Elsevier

Social Science & Medicine

Volume 71, Issue 9, November 2010, Pages 1610-1619
Social Science & Medicine

Migration-related health inequalities: Showing the complex interactions between gender, social class and place of origin

https://doi.org/10.1016/j.socscimed.2010.07.043Get rights and content

Abstract

In this paper, we briefly review theories and findings on migration and health from the health equity perspective, and then analyse migration-related health inequalities taking into account gender, social class and migration characteristics in the adult population aged 25–64 living in Catalonia, Spain. On the basis of the characterisation of migration types derived from the review, we distinguished between immigrants from other regions of Spain and those from other countries, and within each group, those from richer or poorer areas; foreign immigrants from low-income countries were also distinguished according to duration of residence. Further stratification by sex and social class was applied. Groups were compared in relation to self-assessed health in two cross-sectional population-based surveys, and in relation to indicators of socio-economic conditions (individual income, an index of material and financial assets, and an index of employment precariousness) in one survey. Social class and gender inequalities were evident in both health and socio-economic conditions, and within both the native and immigrant subgroups. Migration-related health inequalities affected both internal and international immigrants, but were mainly limited to those from poor areas, were generally consistent with their socio-economic deprivation, and apparently more pronounced in manual social classes and especially for women. Foreign immigrants from poor countries had the poorest socio-economic situation but relatively better health (especially men with shorter length of residence). Our findings on immigrants from Spain highlight the transitory nature of the ‘healthy immigrant effect’, and that action on inequality in socio-economic determinants affecting migrant groups should not be deferred.

Introduction

In economically advanced countries, theoretical and empirical research on health inequalities and on health among migrants has generally developed in parallel, with few attempts to integrate the two fields. Migration and health issues have only been partially addressed within the health equity framework. In this paper, we briefly review theories and findings regarding migrants’ health from the health equity perspective and then analyse migration-related health inequalities in Catalonia taking into account gender, social class, and migration circumstances. The framework of the WHO Commission on Social Determinants of Health (CSDH, 2008) highlights the existence of health inequalities that are dependent on the different spheres that shape an individual’s position in society, such as social class, gender and ethnicity (Solar & Irwin, 2007). Inequalities faced by racial and ethnic minorities have been widely described in countries such as the United States and United Kingdom, which have a very long (decades or centuries) history of migration, intertwined with slavery and colonialism, and established minorities (Nazroo, 2003). In other western European countries, the study of inequalities related to migration dynamics might be also useful, and has attracted growing interest. Catalonia (around 7,000,000 inhabitants), which has experienced a large and now established immigration flow from other areas of Spain, and a more recent one from abroad, can constitute an interesting case study.

Previous work on migrants’ health generally compares the health of international migrants to that of the native population in the destination country. Most findings are consistent with the so-called “healthy immigrant effect”: recently arrived immigrants (usually from poor areas) have generally better health than the native population, or at least better than expected for their socio-economic characteristics; this health advantage is frequently observed to deteriorate more rapidly than among natives, despite a relative socio-economic improvement (Newbold, 2005, Ronellenfitsch and Razum, 2004, Uretsky and Mathiesen, 2007, Vissandjee et al., 2004). A possible explanation for this pattern, proposed in several US studies on Hispanic immigrants (Abraído-Lanza et al., 2005, Escobar et al., 2000, Hosper et al., 2007, Lutsey et al., 2008), suggests that culture-based healthier lifestyles, stronger social bonds and support from the country of origin initially exert a protective effect on immigrants’ health; but that these factors are progressively lost as immigrants undergo a process of “acculturation”, i.e. assimilate dominant culture and habits, and in their offspring. However, in these studies acculturation was not measured directly, but simply as a function of the duration or number of generations of residence; also, searching for a culture-based explanation might divert attention from structural constraints (Viruell-Fuentes, 2007, p. 1525). In fact, there is evidence that immigrants also have better levels of health than the population in their place of origin, and this is especially true for young migrants whose primary goal is to find work; this has been attributed to a labour-related positive health selection due to the high physical demands of the manual jobs that most occupy (Lu, 2008, Marmot et al., 1984, Redstone Akresh and Frank, 2008). Also, many studies show that less privileged social class and poorer socio-economic conditions account partly or totally for the poorer health outcomes of individuals from low-income countries (Hjern et al., 2004, Levecque et al., 2007, Lindström et al., 2001, Rasch et al., 2008, Reijneveld, 1998, Tinghog et al., 2007, Van der Wurff et al., 2004); additional, specific mechanisms of inequality creation have also been postulated such as discrimination (Gee, Ryan, Laflamme, & Holt, 2006) and “othering” (being treated as ‘the other’: Viruell-Fuentes, 2007). Together, these findings – positive health selection, rapid decline in health despite a parallel socio-economic improvement, and socio-economic explanations of inequality – make sense if we attribute this accelerated health decline as the late-effect of cumulative inequality, both in the place of origin, with poorer socio-economic environment in childhood and growth (Ronellenfitsch & Razum, 2004), and in the place of destination, with chronic exposure to work hazards, poor living conditions, hardship and discrimination, mechanisms that are well recognized as causal factors of racial and ethnic inequalities in health (Harris et al., 2006, Krieger, 2003, Nazroo, 2003). The psychobiological impacts of a forced migration, such as separation from friends and relatives and loss of social status, may add to these mechanisms.

