health profiles lifestyles and use of health resources by the unmigrant population resident in spain

7/28/2019 Health Profiles Lifestyles and Use of Health Resources by the Unmigrant Population Resident in Spain

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Health profiles, lifestyles and use of healthresources by the immigrant populationresident in Spain

P. Carrasco-Garrido, A. Gil De Miguel, V. Hernandez Barrera, R. Jimenez-Garca*

Background: Our study aimed at describing the health profiles, life styles and use of health resourcesby the immigrant population resident in Spain. Methods: Cross-sectional, epidemiological study fromthe Spanish National Health Survey (NHS) in 2003. We analysed 1506 subjects of both sexes, aged !16years, resident in Spain. Results: The immigrant population present diseases that are similar to thoseof the autochthonous population. The autochthonous population had significantly higher values foralcohol consumption and smoking (60.8 and 39.6%) than immigrants (39.6 and 27.5%). The percentageof immigrants hospitalized in the preceding 12 months was observed to be higher than that of theSpanish population (11.4 vs. 8.2%, P< 0.05). The immigrant population consumed fewer medical drugsthan the Spanish population (42.6 and 49.9%, respectively). Conclusions: Immigrants in Spain displaybetter lifestyle-related parameters, in that they consume less alcohol and smoke less than theautochthonous 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 excessiveand inappropriate use of other health-care resources.

Keywords: health survey, immigrants, public health

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Introduction

Immigration has reshaped society worldwide and generatednew needs and priorities in many areas, particularly inhealth care.

Large-scale immigration commenced decades ago incountries such as the United States, Canada and in many

Member States of the European Union (EU). Theirconsolidated experience has enabled them to ascertain thehealth-care needs of their immigrant populations,110 andcollect data for their respective national health surveys.2,5,7,8

Thus, the US National Health Interview Survey (NHIS) showsthat the total immigrant health-care cost per capita is 55% lessthan that of autochthonous subjects.2 Similarly, the CanadianCommunity Health Survey (CCHS) reveals that its healthsystem provides its immigrant population with sufficientservices,5 whereas other health surveys conducted in countriessuch as the Netherlands and England reflect inequalities inaccess to health services.7,8

In Spain, however, it was not until the latter part ofthe 1990s that immigration witnessed significant growth.

Currently, the population of Spain stands at more than44 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 hasdoubled, with the result that Spain currently ranks fourth inthe European Union in terms of the number of immigrants.It should be highlighted here that the segment registeringthe 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 HealthSystem all legal immigrants enjoy access to public health care,yet the truth is that immigrants who lack valid identitydocuments and remain in the country as illegal aliens are also

attended by the health system, so that reliable data whichdescribe their real health needs are called for. Accordingly, thefirst ever incorporation into the 2003 National Health Surveyof data on the immigrant population in Spain providesresearchers with a new tool for the study of this group.13

There can be no doubt that the health of the immigrantpopulation has become a relevant topic from a public-health

standpoint. Indeed, this is borne out by the various studies thathave reported differences, not only in health, but also in theaccess to and use of health-care services by this group.1419

In Spain, the health of the immigrant population has beenanalysed by studies using different methodologies, rangingfrom bibliographic reviews17 to descriptive studies of specifichealth-related situations.18,19 To date, however, no studiesaddressing health-related topics have used a nationallyrepresentative sample of the immigrant population.

Given the new socio-demographic situation in Spain thathas come about by the incorporation of immigrants, our studyaimed at describing immigrant health profiles, lifestyles anduse of health resources, and identify possible differencesbetween the immigrant and the autochthonous population.

Methods

Ours was a descriptive, cross-sectional, epidemiological studyanalysing the health profiles and lifestyles of the immigrantpopulation in Spain and their use of health resources.

We used individual secondary data collected by the SpanishNational Health Survey (NHS) in 2003, from the Ministry ofHealth.13 This survey was carried out on a wide sample ofthe non-institutionalized Spanish population by direct inter-view at home. Sampling was in several stages, stratified byconglomerates, with proportional random selection ofthe primary sampling units (towns) and secondary units(sections), and random route, sex and age quotas in the

last units (individuals). These surveys include data from21 650 adults, and required weighing. The methodology hasbeen described elsewhere.13

Our study population was made up of 1506 subjects of bothsexes, aged!16 years, resident in Spain. The immigrantpopulation selected (persons who, when asked What is

Correspondence: Carrasco-Garrido P, PhD, MPH, Unidad deMedicina Preventiva y Salud Publica, Universidad Rey Juan Carlos,Avda. Atenas s/n. Alcorcon, Madrid, Spain, tel: 34 914888877,fax: 34 914888955, e-mail: [email protected]

* Unit of Preventive Medicine and Public Health, Rey Juan CarlosUniversity, Alcorcon, Madrid.

