HEALTH INEQUALITIES AMONG ELDERLY IMMIGRANTS IN EUROPE

HEALTH INEQUALITIES AMONG ELDERLY IMMIGRANTS IN EUROPE DONATELLA LANARI* and ODOARDO BUSSINI* *Department of Economics, Finance and Statistics, University of Perugia Address for correspondence: Donatella Lanari, Department of Economics, Finance and Statistics, University of Perugia, via Pascoli 20, 06123 Perugia, Italy. Tel: +39 075 5855939. E-mail: dlanari@stat.unipg.it. Sessione tematica: Lo stato di salute dei cittadini stranieri in Europa Area disciplinare: Demografia Abstract Background and Aims Over the past few decades, the combination of two processes – ‘demographic ageing’ and ‘international migration’ - have given rise to significant changes in the age and ethnic composition of national populations, causing an increase in middle-aged and older immigrants in Europe (Warnes et al. 2004). Because of the growing proportion of ageing immigrants in Europe, their ethnic diversity and different socio-economic background, immigrants' health may have an impact on national welfare systems in terms of increasing health care costs and social support. This is particularly true for older immigrants who, in contrast with the overall population of immigrants, are particularly at risk of health deterioration, since most changes in health occur in middle and old age. In light of the above, it is important for policy makers to know whether differences in health status between immigrant and non-immigrant populations – and also among immigrants – do exist, so that clearly defined policy measures can be adopted to improve their health. This paper examines aspects of the health and well-being of people aged 50 and older who are resident in Western and Northern European countries, focusing on those whose life circumstances have been strongly influenced by international migration. We define immigrants as people born in a country different from that of their residence, who may have acquired citizenship in the new host country. We thus attempt to ascertain the existence of differences in self-perceived health and depression between native-born and immigrant people by examining the effect of country of origin, length of time in the host country and citizenship on the perceived health of adults in each country investigated. Some studies have shown that immigrants and minority groups in later life tend to have a lower health status than the majority population. However, the link between migration and health is highly complex: it operates in both directions and is mediated by many interacting factors. The selective role of migration towards healthier immigrants (the ‘healthy immigrant effect’) is now an accepted phenomenon (Kennedy, McDonald and Biddle 2006), although many studies have also emphasised the fact that immigrants may lose this initial health advantage over time. The adoption of new health behaviours and health-related norms (acculturation) in the host country has also been speculated to play a substantial role in worsening health (Pérez 2002). Measures and method This study is based on data obtained from the first wave of SHARE collected in 2004/2005; we used the third release (SHARE 2.3.0) which also contains information on birthplace, and were thus able to test the different impact of country of origin on health inequalities. Eight European countries were examined in the analysis taken from the dataset: Austria, Belgium, Denmark, France, Germany, Sweden, Switzerland and The Netherlands, which became the most important European receiving countries after the Second World War. SHARE is a multidisciplinary and cross-national panel database of micro-data, providing information on health, socio-economic status, and social and family networks of individuals aged 50 and over. Binary logistic regression models are used for estimating effects on the health status of ‘being an immigrant’, as opposed to ‘being a native’. In particular, we examine the effect of country of origin, length of time in the host country and citizenship on the health of adults. Because of the age structure of the population, small percentages of foreign-born people suffered from disabilities (ADL and IADL) and we therefore decided to focus exclusively on variations of the following two indicators of health problems: self-perceived health and depressive symptoms. Since evidence suggests that a poor health response category is highly correlated with mortality, self-perceived health, assessed in all countries on a 5-point scale ranging from ‘very good’ to ‘very bad’, was then collapsed into two groups: ‘positive’ (good, very good) and ‘negative’ health perception (less than good). Each of the health indicators was coded as a dichotomous variable, 0 for positive self-perceived health and 1 for negative (or poorer) health perception. Depression was measured by the self-report of a diagnosis, and individuals were asked to indicate whether they were suffering from any of the following symptoms: sad or depressed mood, lack of concentration, sleeping disorder, fatigue, no energy, no appetite, thoughts of suicide. Individuals’ answers were recoded according to the EURO-D scale, and then summarised in two categories: three or more symptoms (modality 1) and less than three (modality 0). The main explicative variable is the immigration status of the person, and a set of demographic and socio-economic variables was also included, in order to test the robustness of our estimations. In analysing immigrant health profiles, we allow for differences across immigrants from different countries of birth and with different lengths of immigration, since many research papers have reported that health differences between natives and immigrants are strongly influenced in a complex way by country of origin and destination of migrants (Sundquist and Li 2006). In order to estimate accurately the effects of both origin and destination countries, some interaction variables between immigrants’ countries of origin and residence were created, since individuals are nested in both. The role of immigration was also analysed by considering the intersection between duration of immigration and citizenship status, to account for heterogeneous (time-dependent) differences among health issues. Due to the large heterogeneity of immigrants, we subdivided our sample into seven immigrant groups, according to cultural affinities, geographic vicinity and statistical consistence, with native-born people serving as the reference. Because most immigrants aged 50+ were from Europe, we distinguished those born in Western, Northern, Eastern and Southern Europe. The other three categories were immigrants from Asia, Africa and Americas/Oceania. In analysing the effect of country of origin on health disparities, the choice to model health differences of foreign-born within European countries by the country-specific interaction variables is largely justified by the heterogeneous migration history of European countries. We also included an interaction variable which considered both citizenship