (table 1). Table 2 presents the distribution of the study partiipants by the main study variables. The mean age was 31.6 years. Some additional information may also be useful in haraterising the sample. They primarily ame from the Sierra region of Euador, whih is home to nearly half the population. Most had migrated to have a better life and to improve their eonomi onditions and had lived in Spain for at least 5 years. Almost one-third already had a stable legal situation, and barely 5% were in a legally prearious situation. One-third of them were aquiring their own home. This is a population with a relatively high eduational level, most of whom (96%) were employed. The majority worked in manual oupations, with temporary work ontrats. The distribution of pereived disrimination was as follows: 37.7% did not report any disrimination, 41.1% had felt Table 1 Perentage distribution of responses to eah question on the disrimination sale (n = 570) How often do you feel that, beause of your Latin Amerian origin, you have been Always Almost always Sometimes Almost never Never 1. disriminated against treated rudely or offensively 3. treated unfairly exluded or ignored verbally insulted or attaked J Epidemiol Community Health 2009;63: doi: /jeh

3 Researh report Table 2 Demographi and soioeonomi harateristis Male Female Total Sex n = 284 n = 286 n = 570 Age (years) (p = 0.028) % ( > Eduation Primary or lower Seondary University Self-pereived health Exellent Very good Good Fair Poor Region Almeria Aliante Madrid Muria Finanial strain (diffiulty making ends meet by end of the month)* A lot Some Neither a lot nor a little Not muh None Eonomi support (ability to borrow J) Emotional support (one or more friends) Soial integration (partiipation in some group or assoiation) *Inludes four respondents who responded neither a lot nor a little. disriminated against on some oasions, and 21% reported feeling disriminated against always or almost always. was not signifiantly assoiated with sex, age, eduational level or self-reported health, but was higher among those residing in Muria. Some 28% of the partiipants met our definition of PPC. About 20% of those who reported no disrimination were PPCs, rising to 30% of those who sometimes felt disriminated against and 41% of those who ontinually pereived disrimination. Neither age nor eduation were signifiantly assoiated with lassifiation as a PPC. Women and partiipants with fair or poor self-rated health were more likely to be PPCs (p,0.001). There were also differenes by regions, with Almeria having the largest proportion of PPCs (36.8%). Table 3 presents the stratified analysis by level of disrimination. The presene or absene of resoures modified the effet of disrimination. The proportion of PPCs was highest when high finanial strain was ombined with ontinuous disrimination, with the result that 75% of the persons in this situation were PPCs. The lak of eonomi support ombined with ontinuous disrimination resulted in a similar situation, with 62% in the ategory of PPC. Neither having friends nor belonging to assoiations modified the assoiation between disrimination and PPC. In the multivariate analysis, the magnitude of the OR for the assoiation between disrimination and PPC after adjusting for the possible onfounding variables (OR 3.0; 95% CI 1.7 to 5.2) varied little with respet to the bivariate analysis (OR 2.8; 95% CI 1.7 to 4.6) (table 4). Table 5 shows the results of the final multivariate model, whih inludes the interation terms for disrimination with available resoures: finanial strain, soial support (emotional and eonomi) and soial integration. The OR for ontinuous disrimination rose to 12 (95% CI 3.5 to 40.3) among those with high finanial strain, and to 10 (2.4 to 41.7) when there was lak of eonomi support. Emotional support had an independent effet on PPC, with an OR of 1.8 (95% CI 1.0 to 3.6) for those who reported having no friends. Soial integration through a ommunity group or assoiation was positively related to the probability of being a PPC, with an OR of 1.7 (95% CI 1.0 to 2.9). DISCUSSION In this population of Euadorian immigrants in Spain, one-fifth reported being disriminated against ontinually. This unjust treatment for reasons of ethni origin seems to have onsequenes for mental health beyond what ould be expeted by soiodemographi harateristis or health status. Moreover, eonomi resoures and the ability to obtain eonomi support in ase of need seemed to attenuate the effets of disrimination. Partiipation in some type of group or assoiation and lak of emotional support from friends were independently assoiated with poor mental health. Other studies have shown that most Latin Amerian immigrants are the objet of double disrimination in their host ountries, both for being poor and due to their ethni origin, 30 although the health onsequenes of this unfair treatment are modulated by their integration proess, whih varies by ethniity. The first survey on disrimination against immigrants in Spain was not made until 2000; it showed that over 60% of the immigrant population had not pereived any disriminatory treatment. Latin Amerian residents were one of the groups that generated the least feelings of rejetion on the part of the Spanish population. 