European Journal of Public Health, Vol. 17, No. 5, 503507

The Author 2007. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

doi:10.1093/eurpub/ckl279 Advance Access published on January 24, 2007


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your nationality?, answered foreign) comprised non-EUcitizens, namely, those defined as any person not comingfrom European Union countries, the United States or Canada.For each such person, two Spanish-born subjects wererandomly selected, duly matched by age, sex, size of townor city and Autonomous Region (Comunidad Autonoma).

As independent variables, we used the populationsprincipal socio-demographic characteristics: co morbidity;self-perception of health; lifestyles e.g. smoking and alcoholconsumption (both defined as dichotomous variables) in the2 weeks immediately preceding the survey; and physicalactivity during leisure time. In order to assess the use ofhealth-care resources, subjects were asked about the following:medical visits (time elapsed since last visit); dental visits in theprevious 3 months; hospitalization (defined as a minimum ofone night in the preceding 12 months); and use of emergencyservices in the preceding 12 months (dichotomous variables).To identify the use of specific resources by women, we askedwhether they had consulted a gynaecologist, had a mammo-graphy, or undergone a cytology cervical smear test (affirma-tive or negative answers).

They were also asked whether they had consumed anytype of medication in the previous two weeks (dichotomousyes/no variable) and whether this had taken the form ofself-medication (taken to mean consumption of over-the-counter medication). Finally, subjects were asked whether theyhad been immunized against influenza in the latest vaccinationcampaign.

Descriptive statistics of the principal variables included inthe study were drawn up. In addition, the relevant frequencydistributions of the qualitative variables were calculated,and we analysed whether there were significant differencesbetween the two study populations. For bivariate comparisonof proportions, Pearsons 2 method or Fishers exact test wasapplied, 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 STATAprogramme, which enabled us to incorporate the samplingdesign into all our statistical calculations (descriptive,chi-squared). For random selection of the autochthonouspopulation, SPSS.v. 12.0 for Windows was used.

Results

Our sample comprised a total of 502 non-EU immigrantsin Spain and 1004 autochthonous subjects. The response ratewas 99.9% for the immigrant and 100% for the autochtho-nous 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 char-

acteristics of both populations is shown in table 1. Attentionshould be drawn to the statistically significant differencesamong the immigrant population in terms of educational level,marital status and monthly income, with the autochthonouspopulation registering a higher percentage of citizens receivingan income of over 1200 euros per month.

Analysis of comorbidity in the two populations showed thatimmigrants had a lower frequency of hypercholesterolaemia(P< 0.05) and allergy (P< 0.05) than the autochthonouspopulation (table 2).

With regard to perceived health and lifestyles, the auto-chthonous population (table 3) had significantly higher valuesfor alcohol consumption and smoking than immigrants(P< 0.05). They also engaged in less physical exercise thanthe immigrant population (P< 0.05).

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 ofthe autochthonous population (11.4 vs. 8.2%, P< 0.05), yet nosignificant differences were observed in the use of other health-care services. Moreover, when medical services used solelyby the female population were examined, the percentageof women immigrants who reported undergoing a smear test(54.5%) proved to be significantly lower than that ofautochthonous subjects (68.8%).

A further noteworthy aspect was that the immigrantpopulation consumed fewer medical drugs than the auto-chthonous population (42.6 and 49.9%, respectively), withthese differences being statistically significant (P< 0.05). Self-

medication was also significantly lower (18.1% for immigrantsvs. 23.1% for the autochthonous population), yet when therespective relative self-medication percentages were compared,these significant differences disappeared (46% for the auto-chthonous population vs. 42.5% for immigrants).

When asked about influenza vaccination as a preventivemeasure, 11.8% of the immigrant vs. 9.6% of the autochtho-nous population had been vaccinated, though these differenceswere not statistically significant.

Discussion

Immigrants in Spain are essentially a young population,2023

who fall within the category of so-called economicimmigrants24 and display characteristics similar to those ofthe autochthonous reference population and data agreeingwith those of Spains National Statistics Institute (Instituto

Nacional de EstadsticaINE) on country of origin,11 albeitwith somewhat lower incomes, a circumstance in line with

Table 1 Socio-demographic variables of the study population.

