Migration and health: setting the scene for public health

Transcription

1 Migration and health: setting the scene for public health Giuseppe Costa 1,2, Teresa Spadea 2, Luisa Mondo 2 1. University of Turin 2. Epidemiology Unit, ASL TO3 Piedmont Region Migration and health: a conceptual framework Importation Adaptation Inequalities In social determinants In risk factors In health care Health vulnerability vulnerability Selection Heterogeneity by ethnic origin by time since migration Relative impact of each mechanism and warnings Implications for policies and public health summary 1

2 summary Migration and health: a conceptual framework Importation Adaptation Inequalities In social determinants In risk factors In health care Health vulnerability vulnerability Selection Heterogeneity by ethnic origin by time since migration Relative impact of each mechanism and warnings Implications for policies and public health IN selection: healthy migrant effect Natural history of migrants health problems OUT- selection: salmon bias Genetic characteristics Migration Exposures in the Migrants health experience profiles country of origin reflect their past medical histories and quality of health care Socioeconomic deprivation Exposures in the host country importation diseases uprooting acculturation effects / social inequalities time since migration racial discrimination / cultural barriers / legal constraints 2

3 summary Migration and health: a conceptual framework Importation Adaptation Inequalities In social determinants In risk factors In health care Health vulnerability vulnerability Selection Heterogeneity by ethnic origin by time since migration Relative impact of each mechanism and warnings Implications for policies and public health Cancer incidence and mortality worldwide,

4 Risk of mortality in migrants by country of arrival and cause Ott J, 2008 Cancer incidence in migrants The Turin Longitudinal Study, females Cancer Site Citizenship status* N RR 95% CI ALL CANCERS BREAST CERVIX PSA PSA PSA PFPM PFPM PFPM ,55 0,36 1,86 0,48 0,27 1,26 0,63 0,47 2,74 * PSA: high-income countries, according to the World Bank classification PFPM: countries with strong migratory pressure (Africa, Asia excluding Israel, South Korea and Japan, Latin America, Central 4

5 summary Migration and health: a conceptual framework Importation Adaptation Inequalities In social determinants In risk factors In health care Health vulnerability vulnerability Selection Heterogeneity by ethnic origin by time since migration Relative impact of each mechanism and warnings Implications for policies and public health IN selection: healthy migrant effect Natural history of migrants health problems OUT- selection: salmon bias Genetic characteristics Exposures in the country of origin Migration experience Socioeconomic deprivation Exposures in the host country importation diseases uprooting acculturation effects / social inequalities time Migration since migration involves uprooting, leaving family and social networks behind, and moving into situations of little guaranteed racial security discrimination / cultural barriers / legal constraints 5

6 IN selection: healthy migrant effect Natural history of migrants health problems OUT- selection: salmon bias Genetic characteristics Exposures in the country of origin Migration experience Socioeconomic deprivation Exposures in the host country importation diseases uprooting acculturation effects / social inequalities time since migration Migration involves acculturation, i.e. the process of acquisition of/integration with the cultural elements racial of the discrimination dominant society / cultural barriers / legal constraints (language, food, behaviours ) Impact of acculturation Studies analysing different health outcomes among Latino in USA (1) Negative effect Mixed or no effect Positive effect Nutrition Exercise behaviours Smoking Substance abuse Health care use Vaccination access to care 7 - Cancer screening Lara M,

7 Impact of acculturation Studies analysing different health outcomes among Latino in USA (2) Negative effect Mixed or no effect Positive effect Birth outcomes Infant mortality Adolescent obesity Chronic conditions Mental health Self assessed health Lara M, 2005 IN selection: healthy migrant effect Genetic characteristics Exposures in the country of origin Natural history of migrants health problems Migrants health profiles reflect their social disadvantage in working and living conditions they move into on arrival in new countries Migration experience OUT- selection: salmon bias Socioeconomic deprivation Exposures in the host country importation diseases uprooting acculturation effects / social inequalities time since migration racial discrimination / cultural barriers / legal constraints 7

8 Self-rated heath by ethnicity - England, 1999 Nazroo J, 2003 Self-rated health according to migration type - Spain, 2006 Women Model 1: Adjusted by age Model 2: Model 1 + social class Model 3: Model 2 + material index Malmusi D,

9 summary Migration and health: a conceptual framework Importation Adaptation Inequalities In social determinants In risk factors In health care Health vulnerability vulnerability Selection Heterogeneity by ethnic origin by time since migration Relative impact of each mechanism and warnings Implications for policies and public health SOCIETY Policy Policy stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility Healthy migrant effect and salmon bias INDIVIDUAL position position Exposure Health impairment Health impairment consequences consequences Control over resources material/education status ties/social support psycho-social behavioural environmental/occupational health care accessibility Health vulnerability Health outcomes death/morbidity hospitalization injury vulnerability effects descending career segregation 9