status in the country of residence, and length of time in the host country since immigration (less than 10 years, 10-20 years, 20-30 years, 30-50 years, more than 50 years). Results As the logistic regressions reveal, some immigrant groups are more likely to perceive worse self-rated health and to suffer from depression than native-born groups, even when demographic and socio-economic variables are taken into account. We found that the fact of being born and living in a specific country, in addition to duration of residence and citizenship, determines an increased risk for health status in specific immigrant groups. In particular, people born in Eastern Europe living in Germany, France and Sweden have the highest ORs of poor health with respect to natives, even after controlling for socioeconomic status, which is in line with several studies (Ronellenfitsch and Razum 2004; Vaillant and Wolff 2010; Pudaric et al. 2003). One plausible explanation is that the Eastern European immigrant population was made up of a large number of refugees, asylum-seekers and displaced persons, for whom migration was accomplished in highly adverse conditions, associated with traumatic experiences. This finding may reflect their unfavourable health conditions before leaving their countries of origin, and the high prevalence of risk factors to which these immigrants were exposed in Eastern Europe (Ronellenfitsch and Razum 2004). In France, immigrants born in Southern Europe and Africa seem to encounter more health problems than the native-born, in terms of self-perceived health, although these differences declined when SES were included in the model. As in other studies which have shown that foreign-born people in Sweden rate poor health with respect to natives, we found that immigrants from Northern Europe – most of them Finnish – have significantly higher ORs than natives (Pudaric et al. 2003; Sundquist and Johansson 1997). Matching results in the international literature, Asian immigrants – mostly from former colonies – living in The Netherlands reported the worst health situation (Uniken Venema et al. 1995), followed by Africans, who reported worse health with respect to natives. Almost the same pattern was found for depressive symptoms. Even after controlling for differences in socioeconomic status, we still found significant differences in reporting depressive symptoms for some immigrant groups with respect to natives. For instance, the higher risks of depression for Eastern and Western people and African immigrants in France could not be explained by the socio-economic factors in the models. In addition, Eastern European people living in Sweden, and African and Asian immigrants living in The Netherlands still had higher risks of depressive symptoms than natives. It is a fact that, from the moment when young immigrants arrive in their country of destination, they undergo a process of acculturation in a new society and are obliged to adapt to living in a new cultural context, which sometimes disrupts their social, cultural and economic connections with their country of origin. Although immigrants are a heterogeneous group, they may have undergone disadvantaged conditions throughout their lives, due to their ‘otherness’ by living in a foreign country, as regards differences in culture, traditions and health beliefs, as well as socio-economic factors. In this sense, their nativity status may be considered a risk factor for poor health. In addition, the past life histories of many migrants may have been characterised by economic difficulties, poverty, discrimination and war, all representing stress factors undermining physical and emotional health. The picture emerging from this study, which shows that immigrants born in Eastern Europe had the highest ORs of poor health and depression, confirms the above description. Lastly, we found that respondents immigrating after the 1970s (time of immigration between 10-30 years) had a greater risk of being in poor health and depression with respect to the native-born. The disadvantaged condition is explained by the fact that immigrants who arrived in the host country 10-30 years ago - that is, from 1974 to 1994 - faced a period characterised by restrictions on immigration imposed by the host government after the energy crisis. Immigrants may have found restricted opportunities because of the sudden halt in recruitment of foreign labour on the part of Western European governments after the recession following the 1973 oil price shock. We also found that immigrants, mostly labour migrants, who made up the mass-migration flows from the 1950s to the 1970s (length of immigration 30-50 years) were also likely to have poorer health than native-born. This group of immigrants, who have now reached old age, arrived and settled in the host country after the Second World War, when the most industrialised countries in Western and Northern Europe welcomed labour migrants who were recruited by local enterprises. According to our model, worse health outcomes for labour migrants are due to the fact that ‘this group includes some of the most disadvantaged and socially excluded of Western Europe’s older people’ (Warnes and Williams 2006). Conclusions and discussion This paper highlights the ‘health vulnerability’ of immigrants aged 50 and over living in Northern and Western Europe suggesting the need for a mix of policy interventions. Since health inequalities may partly be attributed to socio-economic factors, public programmes aimed at reducing health inequalities should aim at compensating for differences among groups in situations such as education, employment, healthcare provision, etc. However, our results indicate that the poorer health status of some immigrant groups is associated with being a foreign-born person, so that culturally based constraints may arise, and efforts simply to expand the availability of health services or gains in socio-economic level may produce little in reducing health inequalities. The situation is further aggravated by the fact that immigrants often find it difficult to receive social protection services because of a lack of information regarding how the host country’s administrative procedures actually function, together with difficulty in providing proof of past employment, denial of pension rights, or problems in transferring their pension and social security rights to their country of origin. Therefore, solutions such as increasing and targeting social services and provision of health care to the more disadvantaged groups of immigrants should be implemented. Bibliography Kennedy, S., McDonald, J. T. and Biddle, N. 2006. The healthy immigrant effect and immigrant selection: evidence from four countries. Social and economic dimension of an aging population (SEDAP) Research Paper No. 164. Pérez, C. E. 2002. Health status and health behaviour among immigrants. Health Reports, 13 (Suppl.), 89-100. Pudaric, S., Sundquist, J. and Johansson S-E. 2003. 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