Spanish National Health Survey 2003

Country of origin

Spanish

population

Immigrant

population

N % N %

Sex

Men 468 46.6 234 46.6

Women 536 53.4 268 53.4

Age group (years)

1624 172 17.1 86 17.1

2534 398 39.6 202 40.2

3544 261 26.0 126 25.1

4554 108 10.8 55 11.0

5564 30 3.0 15 3.0

6574 17 1.7 10 2.0

75 and over 18 1.8 8 1.6

Marital status ()

Single/Divorced/Widow 452 45.0 168 33.5

Married or living together 552 55.0 334 66.5

Educational level (

)No formal education 64 6.4 60 12.0

Junior school 480 47.8 198 39.4

High school 276 27.5 155 30.9

Univer sit y and higher educa tion 184 18.3 89 17.7

Occupational status

Employed 795 79.2 424 84.5

Unemployed 40 4.0 34 6.8

Inactive 169 16.8 44 8.8

Size of town

Rural (10 000 inhabitants) 138 13.8 69 13.8

Urban(>10 000 inhabitants) 866 86.2 433 86.2

Monthly income ()

1200 euros 318 44.7 228 66.5

>1200 euros 394 55.3 115 33.5

Statistically significant differences (P< 0.05).

504 European Journal of Public Health


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findings reported in other studies undertaken in the UnitedStates and Canada.2528

In terms of health problems reported by the autochthonouspopulation in 2003, we failed to find data to support theexistence of a worse state of health among immigrants,inasmuch as they are present with diseases that are similar tothose of the autochthonous population29 and, in some cases,e.g. hypercholesterolaemia or allergy, have significantly lowerprevalence values. Although different studies, such as thatconducted by the Report on the Mental Health in Europe

working group, alert to the vulnerability of this group againstcertain disorders, such as anxiety and depression16,17,3034

(both accompanied by a worse perception of health3536)this circumstance is not reflected in our study population.

The lifestyle-related variables reported by the immigrantpopulation indicate significantly less smoking and alcoholconsumption 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 hada lower likelihood of consuming alcohol than did autoch-thonous subjects.3,37 Another study recently undertaken inSwitzerland, whose immigrant population has socio-demographic characteristics similar to those of the immigrantpopulation in Spain, reports alcohol consumption of 14.7%among immigrants compared with 23.9% among auto-chthonous subjects.38

Similarly, in line with data furnished by the Ontario HealthSurvey on the factors that influence smoking39 in the Canadianpopulation (which showed 9.6% of immigrants vs. 17% ofCanadian-born subjects to be smokers), immigrants in Spainsmoke less than the autochthonous population, a situationalso reflected in other recent studies.27,40 As for physicalactivity, immigrants register significantly higher percentages,in agreement with a study conducted by Dawson et al. inSweden using data from the Swedish Survey of LivingConditions, in which the immigrant population reportedengaging in more physical activity than the local Swedishpopulation.41

Table 2 Distribution of Spanish adult and immigrant

population included in Spanish National Health Survey 2003,

by comorbidity

Country of origin

Spanish population Immigrant population

N % N %

High blood pressure

Yes 59 5.9 23 4.6

No 945 94.1 479 95.4

High cholesterol ()

Yes 51 5.1 12 2.4

No 953 94.9 490 97.6

Diabetes

Yes 21 2.1 12 2.4

No 983 97.9 490 97.6

Respiratory disease

Yes 28 2.8 10 2.0

No 976 97.2 492 98.0

Heart disease

Yes 13 1.3 3 .6

No 991 98.7 499 99.4Sore stomach

Yes 17 1.7 11 2.2

No 987 98.3 491 97.8

Allergy ()

Yes 94 9.4 29 5.8

No 910 90.6 473 94.2

Depression

Yes 25 2.5 8 1.6

No 979 97.5 494 98.4

Obesity

BMI30 895 91.0 453 92.8

BMI > 30 88 9.0 35 7.2


Table 3 Distribution of Spanish adult and immigrantpopulation included in Spanish National Health Survey 2003,

according to perception of health and lifestyle-related

variables

Country of origin

Spanish

population

Immigrant

population

N % N %

Self-assessment of health status

Very good/Good 800 79.7 388 77.3

Fair/Poor/Very poor 204 20.3 114 22.7

Alcohol consumption ()

Yes 610 60.8 232 46.2No 394 39.2 270 53.8

Smoking habit ()

Yes 398 39.6 138 27.5

No 606 60.4 364 72.5

Physical exercise ()

Yes 548 54.6 329 65.5

No 456 45.4 173 34.5


Table 4 Use of sanitary resources among Spanish adult and

immigrant population included in Spanish National Health

Survey 2003

Country of origin

Spanish

population

Immigrant

population

N % N %

Medical consultation

1month 316 31.5 146 29.1

>1month 683 68.0 351 69.9

Never 5 0.5 5 1.0

Dental visit in preceding 3 months

Yes 207 20.6 86 17.1

No 797 79.4 416 82.9

Hospitalization in preceding 12 months ()