Another recurrent characteristic in recent studies on immigration and health is the distinction between immigrants from ‘Western’, ‘high-income’ or ‘developed’ countries, and those from ‘other’, ‘low-income’ or ‘developing’ countries: a distinction which is empirically supported by data, but rarely accompanied by theoretical discussion (Hjern et al., 2004, Hosper et al., 2007, Levecque et al., 2007, Lindström et al., 2001, Pudaric et al., 2003, Rasch et al., 2008). In our view, this distinction makes sense, in that emigration from deprived areas is usually a forced choice, shared by a wide sector of the population, as the result of broad imbalances in economic and social well-being between the countries of origin and destination (Castles, 2003); this often implies entry to the host society in a subordinate position, with little negotiating power, and increased vulnerability to discrimination and exploitation. This type of migration – based on labour movement from impoverished to advantaged and expanding economies – is the predominant or most increasing type in both internal and international migration flows (Lu, 2008, United Nations, 2009) and is the most important for analyses of health inequalities based on power relations. The minority of immigrants who move between wealthy areas are more likely to do so for individual circumstances and opportunities, and do not share the characteristics mentioned above. In this sense, migration is a reflection of global, geographical inequalities between countries, territories and populations.

Finally, the vast majority of studies on health inequalities between natives and immigrants have focused on international migration. However, internal migrants – those who have moved within the same country – are at least four times as many as international ones (UNDP, 2009, p. 1). Most theoretical work makes little distinction between internal and international migration but often suggests that the basic underlying mechanisms and challenges (adaptation to a new life, economic hardship) apply equally to both groups (Lu, 2008). Legal restrictions and greater geographical and cultural distance are the additional barriers (related both to health selection and hazards) faced by international migrants (Lu, 2008). Some of the studies on health inequalities between natives and immigrants from other regions of the same or an adjacent country described poorer health for Finns in Sweden (Pudaric et al., 2003, Westman et al., 2008), higher mortality among Irish and Scottish immigrants in England (Marmot et al., 1984, Raftery et al., 1990, Wild and McKeigue, 1997), but less hypertension and overweight than non-migrants for employment-related internal migrants in Croatia (Kolcić & Polasek, 2009).

Our study area, Catalonia, is a relatively wealthy region within Spain, with its own language, customs, and national identity, with the interesting characteristic of having experienced in the last 50 years two separate waves of interregional and international immigration, in both cases mainly (but not exclusively) from disadvantaged areas. The last decade has seen a rapid increase in foreign immigration, which increased the foreign-born population in municipal continuous registers from 4% in the year 2000 to 14,8% in 2007 (Idescat, 2008). For this reason, good quality data on the health of this sector of the population are just becoming available. 12.6% of the adult immigrant population were born in the highly developed EU-15 countries, while the rest includes 41.1% from Central and South America (from various countries, being Ecuador, 7.9%, the most common); 23.5% from Africa (mostly Morocco, 17.4%); 13.2% from the rest of Europe (Romania, 6%); and 8.8% from Asia. On the other hand, several different waves arrived from other regions of Spain during the second half of last century, especially in the 1950s and 1960s, when the rapidly expanding Catalan economy required workers and the areas of the south and west of Spain were affected by unemployment and poverty. At present in Catalonia there are more people born in other Spanish regions than in Catalonia itself in some age cohorts, such as those aged 55–74 (Idescat, 2008). This heterogeneity has been largely omitted in health studies. Recently, the only study of immigration and health status was published, as far as we are aware, that includes in a separate group Spanish individuals born outside Catalonia (Borrell et al., 2008).

