European cross-country comparisons of immigrants’ health and mortality. Do different integration policy models play a role?

European cross-country comparisons of immigrants’ health and mortality.

Do different integration policy models play a role?

Davide MalmusiAgència de Salut Pública de Barcelona

NORDURM workshop, Stockholm, 5 December 2014

SOPHIE projectAcronym for “Structural Policies and Health Inequalities Evaluation”

Funded by EU FP7 (Nov. 2011 - Oct. 2015)

SOPHIE aims to generate new evidence on the health equity impact of social and economic policies and to develop innovative methodologies for the evaluation of these policies in Europe

Background

SOPHIE project - Migration

SOPHIE aims to generate new evidence on the relationship between the orientation of immigrant integration policies and migration-related inequalities in health

Background

Immigrants’ health (in one slide)Immigrants from less to more advanced countries: • poorer socio-economic conditions• “healthy immigrant effect” vanishing over time1, 2

1 Fernando G De Maio. Immigration as pathogenic… Int J Equity Health 20102 Marie Norredam et al. Duration of residence and disease occurrence… Trop Med Int’l Health 2014

Uretsky, Mathiesen. The effect of years lived in the United States… J Immigr Minor Health 2007

Background

Immigrants’ health and immigration policies

>25,000 deaths of migrants in their way to Europe since 2000 according to «The Migrants’ Files» collaborative journalism project

Background

Immigrants’ health and immigration policiesImmigration policies include control and integration policies1

Few studies on their health impact - mostly from the US, on control policies, on undocumented migrants, single policy cases2

• "Immigration and Customs Enforcement": Fear of deportation impacts mental health and access to healthcare3, large impact on children4

• Drop in autism diagnoses for Hispanic children after Proposition 1875

• Mental health impacts of passing through detention centres6,7

• Intimate partner violence, higher risk for women on spousal dependent visas8

1 Jennifer L Hochschild et al. Immigration regimes and schooling regimes… Theory Res Educ 2010.2 Omar Martinez et al. Evaluating the impact of immigration policies… J Immigr Minor Health 20133 Karen Hacker et al. The impact of Immigration and Customs Enforcement… Soc Sci Med 2011.4 Randy Capps et al. Paying the price: The impact of immigration raids… NCLR 2007. 5 Christine Fountain et al. Risk as social context: immigration policy and autism… Sociol Forum 2011.6 Zachary Steel et al. Two year psychosocial and mental health outcomes for refugees… Soc Sci Med 2011.7 Ann Lorek et al. The mental and physical health difficulties of children held… Child Abuse Neglect 2009.8 A Raj et al. Immigration policies increase south Asian immigrant women’s… J Am Med Womens Assoc 2005.

Background

Immigrants’ health. Cross-country comparisons

Emerging cross-country analyses1,2,3 describe variations in the mortality of immigrants with similar origins…

… but have not yet been linked to immigration policy context

Exceptions in maternal4 and perinatal5 health

“Migrant Integration Policy Index” (MIPEX) overall score not associated with depression (controlling for individual variables)6

1 Raj S Bhopal et al. Mortality from circulatory diseases by specific country of birth… Eur J Public Health 20122 Jacob Spallek et al. Cancer mortality patterns among Turkish immigrants… Eur J Epidemiol 20123 Snorri B Rafnsson et al. Sizable variations in circulatory disease mortality… Eur J Public Health 20134 Paola Bollini et al. Pregnancy outcome of migrant women and integration policy… Soc Sci Med 20095 Sarah F Villadsen et al. Cross-country variation in stillbirth and neonatal mortality… Eur J Public Health 20106 Katia Levecque et al. Depression in Europe: does migrant integration have mental health … Ethn Health 2015

Background

Do current scores reflect policies that settled immigrants have experienced? Are all dimensions equally relevant for health?

Integration policy typologiesThree models are described based on legal and cultural rights:1,2

- 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.3,4

1 Castles, J Ethn Migr Stud 19952 Weldon, Am J Pol Sci 20063 Mahnig and Wimmer, J Int Migr Integr 20004 Heckmann and Schnapper, 2003

Background

A “data-driven” policy typologyMIPEX 2007 Latent Class Analysis. Bart Meuleman 2009 (Dissertation)

Multicultural

Differential exclusionist

Assimilationist

Background

MulticulturalDifferential exclusionistAssimilationist

A “data-driven” policy typologyMIPEX 2007 Latent Class Analysis. Bart Meuleman 2009 (Dissertation)

Background

• Self-rated health (EU-SILC) Published• Mortality (MEHO) Presented at conference• Mental health and discrimination (ESS) Draft• Medical unmet need (EU-SILC) Started• Adolescents’ health (HBSC) Planned 2015• National Health Surveys?