10 SOCIETY Policy Policy stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility Healthy migrant effect and salmon bias INDIVIDUAL position position Exposure Health impairment Health impairment consequences consequences Control over resources material/education status ties/social support psycho-social behavioural environmental/occupational health care accessibility Health vulnerability Health outcomes death/morbidity hospitalization injury vulnerability effects descending career segregation By 2050 more than 230M migrants World s 5th biggest country 64 Million registered migrants in Europe (8.9% of the total population of the EU); 2 M from other EU countries ~2.3 to 8 M irregular migrants in the EU, 1.5 M in Russia 50% women, over represented in the most vulnerable ~0.5 M of trafficked women in the EU alone 1.7 M of refugees and asylum seekers in 2006 mostly from Iraq, Serbia and Montenegro, Russian Federation, Turkey, Afghanistan and Iran Population Action International 1994, IOM

11 The gender distribution among immigrant groups varies widely. Increasing proportion of women: family reunification (50%) and shift in demand from male cheap labor to hotel and domestic female work. Migrant children are a growing component of the child population in Europe (around 8-10% of all births in the EU). No accurate estimates of unaccompanied migrant children. Hardening attitudes and policies in many countries on migration and migrants. More people are moving unofficially, paying large sums of money to be smuggled across borders. Growing industry of trafficking, mostly involving women, girls and boys. Eurostat 2011 Our World according to Distribution of wealth USA UK Germany Switzerland France Russian Federation China Bangladesh Japan Spain Italy India Philippines Fr Guyana Indonesia Australia 11

12 Our World according to Human Poverty Index Canada Russian Federation USA Nigeria Egypt Ethiopia Pakistan India China Bangladesh Thailand Philippines Japan Kenya Indonesia South Africa Australia Our World according to Distribution of health human resources Physicians working Nurses working 12

13 summary Migration and health: a conceptual framework Importation Adaptation Inequalities In social determinants In risk factors In health care Health vulnerability vulnerability Selection Heterogeneity by ethnic origin by time since migration Relative impact of each mechanism and warnings Implications for policies Implications for public health SOCIETY Policy Policy stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility Healthy migrant effect and salmon bias INDIVIDUAL position position Exposure Health impairment Health impairment consequences consequences Control over resources material/education status ties/social support psycho-social behavioural environmental/occupational health care accessibility Health vulnerability Health outcomes death/morbidity hospitalization injury vulnerability effects descending career segregation 13

14 Housing: inadequate, overcrowding determinants of health among migrants 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 Working conditions: employment in the 3-D category (Dirty, Dangerous and Degrading), where the baseline risks of occupational injury are elevated, compounded with longer hours and language barriers impeding understanding of safety measures; forced labor and sexual exploitation Precarious employment - Spain, Amable s model (2006) Porthé V,

15 SOCIETY Policy Policy stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility Healthy migrant effect and salmon bias INDIVIDUAL position position Exposure Health impairment Health impairment consequences consequences Control over resources material/education status ties/social support psycho-social behavioural environmental/occupational health care accessibility Health vulnerability Health outcomes death/morbidity hospitalization injury vulnerability effects descending career segregation Racism, discrimination, occupational class and health 50 Predicted per cent reporting fair or poor health None Verbal Physical or property No or a few Some or most Non manual Racial harassment Do employers discriminate? Class Manual Karlsen and Nazroo,

16 Psychosocial implications: women and children Gender-based violence, sexual abuse and exploitation is a major concern in the 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) Migration and health: a conceptual framework Importation Adaptation Inequalities In social determinants In risk factors In health care Health vulnerability vulnerability Selection Heterogeneity by ethnic origin by time since migration Relative impact of each mechanism and warnings Implications for policies and public health summary 16

17 SOCIETY Policy Policy stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility Healthy migrant effect and salmon bias INDIVIDUAL position position Exposure Health impairment Health impairment consequences consequences Control over resources material/education status ties/social support psycho-social behavioural environmental/occupational health care accessibility Health vulnerability Health outcomes death/morbidity hospitalization injury vulnerability effects descending career segregation Smoking habit by country of origin - Italy, Age-adjusted rates Italians Foreigners Romania Albania M orocco Other Europe not EU Other Africa Smokers _M Smokers _W Heavy smokers _M Heavy smokers _W 0 Latin America Gargiulo L,

