The European Journal of Public Health Advance Access originally published online on January 24, 2007
The European Journal of Public Health 2007 17(5):503-507; doi:10.1093/eurpub/ckl279
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Immigrant Health |
Health profiles, lifestyles and use of health resources by the immigrant population resident in Spain
P. Carrasco-Garrido, A. Gil De Miguel, V. Hernández Barrera and R. Jiménez-García** Unit of Preventive Medicine and Public Health, Rey Juan Carlos University, Alcorcón, Madrid.
Correspondence: Carrasco-Garrido P, PhD, MPH, Unidad de Medicina Preventiva y Salud Pública, Universidad Rey Juan Carlos, Avda. Atenas s/n. Alcorcón, Madrid, Spain, tel: +34 914888877, fax: +34 914888955, e-mail: pilar.carrasco{at}urjc.es
Received October 30, 2006, accepted December 18, 2006
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Abstract |
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Background: Our study aimed at describing the health profiles, life styles and use of health resources by the immigrant population resident in Spain. Methods: Cross-sectional, epidemiological study from the Spanish National Health Survey (NHS) in 2003. We analysed 1506 subjects of both sexes, aged
16 years, resident in Spain. Results: The immigrant population present diseases that are similar to those of the autochthonous population. The autochthonous population had significantly higher values for alcohol consumption and smoking (60.8 and 39.6%) than immigrants (39.6 and 27.5%). The percentage of immigrants hospitalized in the preceding 12 months was observed to be higher than that of the Spanish population (11.4 vs. 8.2%, P < 0.05). The immigrant population consumed fewer medical drugs than the Spanish population (42.6 and 49.9%, respectively). Conclusions: Immigrants in Spain display better lifestyle-related parameters, in that they consume less alcohol and smoke less than the autochthonous population. As for the use of health-care resources, while immigrants register higher percentages of hospitalization compared with the Spanish population, there is no evidence of excessive and inappropriate use of other health-care resources.
Keywords: health survey, immigrants, public health
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Introduction |
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Immigration has reshaped society worldwide and generated new needs and priorities in many areas, particularly in health care.
Large-scale immigration commenced decades ago in countries such as the United States, Canada and in many Member States of the European Union (EU). Their consolidated experience has enabled them to ascertain the health-care needs of their immigrant populations,1–10 and collect data for their respective national health surveys.2,5,7,8 Thus, the US National Health Interview Survey (NHIS) shows that the total immigrant health-care cost per capita is 55% less than that of autochthonous subjects.2 Similarly, the Canadian Community Health Survey (CCHS) reveals that its health system provides its immigrant population with sufficient services,5 whereas other health surveys conducted in countries such as the Netherlands and England reflect inequalities in access to health services.7,8
In Spain, however, it was not until the latter part of the 1990s that immigration witnessed significant growth. Currently, the population of Spain stands at more than 44 million, nearly 9% of which is accounted for by aliens, though this percentage does not reflect the illegal population.11 In the last decade, the number of foreign residents has doubled, with the result that Spain currently ranks fourth in the European Union in terms of the number of immigrants. It should be highlighted here that the segment registering the most important rise is that of economic immigrants, i.e. persons from countries poorer than Spain.12
Thanks to the basic nature of the Spanish National Health System all legal immigrants enjoy access to public health care, yet the truth is that immigrants who lack valid identity documents and remain in the country as illegal aliens are also attended by the health system, so that reliable data which describe their real health needs are called for. Accordingly, the first ever incorporation into the 2003 National Health Survey of data on the immigrant population in Spain provides researchers with a new tool for the study of this group.13
There can be no doubt that the health of the immigrant population has become a relevant topic from a public-health standpoint. Indeed, this is borne out by the various studies that have reported differences, not only in health, but also in the access to and use of health-care services by this group.14–19
In Spain, the health of the immigrant population has been analysed by studies using different methodologies, ranging from bibliographic reviews17 to descriptive studies of specific health-related situations.18,19 To date, however, no studies addressing health-related topics have used a nationally representative sample of the immigrant population.
Given the new socio-demographic situation in Spain that has come about by the incorporation of immigrants, our study aimed at describing immigrant health profiles, lifestyles and use of health resources, and identify possible differences between the immigrant and the autochthonous population.
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Methods |
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Ours was a descriptive, cross-sectional, epidemiological study analysing the health profiles and lifestyles of the immigrant population in Spain and their use of health resources.
We used individual secondary data collected by the Spanish National Health Survey (NHS) in 2003, from the Ministry of Health.13 This survey was carried out on a wide sample of the non-institutionalized Spanish population by direct interview at home. Sampling was in several stages, stratified by conglomerates, with proportional random selection of the primary sampling units (towns) and secondary units (sections), and random route, sex and age quotas in the last units (individuals). These surveys include data from 21 650 adults, and required weighing. The methodology has been described elsewhere.13
Our study population was made up of 1506 subjects of both sexes, aged 16 years, resident in Spain. The immigrant population selected (persons who, when asked ‘What is your nationality?’, answered ‘foreign’) comprised non-EU citizens, namely, those defined as any person not coming from European Union countries, the United States or Canada. For each such person, two Spanish-born subjects were randomly selected, duly matched by age, sex, size of town or city and Autonomous Region (Comunidad Autónoma).