SOPHIE immigrants’ health cross-country studiesStatus Dec. 2014

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.

Methods. Design and dataDesign: 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)

Immigrants’ health by type of integration policies

Methods. VariablesDependent 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 2009)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

Immigrants’ health by type of integration policies

MulticulturalDifferential exclusionistAssimilationist

Countries included by policy modelImmigrants’ health by type of integration policies

Methods. AnalysisDescription 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

Immigrants’ health by type of integration policies

ResultsTertiary education (%)

Men Women

Immigrants’ health by type of integration policies

Managerial, professional or technical occupation (%)Men

Women

ResultsImmigrants’ health by type of integration policies

Household in the lowest income quintile (%)Men

Women

ResultsImmigrants’ health by type of integration policies

Poor self-rated health. Country by countryPredicted prevalence at age 50 via regression (%)

Men Women

Numbers indicate immigrants’ weighted sample size

ResultsImmigrants’ health by type of integration policies

Poor self-rated healthPredicted prevalence at age 50 via regression (%)

Men Women

ResultsImmigrants’ health by type of integration policies

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

ResultsImmigrants’ health by type of integration policies

Immigrants versus nativesPoor self-rated health. Prevalence ratio with 95%CI

ResultsImmigrants’ health by type of integration policies

Limiting longstanding illnessPredicted prevalence at age 50 via regression (%)

Men Women

ResultsImmigrants’ health by type of integration policies

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

ResultsImmigrants’ health by type of integration policies

Immigrants versus nativesLimiting longstanding illness. Prevalence ratio with 95%CI

ResultsImmigrants’ health by type of integration policies

Discussion. Main resultsFirst 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

Immigrants’ health by type of integration policies

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

Discussion. LimitationsImmigrants’ health by type of integration policies

Discussion. LimitationsImmigrants’ health by type of integration policies

Integration policies and immigrants’ mortality:an explorative European study

Umar Ikram1, Davide Malmusi2, Knud Juel3, Gregoire Rey4, Anton Kunst1

1Department of Public Health, Academic Medical Center, Amsterdam; 2Agència de Salut Pública de Barcelona; 3National Institute of Public Health, University of Southern Denmark, Copenhagen; 4INSERM, CépiDc, Le Kremlin-Bicêtre, France

Poster presented at European Public Health Conference 2014

Objective

To assess mortality differences among Turkish- and Moroccan-born immigrants living in three European countries with distinct types of integration policies

• Netherlands multiculturalist

• France assimilationist

• Denmark exclusionist

Methods

Mortality and population data from the Migrant Ethnic Health Observatory project (Netherlands 1996-2006 open cohort; Denmark 1992-2001 open cohort; France 2005-07 unlinked mortality register and census data)

Immigrants from Turkey and Morocco, and local-born populations aged 20-69 years

Age-standardised mortality rates by sex, country of residence and country of birth

Mortality rate ratios calculated using Poisson regression

Integration policies and immigrants’ mortality:an explorative European study

Umar Ikram1, Davide Malmusi2, Knud Juel3, Gregoire Rey4, Anton Kunst1

1Department of Public Health, Academic Medical Center, Amsterdam; 2Agència de Salut Pública de Barcelona; 3National Institute of Public Health, University of Southern Denmark, Copenhagen; 4INSERM, CépiDc, Le Kremlin-Bicêtre, France

Integration policies and immigrants’ mortality:an explorative European study

Umar Ikram1, Davide Malmusi2, Knud Juel3, Gregoire Rey4, Anton Kunst1

1Department of Public Health, Academic Medical Center, Amsterdam; 2Agència de Salut Pública de Barcelona; 3National Institute of Public Health, University of Southern Denmark, Copenhagen; 4INSERM, CépiDc, Le Kremlin-Bicêtre, France

Results

Compared with their peers in the Netherlands, Turkish-born had higher mortality in Denmark but lower in France. The mortality differences between immigrants and local-born population were largest in Denmark and lowest in France.

Future studiesAdequate cross-country samples of migrants with similar originsOther health indicators and populationsMultilevel (MIPEX dimensions scores, GDP, welfare policy…)Qualitative studies to uncover how policy gets under the skin

Conclusions and recommendationsIntegration policy models appear to make a difference on migrants’ health across Europe.The “exclusionist” model is associated with larger socioeconomic segregation and poorer health for migrants.Inclusive social policies and reduced barriers to full citizenship may have health benefits.

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Thank you! Gracias!Gràcies!Grazie!

Photos: Roberto Brancolini, Roberto Malaguti

sophie-project.eu

@sophieproject

Framework Spanish Commission

Conceptual framework: Immigration policy and migrants’ health