The migration dimension cannot be understood independently of social class and gender, as all three are key intertwined mechanisms of power relations in society (Anthias, 2001). Through processes such as exploitation, domination and discrimination, power determines the extent to which an individual or group can influence their surrounding environment, and it entails privileges, opportunities, access to resources and health-damaging exposures (the so-called intermediary determinants of health in the CSDH framework) throughout life. Studies describing health inequalities by both social class and gender are increasing, and in Catalonia women in disadvantaged classes have the worst indicators of morbidity and self-assessed health (Borrell, Benach, & CAPS-FJ Bofill Working Group, 2006). As described, several studies have simultaneously explored socio-economic position and migration status (Levecque et al., 2007, Marmot et al., 1984, Reijneveld, 1998), and others socio-economic position and race/ethnicity (see Davey Smith, 2000, Krieger, 2003). However, only a few studies have attempted to analyse inequality in three dimensions simultaneously, usually with gender, socio-economic position and race/ethnicity (Almeida-Filho et al., 2004, Clarke et al., 2009, Pamuk et al., 1998, Schulz and Mullings, 2006), but also with migration status (Borrell et al., 2008). A recent study in California showed that body mass index among immigrants increases with length of residence, and the pace of increase is higher among women, those with the lowest education level, and Hispanics (Sanchez-Vaznaugh, Kawachi, Subramanian, Sánchez, & Acevedo-Garcia, 2008). Pamuk et al. (1998) found that a stable racial minority such as Black people in the US had poorer self-rated health than Whites at each level of income, whereas the Hispanic (a large proportion of whom were immigrants) had equal or better health; and that women had worse health than men among Black and Hispanic, but not among Whites.

In summary, it seems reasonable that an analysis of migration-related health inequalities requires a classification of migration type that takes into account the duration of residence and characteristics of the place of origin, i.e. its grade of economic development, and localization within or outside the receiving country. The aim of the next section is to test empirically the relevance of this classification and to explore the intersections of migration type with gender and social class in the analysis of social inequalities in health status in Catalonia. Also, we will look at the distribution, in the same dimensions, of socio-economic assets and privileges – the intermediary determinants – and at their contribution to the relationship between migration type and health.

Section snippets

Study population, sample and data collection

The population context was the 2006 non-institutionalised population of Catalonia, Spain. Two cross-sectional surveys carried out on the same population were used: the Enquesta de Condicions de Vida i Hàbits de la Població (which we will refer to as the Living Conditions Survey, LCS) and the Enquesta de Salut de Catalunya (the Health Interview Survey, HIS). Both surveys are part of the regional government’s official statistical plan, and share the following characteristics: a random sampling

Socio-demographic description of the samples

A total of 3510 women and 3597 men composed the LCS sample, and 5086 women and 5322 men composed the HIS sample. Table 1 displays the distribution of the samples by sex and social class and by sex and origin; and for each category, mean age, and age-adjusted socio-economic situation and health status.

Social class IV was the largest group in both sexes and both surveys. In both surveys, women in manual classes (III-m to V) were generally older than in non-manual classes, whereas no such pattern

Discussion

This study analyses inequalities in socio-economic determinants and self-assessed health status according to gender, social class and migration type, defined on the base of sociological theory, historical context and literature review. As discussed below, the findings show that this migration type classification helps to detect and understand migration-related health inequalities, which:

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    affect both internal and international immigrants, but are mainly limited to immigrants from poor areas, as a

Acknowledgement

This work was undertaken as part of Davide Malmusi’s doctoral dissertation at the Universitat Pompeu Fabra. Davide Malmusi was partially supported by the IV grant for young epidemiologists “Enrique Nájera” awarded by the Sociedad Española de Epidemiología and sponsored by the Escuela Nacional de Sanidad.

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