As independent variables, we used the population's principal socio-demographic characteristics: co morbidity; self-perception of health; lifestyles e.g. smoking and alcohol consumption (both defined as dichotomous variables) in the 2 weeks immediately preceding the survey; and physical activity during leisure time. In order to assess the use of health-care resources, subjects were asked about the following: medical visits (time elapsed since last visit); dental visits in the previous 3 months; hospitalization (defined as a minimum of one night in the preceding 12 months); and use of emergency services in the preceding 12 months (dichotomous variables). To identify the use of specific resources by women, we asked whether they had consulted a gynaecologist, had a mammography, or undergone a cytology cervical smear test (affirmative or negative answers).
They were also asked whether they had consumed any type of medication in the previous two weeks (dichotomous ‘yes’/‘no’ variable) and whether this had taken the form of self-medication (taken to mean consumption of over-the-counter medication). Finally, subjects were asked whether they had been immunized against influenza in the latest vaccination campaign.
Descriptive statistics of the principal variables included in the study were drawn up. In addition, the relevant frequency distributions of the qualitative variables were calculated, and we analysed whether there were significant differences between the two study populations. For bivariate comparison of proportions, Pearson's 
2 method or Fisher's exact test was applied, with values of P < 0.05 taken as significant.
Estimates were made by incorporating the sampling weights, using the ‘svy’ (survey command) functions of the STATA programme, which enabled us to incorporate the sampling design into all our statistical calculations (descriptive, chi-squared). For random selection of the autochthonous population, SPSS.v. 12.0 for Windows was used.
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Results |
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Our sample comprised a total of 502 non-EU immigrants in Spain and 1004 autochthonous subjects. The response rate was 99.9% for the immigrant and 100% for the autochthonous population. As for the immigrants' country of origin, 56% came from Latin America, 25.3% from Africa, 13.9% from European countries, and 4.8% from Asia.
The distribution of the various socio-demographic characteristics of both populations is shown in table 1. Attention should be drawn to the statistically significant differences among the immigrant population in terms of educational level, marital status and monthly income, with the autochthonous population registering a higher percentage of citizens receiving an income of over 1200 euros per month.
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Analysis of comorbidity in the two populations showed that immigrants had a lower frequency of hypercholesterolaemia (P < 0.05) and allergy (P < 0.05) than the autochthonous population (table 2).
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With regard to perceived health and lifestyles, the autochthonous population (table 3) had significantly higher values for alcohol consumption and smoking than immigrants (P < 0.05). They also engaged in less physical exercise than the immigrant population (P < 0.05).
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On comparing differences in the use of health-care resources (table 4), the percentage of immigrants hospitalized in the preceding 12 months was observed to be higher than that of the autochthonous population (11.4 vs. 8.2%, P < 0.05), yet no significant differences were observed in the use of other health-care services. Moreover, when medical services used solely by the female population were examined, the percentage of women immigrants who reported undergoing a smear test (54.5%) proved to be significantly lower than that of autochthonous subjects (68.8%).
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A further noteworthy aspect was that the immigrant population consumed fewer medical drugs than the autochthonous population (42.6 and 49.9%, respectively), with these differences being statistically significant (P < 0.05). Self-medication was also significantly lower (18.1% for immigrants vs. 23.1% for the autochthonous population), yet when the respective relative self-medication percentages were compared, these significant differences disappeared (46% for the autochthonous population vs. 42.5% for immigrants).
When asked about influenza vaccination as a preventive measure, 11.8% of the immigrant vs. 9.6% of the autochthonous population had been vaccinated, though these differences were not statistically significant.
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Discussion |
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Immigrants in Spain are essentially a young population,20–23 who fall within the category of so-called economic immigrants24 and display characteristics similar to those of the autochthonous reference population and data agreeing with those of Spain's National Statistics Institute (Instituto Nacional de Estadística—INE) on country of origin,11 albeit with somewhat lower incomes, a circumstance in line with findings reported in other studies undertaken in the United States and Canada.25–28
In terms of health problems reported by the autochthonous population in 2003, we failed to find data to support the existence of a worse state of health among immigrants, inasmuch as they are present with diseases that are similar to those of the autochthonous population29 and, in some cases, e.g. hypercholesterolaemia or allergy, have significantly lower prevalence values. Although different studies, such as that conducted by the ‘Report on the Mental Health in Europe’ working group, alert to the vulnerability of this group against certain disorders, such as anxiety and depression16,17,30–34 (both accompanied by a worse perception of health35–36) this circumstance is not reflected in our study population.