33 Two years later, a more speifi survey showed that Euadorians were the least integrated of the three major immigrant groups investigated (Moroo, Colombia, Euador), and the ones who most often (24%) reported suffering disrimination. Pereived disrimination was more frequent in Muria, the study area with the largest proportion of Euadorians in relation to the total population (3.7%) and to the foreign-born population (26%). For instane in Totana, a muniipality of nearly inhabitants, the proportion of Euadorians is 12%. It is possible that the loal populations have diffiulties in aepting large numbers of foreigners in their ommunities. Consistent with our findings, pereived disrimination was not assoiated with soiodemographi variables, duration of residene in Spain, or administrative situation. 10 In another study in an urban setting, 34 some 50% of Euadorians surpassed only by the Afrians said they had felt disriminated against at some time due to ultural differenes, national origin or physial harateristis. Euadorians, primarily of Mestizo origin, have even reported experiening disrimination among their own people J Epidemiol Community Health 2009;63: doi: /jeh

4 Table 3 Stratified analysis of the assoiation between disrimination and possible psyhiatri ase (GHQ>5) aording to finanial strain, eonomi support, emotional support and soial integration N % GHQ>5 p Value Finanial strain,0.001 Never A little Some A lot Sometimes A little Some A lot Always/Almost always A little Some A lot Eonomi support,0.001 Never Support No support Sometimes Support No support Always/Almost always Support No support Emotional support Never No friends Friends Sometimes No friends Friends Always/Almost always No friends Friends Partiipation in groups or assoiations Never No Yes Sometimes No Yes Always/Almost always No Yes Answering the first researh question, a lear and strong assoiation was found between pereived disrimination and mental health, oiniding with Paradies reent review, 6 whih reported that the most onsistent assoiation found was between self-pereived raism and poorer mental health. Most of the studies inluded in the review were onduted in native ethni minorities (primarily Afro Amerians) in the United States; those arried out in Latino populations referred mainly to first and seond generation Mexian immigrants. Only 11% of the 138 studies inluded addressed speifi aspets of the immigrant experiene. The seond researh question dealt with how the availability of eonomi resoures and emotional support might modify the assoiation between disrimination and mental health. The present results are onsistent with Pearlin s oneptual model. Finanial stress has been identified as a soure of depression, and this has also been seen in Hispani elders in the USA, but its interation with disrimination was not examined in those studies. Eonomi support in times of risis has been identified as protetive for depression in a population of poor Afro Amerian mothers, but that study did not examine the joint effets of ethni disrimination and lak of eonomi support. 39 The present findings support the onlusions of a reent review that finanial strain is one of the most powerful stressors, together with unemployment, that ould explain the Researh report mehanisms by whih ethni disrimination influenes health. 17 However, beause only 4% of the immigrants in the present sample reported being unemployed, it was not possible to study the effets of unemployment on mental health. Having friends was independently assoiated with good mental health. Some 88% of the Euadorians in the present sample said they had friends in Spain, mostly Spaniards, (46%) and only 22% had friends exlusively from other ountries. Probably beause the present sample was a relatively wellestablished population of immigrants, it did not orroborate the findings of another study that Euadorian immigrants have diffiulties making Spanish friends, 10 despite their shared language. 40 In agreement with the present findings, Finh reported in a study of Latinos of Mexian origin in California, that disrimination was assoiated with poorer self-rated health only among those who laked soial support. 21 Other studies have found direts effets of disrimination on depression, independently of soial support and inome. 41 It is diffiult to interpret the negative effet of partiipation in ommunity groups, suh as parent teaher and neighbourhood assoiations omposed mainly of Spaniards. It is possible that suh partiipation aentuates immigrants feelings of otherness in relation to natives. 42 The present results are onsistent with a study showing that partiipation in ommunity J Epidemiol Community Health 2009;63: doi: /jeh

