1 Understanding the Health Profile of ImmigrantsJeff Dennis, Ph.D. Research Assistant Professor Department of Internal Medicine, TTUHSC
2 Objectives Define “migration” and describe population of international migrants Discuss U.S. Immigrant Health Hispanic/Latino health (Hispanic Paradox) Health Care policy Health care access I have no financial disclosures relating to this presentation
3 Defining key terms Today’s presentation will focus on one specific type of migration – international migration International migration: typically defined as a person moving to another country for at least one year (source) Generally excludes tourists, short term workers Different definitions may exclude involuntary migration Internal migration: moves within states and/or countries are meaningful, yet outside the scope of today’s talk
4 International MigrationThe United Nations estimates about 232 million people worldwide reside somewhere other than the country where they were born (source) Capturing implications for health are too broad for a single hour talk. These immigrants include: Skilled & unskilled Documented & undocumented Refugees & asylum seekers
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6 Migrant health worldwideUnited Kingdom Lower mortality for migrant groups, particularly those maintaining more traditional lifestyles Asylum seeking immigrants – higher prevalence of infectious disease, untreated mental illness Australia – 24% immigrant population Larger immigrant groups – Chinese, Italians, Greeks – have lower mortality than Australian population Maintenance of traditional Mediterranean diet and strong social networks identified as one protective factor for Italians & Greeks Health advantages of migrants seem to wane with time Despite mostly favorable outcomes, migrants have higher rates of diabetes (Source 1, 2, 3)
7 Migrant health worldwideSouth Africa major economic migration point for southern Africa Occupational hazards Double the HIV prevalence among migrant workers Economic insecurity of female migrants contributes to HIV vulnerability Limited opportunities and disempowerment of women may contribute to increased use of transactional sex for economic survival (Source 1, 2)
8 U.S. Immigrant PopulationAbout 40 million foreign-born individuals living in the U.S. in 2010 Approximately 13% of the total U.S. population (up from <5% in 1970) To contrast, 8.4% of U.S. adults in 2012 had a parent born outside of the country Estimates suggest about 11.5 million undocumented High School graduation rates: African & Asian immigrants – 87% Mexico & Central American immigrants – 38% (Census; Derose et al. 2007; Pew Research Center; Wallace et al ; Washington Post)
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10 Arias 2010
11 Life Expectancy, (Singh & Miller 2004)
12 Healthy Migrant EffectMigration occurs disproportionately for economic reasons As such, most research finds or hypothesizes a health “selection” effect That is, individuals who migrate are, on average, healthier compared to the population of the sending country Particularly for low skill migrants, risks and physical hardships of migration are substantial (Source 1)
13 The Hispanic Paradox A large body of research over the past 30 years has noted consistently favorable health outcomes among individuals of Hispanic or Latino descent Recent figures suggest life expectancy of Hispanics is higher than both whites and African Americans in the U.S. The “paradox” is that Hispanic socioeconomic status more resembles African Americans, yet their health profile more resembles whites That is, in the U.S. socioeconomic status strongly correlates with health & life expectancy, yet this is seemingly a contradiction
14 Explaining the ParadoxData artifacts – recorded as Hispanic in Census, but death record identifies as Caucasian (would undercount Hispanic, overcount white mortality rates) “Salmon” bias – Hispanic individuals counted in Census, but return home in retirement/illness, so mortality rate is an undercount Cultural benefits – traditional diet may be lower in saturated fats, higher social support via familial norms (source)
15 Paradox lost over time? Acculturation – the process of immigrants adopting the culture of their receiving country Benefits: adoption of receiving country language removes barriers to communication with health providers Citizenship/legal status afford more rights to public health services or government insurance Detriments: Evidence suggests that, nonetheless, the typically exceptional health of immigrants regresses to the mean over time. Adoption of diet, sedentary lifestyle, may have long term impact on health