The lifestyle-related variables reported by the immigrant population indicate significantly less smoking and alcohol consumption than that of the Spanish population. We observed similar results in a study based on data drawn from the US National Health Survey, in which immigrants had a lower likelihood of consuming alcohol than did autochthonous subjects.3,37 Another study recently undertaken in Switzerland, whose immigrant population has socio-demographic characteristics similar to those of the immigrant population in Spain, reports alcohol consumption of 14.7% among immigrants compared with 23.9% among autochthonous subjects.38
Similarly, in line with data furnished by the Ontario Health Survey on the factors that influence smoking39 in the Canadian population (which showed 9.6% of immigrants vs. 17% of Canadian-born subjects to be smokers), immigrants in Spain smoke less than the autochthonous population, a situation also reflected in other recent studies.27,40 As for physical activity, immigrants register significantly higher percentages, in agreement with a study conducted by Dawson et al. in Sweden using data from the Swedish Survey of Living Conditions, in which the immigrant population reported engaging in more physical activity than the local Swedish population.41
In Spain, the immigrant population, both legal and illegal, enjoys access to public health care, so that one cannot speak of this group having difficulties in access to health-care services. This is reflected in the Informe España 2003 country brief, which shows that 82% of immigrants know where to obtain information on health care and 62.7% make satisfactory use of social services.42
Our results show no greater overall use of health services by immigrants or patterns of use substantially different to those of the autochthonous population.17 While these findings are in line with research conducted in countries with similar health-care systems,5,24 certain changes in the use of specific health-care resources are nevertheless beginning to be detected, such as those reported by Stronks et al.7 in a study undertaken in the Netherlands, where access to more specialized health care was found to be lower in the immigrant group (4.2 vs. 8.3% for autochthonous subjects), and by Szczepura, in a study undertaken in the UK.14 Other authors, however, have reported the difficulties of and inequalities faced by immigrants in access to health services,3 e.g. Frisbie et al.,43 who state that 32% of immigrants compared with 22.7% of US subjects had not visited a doctor in the preceding year, percentages much higher than those for immigrants to Spain. This circumstance is aggravated when the immigrant is an illegal alien in the country of residence.4,44
It should be stressed that we observed a significantly higher percentage of hospitalizations among the immigrant than among the autochthonous population (11.4 vs. 8.2%). These findings are in line with those reported by Sanz et al.29 for Spain, albeit with percentages higher than ours (23%), but differ from the data reported in the hospital-admission-based study by Cots et al.,45 in which 9.1% of all admissions attended in the study hospital were foreign nationals. Other studies, such as that conducted using a health survey in Amsterdam,7 reflect that the immigrant population registers a lower percentage of hospitalizations than the autochthonous population (4.8% for Turkish immigrants vs. 6.8% for the autochthonous population). In contrast, Dunn et al.26 using data from the Canadian National Population Health Survey, observed practically equal hospitalization rates on comparing the immigrant with the autochthonous population (11.4 vs. 11%). These rates are identical to those of immigrants in Spain but higher than those observed in the study by Cacciani et al.46, undertaken in Italy with data from the Italian Hospital Information System.
The percentage of women immigrants who had had a smear test was significantly lower than that of Spanish women (54.5 vs. 68.8%). We found higher results in the telephone-survey-based study by Carrasquillo et al.47 on the use of cervical cancer screening tests among a representative sample of all women immigrants in the United States (73% in immigrant women vs. 89% in autochthonous women).
Lastly, immigrants in Spain report consuming fewer medical drugs than the autochthonous population (42.6 vs. 49.9%). In this respect, the recent study by Lasser et al. which used the Joint Canada/US Survey of Health to compare access to care, health status and health disparities between the two different health systems, reported no difficulties in access to essential medicines among both US and Canadian immigrants, although the probability of forgoing a required medicine for financial reasons was twice as high in the USA as in Canada, OR: 2.12 (1.73–2.59).48 This finding may be due to the existence of a universal-coverage-style health system that attenuates health inequalities, including access to medication, a situation that is rarely found in other countries with other types of health systems.49
There are a number of possible study limitations. First, the use of unvalidated self-declared data means that we cannot forget that some responses could be socially conditioned. Second, another possible limitation of the NHS is that the validity of the questions used to classify subjects according to the health-status variables has not been evaluated. Third, the immigrant population included in the National Health Survey may have been living in Spain for longer.
Lastly, the initial response rate to the 2003 NHS was 67%; therefore, the existence of possible non-response bias must be considered. According to the National Statistics Institute (INE), the initial non-response rate was slightly higher among males, non-Spanish subjects, and those in the 40–65 age group.13
In conclusion, ours is the first study to use a nationally representative sample of the immigrant population in Spain. Immigrants display better lifestyle-related parameters, in that they consume less alcohol, smoke less, and do more physical exercise than the autochthonous population. As for the use of health-care resources, while immigrants register higher percentages of hospitalization than the autochthonous population, there is no evidence of excessive and inappropriate use of other health-care resources.
Accordingly, the health-related needs of immigrants are comparable to those of the autochthonous population: what could generate inequalities, however, would be socio-cultural, language and economic differences.
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Acknowledgement |
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This study forms part of a research project funded by F.I.S. (Fondo de Investigaciones Sanitarias-Health Research Fund) from the Carlos III Institute of Public Health.
Key points
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References |
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