Yes 82 8.2 57 11.4

No 922 91.8 445 88.6

Emergency visit in preceding 12 months

Yes 275 27.4 150 29.9

No 729 72.6 352 70.1

Gynaecologist visitsYes 438 81.7 213 79.5

No 98 18.3 55 20.5

Mammography

Yes 177 33.0 75 28.0

No 359 67.0 193 72.0

Cytology ()

Yes 369 68.8 146 54.5

No 167 31.2 122 45.5

Medications consumption ()

Yes 501 49.9 214 42.6

No 503 50.1 288 57.4

Self-medication ()

Yes 232 23.1 91 18.1

No 772 76.9 411 81.9

Influenza vaccination

Yes 96 9.6 59 11.8

No 908 90.4 443 88.2


Health of immigrants in Spain 505


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In Spain, the immigrant population, both legal and illegal,enjoys access to public health care, so that one cannot speak ofthis group having difficulties in access to health-care services.This is reflected in the Informe Espana 2003 country brief,which shows that 82% of immigrants know where to obtaininformation on health care and 62.7% make satisfactory useof social services.42

Our results show no greater overall use of health servicesby immigrants or patterns of use substantially different tothose of the autochthonous population.17 While these findingsare in line with research conducted in countries with similarhealth-care systems,5,24 certain changes in the use of specifichealth-care resources are nevertheless beginning to be detected,such as those reported by Stronks et al.7 in a study undertakenin the Netherlands, where access to more specialized healthcare was found to be lower in the immigrant group (4.2 vs.8.3% for autochthonous subjects), and by Szczepura, in a studyundertaken in the UK.14 Other authors, however, havereported the difficulties of and inequalities faced by immi-grants in access to health services,3 e.g. Frisbie et al.,43 whostate that 32% of immigrants compared with 22.7% of USsubjects 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 anillegal alien in the country of residence.4,44

It should be stressed that we observed a significantly higherpercentage of hospitalizations among the immigrant thanamong the autochthonous population (11.4 vs. 8.2%). Thesefindings 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 admissionsattended in the study hospital were foreign nationals. Otherstudies, such as that conducted using a health survey inAmsterdam,7 reflect that the immigrant population registersa lower percentage of hospitalizations than the autochthonouspopulation (4.8% for Turkish immigrants vs. 6.8% for theautochthonous population). In contrast, Dunn et al.26 usingdata from the Canadian National Population Health Survey,observed practically equal hospitalization rates on comparingthe immigrant with the autochthonous population (11.4 vs.11%). These rates are identical to those of immigrants in Spainbut higher than those observed in the study by Cacciani et al.46,undertaken in Italy with data from the Italian HospitalInformation System.

The percentage of women immigrants who had had a smeartest was significantly lower than that of Spanish women (54.5vs. 68.8%). We found higher results in the telephone-survey-based study by Carrasquillo et al.47 on the use of cervicalcancer screening tests among a representative sample of allwomen immigrants in the United States (73% in immigrantwomen vs. 89% in autochthonous women).

Lastly, immigrants in Spain report consuming fewer medicaldrugs than the autochthonous population (42.6 vs. 49.9%). Inthis respect, the recent study by Lasser et al. which used theJoint Canada/US Survey of Health to compare access to care,health status and health disparities between the two differenthealth systems, reported no difficulties in access to essentialmedicines among both US and Canadian immigrants,although the probability of forgoing a required medicine forfinancial reasons was twice as high in the USA as in Canada,OR: 2.12 (1.732.59).48 This finding may be due to theexistence of a universal-coverage-style health system thatattenuates health inequalities, including access to medication,a situation that is rarely found in other countries with othertypes of health systems.49

There are a number of possible study limitations. First, theuse 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 thevalidity of the questions used to classify subjects according tothe health-status variables has not been evaluated. Third,the immigrant population included in the National HealthSurvey 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 beconsidered. According to the National Statistics Institute(INE), the initial non-response rate was slightly higheramong males, non-Spanish subjects, and those in the 4065age group.13

In conclusion, ours is the first study to use a nationallyrepresentative sample of the immigrant population in Spain.Immigrants display better lifestyle-related parameters, in thatthey consume less alcohol, smoke less, and do more physicalexercise than the autochthonous population. As for the useof health-care resources, while immigrants register higherpercentages of hospitalization than the autochthonous popula-tion, there is no evidence of excessive and inappropriate useof other health-care resources.

Accordingly, the health-related needs of immigrants arecomparable to those of the autochthonous population: whatcould generate inequalities, however, would be socio-cultural,language and economic differences.

Acknowledgement

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

The health of the immigrant population has becomea relevant topic from a public-health standpoint.

The immigrant population display better lifestyle-related parameters, in that they consume less alcoholand smoke less than their Spanish counterparts.

There is no evidence of excessive and inappropriateuse of other health-care resources for the immigrantpopulation.

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