18 SOCIETY Policy Policy stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility Healthy migrant effect and salmon bias INDIVIDUAL position position Exposure Health impairment Health impairment consequences consequences Control over resources material/education status ties/social support psycho-social behavioural environmental/occupational health care accessibility Health vulnerability Health outcomes death/morbidity hospitalization injury vulnerability effects descending career segregation Precarious employment and injury risk - Italy, Serious injuries by length of contract Raw injury rates (y-axis) and relative risks (arrows) adjusted for gender, age, skill level, economic activity and year *** *** 1.13*** 1.20*** 1.35*** * p<0.10 ** p<0.05 *** p< < 3 mesi 3-6 mesi 7-11 mesi mesi anni >= 3 anni PFPM PSA 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 Bena A,

19 Effort-Reward Imbalance (ERI) among hotel room cleaners - USA, 2002 Krause N, 2010 summary Migration and health: a conceptual framework Importation Adaptation Inequalities In social determinants In risk factors In health care Health vulnerability vulnerability Selection Heterogeneity by ethnic origin by time since migration Relative impact of each mechanism and warnings Implications for policies and public health 19

20 SOCIETY Policy Policy stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility Healthy migrant effect and salmon bias INDIVIDUAL position position Exposure Health impairment Health impairment consequences consequences Control over resources material/education status ties/social support psycho-social behavioural environmental/occupational health care accessibility Health vulnerability Health outcomes death/morbidity hospitalization injury vulnerability effects descending career segregation Limitations in health care OUTCOME QUALITY ACCESSIBILITY PERCEPTION ENTITLEMENT 20

21 Entitlement FRA - European Agency for Fundamental Rights, 2012 Preventive controls by country of origin - Italy, Percentage of people declaring no controls for blood pressure, cholesterol and glycaemia in the previous 5 years Age-adjusted rates Males Females Italians Foreigners Romania Albania Morocco Other Europe not EU Other Africa Latin America Gargiulo L,

22 Pap-test practice by country of origin and education Italy, Age-adjusted rates Italians Foreigners Romania Albania Morocco Other Europe not EU Other Africa Latin America 0-9 years of education 10+ years of education Total Gargiulo L, 2008 Urgent hospital admissions by citizenship and legal status Marche Region (Italy), Carletti P,

23 Birth outcomes Italy, Relative risks of immigrants vs. natives in different EU countries Total Countries with strong integration* Countries with light integration** Birthweight <2500 gr 1.43 ( ) 0.98 ( ) 1.54 ( ) Gestational age < 37 weeks 1.24 ( ) 1.16 ( ) 1.47 ( ) Early Mortality 1.50 ( ) 1.41 ( ) 1.56 ( ) Congenital malformations 1.61 ( ) 0.94 ( ) 1.78 ( ) * Belgium, Denmark, Norway, the Netherlands and Sweden ** Austria, France, Germany, Italy, United Kingdom, Spain and Switzerland Bollini P, 2009 summary Migration and health: a conceptual framework Importation Adaptation Inequalities In social determinants In risk factors In health care Health vulnerability vulnerability Selection Heterogeneity by ethnic origin by time since migration Relative impact of each mechanism and warnings Implications for policies and public health 23

24 SOCIETY Policy Policy stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility Healthy migrant effect and salmon bias INDIVIDUAL position position Exposure Health impairment Health impairment consequences consequences Control over resources material/education status ties/social support psycho-social behavioural environmental/occupational health care accessibility Health vulnerability Health outcomes death/morbidity hospitalization injury vulnerability effects descending career segregation Educational differences in mortality rates in EU27 in 2000s Eurothine,

25 Respondents aged 35 to 54 with complaints, injuries, diseases that limit everyday activities, such as working, shopping Measles epidemics in Bulgaria 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 25

26 SOCIETY Policy Policy stratification Racial discrimination / cultural and legal barriers Genetic/acquired susceptibility Healthy migrant effect and salmon bias INDIVIDUAL position position Exposure Health impairment Health impairment consequences consequences Control over resources material/education status ties/social support psycho-social behavioural environmental/occupational health care accessibility Health vulnerability Health outcomes death/morbidity hospitalization injury vulnerability effects descending career segregation vulnerability: the costs for care FRA - European Agency for Fundamental Rights,

27 Migration and health: a conceptual framework Importation Adaptation Inequalities In social determinants In risk factors In health care Health vulnerability vulnerability Selection Heterogeneity by ethnic origin by time since migration Relative impact of each mechanism and warnings Implications for policies and public health summary IN selection: healthy migrant effect Natural history of migrants health problems OUT- selection: salmon bias Genetic characteristics Exposures in the country of origin Migration experience Socioeconomic deprivation Exposures in the host country importation diseases uprooting acculturation effects / social inequalities time since migration racial discrimination / cultural barriers / legal constraints 27

