Health effects of migration

Abstract

The proportion of citizens with an ethnic minority background in Denmark is rising and considerations about how to adapt health care services to the needs of this part of the population are becoming increasingly relevant. To do this, knowledge is needed about the factors influencing the health of these population groups. Migration is one of these factors.

The process of migration influences the somatic and mental health of migrants and is described in this article. Ethnicity, social position and aspects related to communication also influence migrants' health; however, we do not discuss these factors [1].

Definition

Migration is a process of social change during which a person moves from one cultural setting to another in order to settle for a longer period of time or permanently [2]. People may migrate from rural to urban areas, between neighbouring countries or over longer distances; migration therefore covers a broad variety of processes [3]. The migration process includes conditions in the country of origin, during the journey, and in the recipient country.

Migrants can be defined in various ways, e.g., as internally displaced, asylum seekers, refugees, or immigrants [4]. It is difficult to distinguish between forced and voluntary migration; the reasons for migration often include both elements [4, 5].

Reasons for migration can be divided into push factors (driving the individual out of the country of origin) and pull factors (attracting the individual towards the recipient country). Push factors include war, poverty, hunger etc., while pull factors include employment opportunities and political and religious freedom [1, 6]. These factors affect both the nature of the migration and the migrants' health [3]. There are large differences in both the reasons for migrating and the conditions related to the migration.

Migrants constitute a very diverse group with different ethnic and socioeconomic backgrounds and disease patterns in the countries of origin etc. Thus, migrants' health is influenced by a broad range of factors [2, 4-6].

Morbidity among migrants

Knowledge about the health status of migrants is often limited due to lack of data. This is because migrants are often excluded from surveys. There may be several reasons for this, including insufficient knowledge of the language, lack of professional interpreters, and greater costs when conducting surveys and interviews among migrants. In addition, there are difficulties in engaging migrants in these surveys. This may be due to the migrants' feelings of less trust and to their contact with the surrounding society and its institutions, with fewer and less positive experiences related to encounters with official institutions in the country of origin and the recipient country.

However, existing data show greater morbidity among migrants, especially concerning mental health problems, depression, post-traumatic stress syndrome, psychosomatic complaints and anxiety; certain chronic diseases, such as diabetes; and infectious diseases, such as tuberculosis and hepatitis B [3, 4, 6, 7]. There is a lack of consistency in the findings on migrant health. Some studies show that the morbidity patterns among migrants are not markedly different from the background population in the recipient country; other studies indicate a lower prevalence of certain diseases among migrants compared to the background populations in the recipient countries, e.g., depression [2, 3, 8].

Morbidity patterns among migrants will approach those among the background population in the recipient country in the course of time. Morbidity due to infectious diseases common among citizens in the countries of origin will decrease upon arrival in the recipient country. In contrast, negative as well as positive changes in migrants' exposure to risk factors for lifestyle related diseases will occur over a longer period of time [4]. For example, a study of changes after migration found an increase in cardiovascular morbidity among Japanese migrants to the US due to a gradual change of exposure to different risk factors [9].

How does migration influence morbidity?

The migration process may imply a number of stressors and strains that influence migrants' morbidity in several ways ( Figure 1 ).

Is it mainly the healthy people who migrate?

There is often a selection in the people who migrate, as migrants are often healthier and younger than the majority in their countries of origin [2-4]. This is called the healthy migrant effect . The effect may fade out over time because migrants are exposed to risk factors in the recipient country. However, some migrants, especially refugees, may migrate because of a need for protection or treatment. This is the case for many quota refugees selected from refugee camps who often have chronic diseases or disabilities.

Health risks during migration

Migrants may be exposed to health risks before, during and after leaving their countries of origin. Before and during the journey, migrants may experience wars, torture, imprisonment, loss of relatives, long stays in refugee camps, socioeconomic hardship etc. Some of the risks experienced after arriving in the recipient country include imprisonment, long-lasting asylum seeking processes, language barriers, lack of knowledge about health services in the new social context, discrimination and marginalization [10]. Additionally, long periods in refugee camps in the recipient country may cause existential insecurity, leading to stress reactions with negative health impacts [4]. These impacts may happen directly through a higher stress response resulting in, for example, higher blood pressure, or indirectly through unhealthy behaviours, e.g. drug abuse, lack of resources to prioritize disease preventing behaviour and to seek health care when needed, or poorer adherence to medical advice [1-4, 6].

Migrants often live in a social context where new social, political and language realities result in great demands on their coping skills and adaptability [2, 5]. Some of the difficulties faced by migrants are unemployment, discrimination, loss of social status and change of roles, e.g. within the family [1, 2]. The resulting stress response and health consequences are mediated by the migrant's social resources and depend on the magnitude of strains in the recipient country [3, 6]. Thus, the effect of the adaptation process on mental health in particular depends on e.g. social network, gender, age, language skills, educational level, religious beliefs, the reasons for migration and the reception upon arrival in the recipient country [3, 6].

Social network especially, may be of importance to migrants' mental health and health behaviour. Lack of social support, large geographic distances to members of the social network, and high expectations from relatives in the countries of origin are sometimes additional stressors leading to mental health problems and risky health behaviour among migrants [3]. Mental health problems and risk behaviour thus may be seen as a way to adapt to a new social context [2]. It is not only first generation migrants who face substantial demands on their coping capabilities; second generation migrants also experience stress due to the challenges they face when adapting to the surrounding society [3]

Migration may influence risk perceptions and risk behaviour

Migration may influence risk perceptions and risk behaviour in several ways. Firstly, losses related to e.g. socialisation, identity processes, and minority status may affect migrants' risk perception and thereby their health behaviour. This happens because migrants may react to the experienced losses by focusing on their past, i.e. turning their attention towards their past in their countries of origin, instead of focusing on the future. In addition, the many losses experienced during the migration process may lead to a feeling of lack of connection between current risk behaviour and future health effects. Furthermore, psychosocial issues related to lower social positions, unemployment and being a minority may lead to migrants having to cope with these acute issues rather than future health effects of current health behaviour. All this may have negative effects on migrants' health [1].

Conclusions and perspectives

Table 1 provides an overview of the key points of this article. Migration may have negative health consequences due to physical and psychosocial strains experienced by migrants throughout the entire migration process. These strains may lead to stress and risk behaviours having a negative effect on the migrant's somatic and mental health. The migrant's social resources, such as social network, may act as buffers in this process.

The health effects of migration make it relevant to consider how migrants' health can be improved. Fundamentally, there is a lack of knowledge regarding migrants' exposure to risk factors, morbidity, and psychosocial needs. A systematic survey of these factors could provide a basis for the design of more adequate health services. There is a need for both cross-sectional and cohort studies as well as intervention studies in order to discover the multiple influences of migration on health and the possibilities for designing and implementing effective health services for these population groups.

Migrants' health can probably be improved through a number of initiatives. Some of these deal with the reduction of structural and cultural barriers in the health systems. Access to health services should be improved, especially for vulnerable groups of migrants, such as refugees who have experienced multiple psychosocial stressors. On both national and local levels, disease prevention interventions should to a higher extent take into consideration the migrants' conditions, risk perceptions, and barriers and possibilities for healthy behaviours. Targeted interventions based on involvement of the target group - with special emphasis on special needs among vulnerable groups - should be implemented. Additionally, broader societal interventions, including recognition and inclusion of migrants, may improve psychosocial circumstances among migrants with positive health effects.

This article is based on a study first published in Ugeskr Læger 2006; 168: 3006-08.