The Social Determinants of Migrant Health

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The Social Determinants of Migrant Health
7th Summer Institute on Migration and Global
Health Los Angeles, California, USA

• Michael A. Rodriguez, MD, MPH
• Professor , UCLA Department of Family Medicine
• June 25th, 2012

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Migrants

• Regular and irregular situations
• Trafficked
• Asylum seekers
• Refugees and displaced persons

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U.S. Immigrants Today

• 38.5 million are foreign born
• Latinos and Asians combined make up approximately
  80 of the US, foreign-born population
• Most recent immigrants (lt10yrs in US) are working
  age and live in metropolitan areas.
• Lots of media attention and policy discussions
  about their use of public services

Pew Hispanic Center tabulations of 2009
American Community Survey (1 IPUMS) US Census
Bureau, Census of Population, 1960 to 2000, and
2007 American Community Survey
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Poverty Other Factors Contributing to Health
Problems
Poverty
Social inequality
Government Policy
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Poverty Health
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Social Determinants of Health Conceptual
Framework
SOCIOECONOMIC POLITICAL CONTEXT
Governance
Poverty/ Socioeconomic Position
Material Circumstances (Living and
Working Conditions, Food Availability,
etc.) Behaviors and Biological
Factors Psychosocial Factors
Local Government Civil Society
Macroeconomic Policies
IMPACT ON EQUITY IN HEALTH AND WELL-BEING
Social Class Gender Ethnicity (racism)
?------------? Education Occupation Income
Social Policies Labour Market, Housing, Land
Public Policies Education, Health, Social
Protection
Social Cohesion Social Capital
Culture and Societal values
Health System
STRUCTURAL DETERMINANTS SOCIAL DETERMINANTS OF
HEALTH INEQUITIES
INTERMEDIARY DETERMINANTS SOCIAL DETERMINANTS
OF HEALTH
Modified from Solar O and Irwin A. A conceptual
framework for action on the social determinants
of health. Social Determinants of Health
Discussion Paper 2 (Policy and Practice). World
Health Organization (WHO), Geneva, 2010.
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Disparities
differences in health which are not only
unnecessary and avoidable but, in addition, are
considered unfair and unjust
World Health Organization. Whitehead M. The
concepts and principles of equity and health.
Int J Health Serv. 199222(3)429-445.
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Conceptual Framework of Impact of Migration on
Health
Migration Factors -Health advantage (Before
During) Paradox -Separation -Injuries -Refugee
s/stress -Physical attacks, etc.
Access-to-Care Issues -Patient factors -Health
care -Provider factors system factors
Sociodemographic Characteristics -Age -Gender -Cul
ture -Household composition -Religion -Ethnicity,
etc.
Socioeconomic Characteristics -Education -Income/w
ealth/assets -Occupation
HEALTH PHYSICAL MENTAL SOCIAL
Lifestyle Health Risk Behaviors
Post-Migration Factors -Unemployment -Underemploym
ent -Family separation -Discrimination -Acculturat
ion -Legal status
Other Determinants of Health -Environmental
circumstances -Length of stay in new
environments
Adapted from Noh S. et al. Centre of Excellence
for Research in Immigration and Settlement
(CERIS) in Toronto and Canadian Heritage, 2001.
Viruell-Fuentes EA. Social Science
Medicine. 2007651524-1535.
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The Migration Experience Post-Migration

• Post-migration living difficulties
• Communication problems (Schweitzer RD et al.,
  2011)
• Acculturation (Viruell-Fuentes EA et al., 2007
  Lara M et al., 2005)
• Concern for family left behind (Schweitzer RD et
  al., 2011)
• Relatively lower socioeconomic status,
  unemployment, underemployment (Barker ASV, 2010 )
• Discrimination and stigmatized status
  (Viruell-Fuentes EA et al., 2007)

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Immigrants vs. Total Population Educational
Attainment
Source United States, American Community
Survey, 2009
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Immigrants vs. Total Population People Below
Poverty Line
Source United States, American Community
Survey, 2009
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Immigrants vs. Total Population Occupations
Source United States, American Community
Survey, 2009
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Lifestyle Health-Related Behaviors of Immigrants
in the United States