5 Researh report Table 4 Crude and adjusted odds ratios (95% onfidene intervals) for the assoiation between disrimination and possible psyhiatri ase (GHQ-28>5) Crude OR (95% CI) Adjusted OR (95% CI) Never Sometimes 1.8 (1.2 to 2.8) 1.6 (1.0 to 2.6) Always/Almost always 2.8 (1.7 to 4.6) 3.0 (1.7 to 5.2) Sex Male 1.0 Female 3.0 (1.9 to 4.5) Age (years) ( (0.6 to 2.2) (0.8 to 2.4) (0.6 to 3.6) > (0.2 to 2.1) Eduational level University 1.0 Primary or lower 1.1 (0.5 to 2.2) Seondary 0.7 (0.4 to 1.4) Region Madrid 1.0 Almeria 2.3 (1.2 to 4.4) Aliante 1.5 (0.8 to 2.8) Muria 1.6 (0.9 to 2.9) Self-pereived health Exellent/Good 1.0 Fair/Poor 4.2 (2.7 to 6.5) ativities inreased psyhologial distress in Pakistani immigrants in Norway. 43 The Euadorians interviewed in the present study partiipate very little in immigrant assoiations. Thus, they may not benefit from the ethni support that has been reported to moderate depression, for example, in Korean refugees and immigrants in Canada. 28 Study limitations The hoie of a ut-off point for the GHQ has been the subjet of ontroversy. Goldberg showed that the ut-off to distinguish those who have a high probability of psyhiatri disorder from those who do not varied between 3 and 7 in studies onduted aross different ountries The present hoie of 4/5 orresponds to a validation study arried out in Greee, 45 and has been used in Madrid, Andaluia and other studies. The disrimination sale used desribes the frequeny and nature (insult, aggression, demeaning treatment) of the type of disrimination experiened, but not the plae or sphere of ativity where it ourred, without establishing a temporal framework. Given the lak of homogeneity in the measure of disrimination used in the studies onsulted, a detailed omparison of the results is diffiult. 6 The method used to selet the sample in this study most likely led to the identifiation of a well established subpopulation of Euadorian immigrants in Spain, as suggested by the fats that they had lived in Spain for a median of 5 6 years, that only 5% were in a prearious situation and only 4% were unemployed, that almost one-third were buying an apartment, and fully 47% had Spanish friends. Thus, the present results refer to a subgroup of immigrants who have been relatively fortunate in the integration proess, and not to the whole immigrant population. Conerning measurement bias, the strong assoiations between the fators assoiated with mental health, suh as sex and poor pereived health, as well as the lak of assoiation between experienes of disrimination and age, sex or eduation, support the validity of the measures of mental health and disrimination in the present work. The relatively high integration of the present sample may have influened estimation of the extent of disrimination as pereived disrimination may depend on the length of residene in Spain and on umulative experienes in different settings. 49 Lastly, as this was a ross-setional study, it annot be ruled out that poorer mental health status leads to a greater pereption of Table 5 Final multiple logisti regression model for possible psyhiatri ase (GHQ-28>5) aording to disrimination, eonomi resoures, emotional support and soial integration OR* (95% CI) Finanial strain Never Little 1 Some 1.4 (0.6 to 3.2) A lot 1.7 (0.5 to 5.1) Sometimes Little 2.4 (1.1 to 5.2) Some 2.6 (1.1 to 5.7) A lot 3.5 (1.2 to 10.1) Always/Almost always Little 3.1 (1.2 to 8.0) Some 1.1 (0.4 to 3.1) A lot 11.9 (3.5 to 40.3) Eonomi support Never Support 1 No support 2.6 (1.1 to 6.3) Sometimes Support 2.4 (1.1 to 5.2) No support 1.1 (0.4 to 3.1) Always/Almost always Support 3.1 (1.2 to 8.0) No support 10 (2.4 to 41.7) Emotional support (no friends) 1.8 (1.0 to 3.6) Soial integration (partiipation in some group or assoiation) 1.7 (1.0 to 2.9) *Adjusted for sex, age, eduational level, region and self-rated health. 770 J Epidemiol Community Health 2009;63: doi: /jeh

6 What is already known on this subjet There is inreasing sientifi evidene that ethni disrimination has negative onsequenes on the mental and physial health of those who suffer it. The majority of studies refer to native or immigrant ethni groups in English-speaking ountries, whereas few studies have addressed this issue in immigrants in ountries of southern Europe. What this study adds This study fouses on Euadorian immigrants, who omprise the largest immigrant group from Latin Ameria in Spain. They report frequent experienes of disrimination, whih is assoiated with psyhologial distress and may be further exaerbated among those faing eonomi stress and those without eonomi support. disrimination, although longitudinal studies seem to onfirm the reverse Another possible explanation is that at least part of the assoiation between disrimination and depression is the result of onfounding fators not measured in the present study. For instane, personality fators, substane misuse problems and other fators whih are known to inrease the likelihood of mental disorder may also be assoiated with the likelihood of subjetive experienes of disrimination. Conlusion Ethni disrimination seems to be a relatively frequent and inreasingly ommon phenomenon in Spain and other European ountries, 51 and the eonomi situation of immigrants is deteriorating due to rising unemployment. 52 appears to have mental health onsequenes among longestablished immigrant populations, who are atively involved in the labour fore and who often have Spanish friends. seems partiularly harmful among those with finanial strain and laking needed eonomi support. As the effets of disrimination derease when the immigrant has aess to help at times of risis, the soial servies in Spain should seek to detet immigrants suffering a ombination of ethni disrimination and lak of eonomi resoures as target populations for health and soial poliy interventions. 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