28 Healthy migrant effect and/or salmon bias? The health of returned migrants in Mexico Total sample With migration experience Without migration experience p-value Demographic characteristics Age <0.01 Urban 40.5% 30.7% 43.4% <0.001 Married 96.8% 95.9% 97.1% -- Anthropometric characteristics Height (m) <0.05 Weight (kg) <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 Early life health Adult health Ullmann SH, 2011 Migration and health: a conceptual framework Importation Adaptation Inequalities In social determinants In risk factors In health care Health vulnerability vulnerability Selection Heterogeneity by ethnic origin by time since migration Relative impact of each mechanism and warnings Implications for policies Implications for public health summary 28

29 Health indicators by country of origin - Italy, Italians Foreigners Romania Albania M orocco Other Europe not EU Other Africa Latin America Good/very good _M At least one chronic disease _M Good/very good _F At least one chronic disease _F Gargiulo L, 2008 All-cause mortality in migrants by age at arrival and length of residence The Turin Longitudinal Study, Hazard ratios adjusted for SES characteristics Men and women Length of stay years years 40+ years Age at arrival Turin-born ,57 0,77 0,81 [ ] [ ] [ ] ,77 0,81 0,95 [ ] [ ] [ ] 45+ 1,04 1,10 1,50 [ ] [ ] [ ] Rasulo D,

30 Diabetes in migrants by length of residence - USA, Oza-Frank R, 2011 Overweight in migrants by country of origin and length of residence - USA, Oza-Frank R,

31 Migration and health: a conceptual framework Importation Adaptation Inequalities In social determinants In risk factors In health care Health vulnerability vulnerability Selection Heterogeneity by ethnic origin by time since migration Relative impact of each mechanism and warnings Implications for policies and public health summary IN selection: healthy migrant effect Conclusions on impact on epidemiologic profile OUT- selection: salmon bias Genetic characteristics Exposures in the country of origin importation diseases Migration experience Low negative short uprooting Socioeconomic deprivation Exposures in the host country High negative long acculturation effects / social inequalities time since migration Low racial negative discrimination long / cultural barriers / legal constraints High negative/positive long 31

32 summary Migration and health: a conceptual framework Importation Adaptation Inequalities In social determinants In risk factors In health care Health vulnerability vulnerability Selection Heterogeneity by ethnic origin by time since migration Relative impact of each mechanism and warnings Implications for policies and public health TIME FOR ACTION: IT IS CONVENIENT Economic costs of DALYs lost because of health inequalities in Europe: % GDP (Mackenbach et al, 2007) Eurothine,

33 TIME FOR ACTION: IT IS CONVENIENT IN selection: healthy migrant effect OUT- selection: salmon bias Genetic characteristics Exposures in the country of origin Migration experience Socioeconomic deprivation Exposures in the host country importation diseases acculturation effects social inequalities time since migration mechanisms entry points for interventions racial discrimination / EQUITY cultural barriers AUDIT / legal constraints OF STRATEGIES PROGRAMS INTERVENTIONS ANSWERS FROM EUROPE No harmonized EU migration health policy TWO COMMUNICATIONS OF THE EU COMMISSION: 1) SOLIDARITY IN HEALTH AND SOCIAL DETERMINANTS (2009) 2) ROMA INTEGRATION STRATEGY (2011) Population Action International 1994, IOM

34 EU ACTION SPECTRUM OF POLICIES TACKLING HEALTH INEQUALITIES A B Agenda Type Evaluation Target High Medium/Hi gh Comprehen sive crossgovernment strategies Isolated Crossgovernment C Medium SDH/Health sector D Low Health sector di t/ High Medium/Hi gh Low/mediu m Low gradient Vulner/High Vulner/ Whole Society as h l Number of initiative s > / + di Countries England Finland Ireland Norway Sweden Wales Belgium Denmark Germany Spain Netherlands Scotland Estonia Hungary Italy Latvia Lithuania Austria Czech Republic F P l d Access of irregular migrants to healthcare by law in 10 EU Member States Note*: for free does not exclude means tests or payment of a symbolic or reduced price Source: FRA 34

35 Council Conclusions on National Roma Strategies Joint action EQUITY ACTION 16 MSs more than 30 regions engaged in EQUITY AUDIT OF POLICIES AND INTERVENTIONS (21 May 2012) EU health programme activities: 35

36 TIME FOR ACTION: IT IS CONVENIENT IN selection: healthy migrant effect OUT- selection: salmon bias Genetic characteristics Exposures in the country of origin Migration experience Socioeconomic deprivation Exposures in the host country importation diseases acculturation effects social inequalities time since migration racial discrimination / cultural barriers / legal constraints 36