• Acculturation/assimilation processes
• Unhealthy dietary practices (e.g. diets high in
  fat and low in fruits and vegetables)
• Sedentary lifestyles
• Smoking Drinking
• Unhealthy lifestyle behaviors associated with
  greater length of residence

Kaplan MS et al. Am J Prev Med.
200427(4)323-326.
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Decreased Physical Activity

• Reduced walking or biking to and from school
• Safety concerns
• Schools with less physical education
• After school programs
• Environment
• Urban and suburban designs that discourage
  walking and other physical activities
• Unsafe neighborhoods discouraging outdoor
  activities

Source Institute of Medicine of the National
Academics California Adolescent Nutrition and
Fitness Program California Pan-Ethnic Health
Network, 2003
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www.preventioninstitute.org PIJT3013-116 08/02
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Acculturation Effects on Health-Related Behaviors
The Migration Experience Post-Migration
Source Lara M, Gamboa C, Kahramanian MI, Morales
LS, Bautista DE. Acculturation and Latino health
in the United States a review of the literature
and its sociopolitical context. Annu Rev Public
Health. 200526367-97.
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The Migration Experience Post-Migration
Acculturation Effects on Health Outcomes
Source Lara M, Gamboa C, Kahramanian MI, Morales
LS, Bautista DE. Acculturation and Latino health
in the United States a review of the literature
and its sociopolitical context. Annu Rev Public
Health. 200526367-97.
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Immigrant Workers in the United States
The Migration Experience Post-Migration

• ? One in six workers in the US are born abroad
• ? US states have high shares of immigrants in
  its workforce (e.g. California-35, New York-27,
  New Jersey-26)
• ? Latino immigrant workers are most prevalent
• ? Immigrants are overrepresented among
  low-educated workers (Account for 48 of workers
  without high school degree only 15 of
  college-educated workers ages 25 and older)
• ? Brain waste more than 1 in 5
  college-educated immigrants were unemployed or
  worked in unskilled jobs such as dishwashers,
  security guards, and housemaids

Source Batalova J. Profile of Immigrant Workers
in the United States. Migration Policy Institute.
MPI Data Hub, 2011.
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Immigrants and Work-Related Injuries
The Migration Experience Post-Migration

• Immigrant labor markets ? informal labor
  contractors/smaller employers less likely to
  report treat injuries (incl. life-threatening)
• Undocumented, vulnerable to detection and
  deportation

Ortega AN et al. Arch Intern Med.
2007167(21)2354-2360.

• Hazardous workplace practices and conditions
• Among Latinos from 2003 to 2006, foreign-born
  workers 59 higher work-related injury death rate
  than native-born counterparts
• Immigrant labor concentrated in manufacturing,
  construction and agricultural work

Centers for Disease Control and Prevention.
1992-2006.
Silverstein M. Am J Public Health.
200898(3)416-423.
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Occupational hazards and coping mechanisms among
Latina household workers
Richards A, Portillo M, Gonzalez R, Zuniga N,
Ryan G Rodriguez M. (2009). Airing our dirty
laundry Community based participatory research
to explore occupational hazards and coping
mechanisms among Latina household workers. Poster
Session presented at the Robert Wood Johnson
Foundation Clinical Scholars, 2009 National
Meeting, La Jolla, CA.
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Barriers to Access-to-Care for Immigrants
Adapted from Rodriguez et al. (2009). Trauma
Violence Abuse. 10(4) 358-374.
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Patient Factors Home Language and
English-Speaking Proficiency Among Foreign-Born
in United States
Barriers to Access-to-Care for Immigrants
Household Language (N38.5 million foreign-born)
English Proficiency
Source United States, American Community
Survey, 2009
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Provider/System Factors
Barriers to Access-to-Care for Immigrants

• Lack of multi-ethnic, bilingual providers
• Language barriers impeding verbal communication
  between patients and providers
• Lack of understanding of cultural backgrounds,
  health beliefs, historically used health
  practices, etc.
• Insufficient supply of interpreter services

Fiscella K et al. Med Care. 200240529.
Givens JL et al. Gen Hosp Psychiatry.
20072918291.
Casey MM et al. Am J Public Health.
2004941709-1711.
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Patient Factors Legal Status of Immigrants, 2010
Barriers to Access-to-Care for Immigrants
Total Immigrants38.5 million
SOURCE 2010 Pew Hispanic Center estimates based
on augmented March Supplements to the Current
Population Survey.
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Undocumented

