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The Social Determinants of Migrant Health

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 25 th , 2012. Migrants. Regular and irregular situations Trafficked

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The Social Determinants of Migrant Health

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  1. 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

  2. Migrants • Regular and irregular situations • Trafficked • Asylum seekers • Refugees and displaced persons

  3. 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 (<10yrs 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

  4. Poverty & Other Factors Contributing to Health Problems Poverty Social inequality Government Policy

  5. Poverty & Health

  6. 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 Policies Labour Market, Housing, Land Social Class Gender Ethnicity (racism) ------------ Education Occupation Income 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.

  7. 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. 1992;22(3):429-445.

  8. Conceptual Framework of Impact of Migration on Health Migration Factors -Health advantage (Before & During) Paradox -Separation -Injuries -Refugees/stress -Physical attacks, etc. Access-to-Care Issues -Patient factors -Health care -Provider factors system factors Sociodemographic Characteristics -Age -Gender -Culture -Household composition -Religion -Ethnicity, etc. Socioeconomic Characteristics -Education -Income/wealth/assets -Occupation HEALTH PHYSICAL MENTAL SOCIAL Lifestyle Health Risk Behaviors Post-Migration Factors -Unemployment -Underemployment -Family separation -Discrimination -Acculturation -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. 2007;65:1524-1535.

  9. 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)

  10. Immigrants vs. Total Population Educational Attainment Source: United States, American Community Survey, 2009

  11. Immigrants vs. Total Population People Below Poverty Line Source: United States, American Community Survey, 2009

  12. Immigrants vs. Total Population Occupations Source: United States, American Community Survey, 2009

  13. 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. 2004;27(4):323-326.

  14. 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

  15. www.preventioninstitute.org PIJT3013-116 08/02

  16. The Migration Experience: Post-Migration Acculturation Effects on Health-Related Behaviors 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. 2005;26:367-97.

  17. 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. 2005;26:367-97.

  18. The Migration Experience: Post-Migration Immigrant Workers in the United States  One in six workers in the US are born abroad  US states have high shares of immigrants in itsworkforce (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.

  19. The Migration Experience: Post-Migration Immigrants and Work-Related Injuries • 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. 2007;167(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. 2008;98(3):416-423.

  20. 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.

  21. Immigrants Health Care Services Barriers to Access-to-Care for Immigrants • Adapted from: Rodriguez et al. (2009). Trauma Violence Abuse. 10(4): 358-374.

  22. Patient Factors: Home Language and English-Speaking Proficiency Among Foreign-Born in United States Barriers to Access-to-Care for Immigrants Household Language (N=38.5 million foreign-born) English Proficiency Source: United States, American Community Survey, 2009

  23. Barriers to Access-to-Care for Immigrants Provider/System Factors • 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. 2002;40:52–9. Givens JL et al. Gen Hosp Psychiatry. 2007;29:182–91. Casey MM et al. Am J Public Health. 2004;94:1709-1711.

  24. Barriers to Access-to-Care for Immigrants Patient Factors: Legal Status of Immigrants, 2010 Total Immigrants=38.5 million SOURCE: 2010 Pew Hispanic Center estimates based on augmented March Supplements to the Current Population Survey.

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

  26. 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.

  27. Gonzalez HM, Vega WA, Rodriguez MA, et al. Diabetes Awareness and Knowledge Among Latinos: Does a Usual Source of Healthcare Matter? JGIM. 2009;24 Suppl 3:528-533.

  28. 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. 2005;3(3):235-241.

  29. 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. 2009;24 Suppl 3:508-513.

  30. 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. 2009;24 Suppl 3:508-513.

  31. 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. 2009;24 Suppl 3:508-513.

  32. Reyes-Ortiz CA, Rodriguez MA & Markides KS. The Role of Spirituality Healing with Perceptions of the Medical Encounter among Latinos. JGIM. 2009;24 Suppl 3:542-547.

  33. Figure 1. Place of health care by nativity and immigration status among Latinos aged >18 years

  34. 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. 2011;68(4):428-433.

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