16 Health Care Policy & ImmigrationLegal immigrants generally must have 5 years residence in the U.S. to be eligible for Medicare or Medicaid Estimates vary, but generally accepted that immigrant population contributes more to Medicare than they receive – as much as $3.5 billion/year In most of the U.S., undocumented immigrants are eligible only for emergency medical services This form of treatment is typically more expensive, intended to require Emergency Dept. to ensure patient is stable Not eligible to buy insurance through health insurance exchanges Among highest cost may be those requiring emergency care for chronic conditions, such as dialysis Texas Medical Association estimates emergent dialysis to be 3.7 times more expensive, costing about $10 million yearly for an estimated 1,000 individuals requiring emergent dialysis (Kuruvilla & Raghavan 2014; Zallman et al. 2015)
17 Use of health care servicesData on ultimate costs to health care system are difficult to obtain, as citizenship not frequently recorded Often may be recorded in broader category of “uncompensated care” Estimates differ substantially: from $1.1 billion nationally to $1.3 billion for Texas alone About 60% of undocumented immigrants use health care in a given year Compared to 87% of US natives Use Emergency Services 2.5 times less; twice as likely to be uncompensated care Los Angeles area study Undocumented immigrants comprised 12% of population, accounted for about 6% of health care costs (Stimpson et al. 2013; Wallace et al. 2012)
18 Per Capita Annual Health Care Spending Of Respondents To The Medical Expenditure Panel Survey, 2000–09, By Care Setting And Nativity And Legal Status. Per Capita Annual Health Care Spending Of Respondents To The Medical Expenditure Panel Survey, 2000–09, By Care Setting And Nativity And Legal Status Jim P. Stimpson et al. Health Aff 2013;32: ©2013 by Project HOPE - The People-to-People Health Foundation, Inc.
19 Health care experience“Language brokering” Use of children as language interpreters between non-English speaking patient and health care provider Even when child is U.S.-born and fluent in both languages, research reports barriers in communicating specifics in regard to medical terminology Challenges also emerge with highly sensitive information, including privacy issues for parent However, may feel more comfortable using child as translator than (non-clinical) office support staff In a small sample of 5th and 6th grade children of non-English speaking parents 40% reported having translated for a parent at the doctor’s office (Katz 2014; Orellana, Dorner, & Pulido 2003)
20 Language brokering For providers, challenge in balancing how toaddress child vs. parent Must recognize not only cultural norms for provider-patient interaction, but also be cognizant of cultural Norms relating to respect andappropriateness between child-parent Katz 2014) Image source
21 Refugee health Primary focus on public health issuesVaries widely, circumstances may change rapidly E.g., Syria, in about 5 years time, went from a major receiving country to a major sending country Very difficult to obtain good data Hard to examine life expectancy and chronic disease in the midst of conflict More importantly, war/conflict damages medical and public health infrastructure Primary focus on public health issues Access to water, food, sanitation, health care services Further, impact and/or pressures on health care system of receiving country
22 Refugee health Among the largest refugee streams is Afghan refugees to Pakistan, stretching back to conflict beginning in 1979 About 1.5 million Afghans are registered as refugees in Pakistan Reproductive health is severely lacking Less than half of Afghan refugee women had a trained attendant at birth Further, polio vaccinations are a major focus in this area, as Afghanistan and Pakistan have about 20% of remaining polio cases in the world Refugee settlements are at particular risk given poor basic public health services Sources: 1, 2
23 Summary thoughts Economic migrants populations, on average, are healthy for reasons of selectivity Immigrants use less health than native born persons More likely to use uncompensated care More likely to have language barriers impacting health care quality
24 Thank you! Questions/Comments?
25 David RJ, Collins JW Jr. N Engl J Med 1997;337:1209-1214.Distribution of Birth Weights among Infants of U.S.-Born White and Black Women and African-Born Black Women in Illinois, 1980–1995. Figure 1. Distribution of Birth Weights among Infants of U.S.-Born White and Black Women and African-Born Black Women in Illinois, 1980–1995. The calculation of frequencies was based on all singleton births in Illinois. The study population included the infants of 3135 black women born in sub-Saharan Africa, 43,322 black women born in the United States (a sample that included 7.5 percent of the total number of black women giving birth in Illinois), and 44,046 U.S.-born white women (2.5 percent of the total number of white women giving birth in Illinois). David RJ, Collins JW Jr. N Engl J Med 1997;337:
26 Life Expectancy, (Singh & Miller 2004)