• Denied access to public health services
• Reluctant to use services for fear of being
  detected

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Bauer H, Rodriguez MA, et al. Barriers to Health
Care for Abused Latina and Asian Immigrant Women.
Journal of Health Care for the Poor and
Underserved. 2000 11(1)33-44.
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Gonzalez HM, Vega WA, Rodriguez MA, et al.
Diabetes Awareness and Knowledge Among Latinos
Does a Usual Source of Healthcare Matter? JGIM.
200924 Suppl 3528-533.
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Rodriguez MA, Ward LM Perez-Stable EJ. Breast
and Cervical Cancer Screening Impact of Health
Insurance Status, Ethnicity and Nativity of
Latinas. Annals of Family Medicine.
20053(3)235-241.
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Rodriguez MA, Bustamante AV Ang A. Perceived
Quality of Care, Receipt of Preventive Care, and
Usual Source of Health Care Among Undocumented
and Other Latinos. J Gen Intern Med. 200924
Suppl 3508-513.
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Rodriguez MA, Bustamante AV Ang A. Perceived
Quality of Care, Receipt of Preventive Care, and
Usual Source of Health Care Among Undocumented
and Other Latinos. J Gen Intern Med. 200924
Suppl 3508-513.
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Rodriguez MA, Bustamante AV Ang A. Perceived
Quality of Care, Receipt of Preventive Care, and
Usual Source of Health Care Among Undocumented
and Other Latinos. J Gen Intern Med. 200924
Suppl 3508-513.
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Reyes-Ortiz CA, Rodriguez MA Markides KS. The
Role of Spirituality Healing with Perceptions of
the Medical Encounter among Latinos. JGIM.
200924 Suppl 3542-547.
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Figure 1. Place of health care by nativity and
immigration status among Latinos aged gt18 years
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Mental Health Outcomes of US Immigrants vs.
Non-migrant Family Members of Migrants
Breslau J et al. Migration from Mexico to the
United States and Subsequent Risk for Depressive
and Anxiety Disorders. Arch Gen Psychiatry.
201168(4)428-433.
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Health Outcomes of Immigrants vs. US Population
Cunningham SA et al. Health of foreign-born
people in the United States A review. Health and
Place. 200814623-635.
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Migrant Health and aHuman Rights Perspective

• Migrants, as all humans, are entitled to basic
  human rights, including health
• Right to health should be formally recognized in
  national laws

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WHO Resolution 61.17, 2008

• Promotes inclusion of migrant health in regional
  health strategies
• Develop and support assessments and studies and
  share best practices
• Strengthen service and health providers capacity
  to address migrant needs
• Engage in bilateral and multilateral
  collaboration
• Establish technical network for research
  cooperation

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Right to Health

• enjoyment of the highest attainable standard of
  health is one of the fundamental human rights to
  every human being, without discrimination of
  race, religion, political belief or social
  situation WHO constitution, 1948
• International Convenant on Economic, Social, and
  Cultural Rights 1966
• Interrelated with right to other civil,
  political, economic, social and cultural rights

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Essential Components of a Right to Health

• Availability
• Accessibility
• Acceptability
• Quality

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Social Determinants of Healthand Development

• Socioeconomic, cultural, environmental, living
  and working conditions are foundations for
  enabling physical, mental and social well-being.
  
• Concepts of health and development in MDGs
• Direct Child health (4th), maternal health (5th)
• Indirect Ending poverty and hunger, Women
  empowerment
• Migration transcends development goals

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Recommendations

• Develop and implement integration and prevention
  strategies to decrease stigmatization, social
  exclusion, discrimination and marginalization of
  migrants.
• Facilitate ethnic community participation in
  development of programs and policies

International Organization for Migration, 2009
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Recommendations

• Ensure that national policies and laws respect
  the rights of migrants and improve access to
  health promotion, prevention, care and treatment
  for all migrants regardless of immigration status
• Support research to assess and document the links
  between migration and social determinants of
  health enhance national and international
  surveillance systems and ensure inclusion of
  disaggregated health data on migrant populations

International Organization for Migration, 2009
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Gracias! Thank You!