2. State of health of migrants and minorities

From Switzerland Wiki

The health of the migrant population in Switzerland has become, especially since the 1990s, a research subject and a source of concern. However, the data sources offering detailed information on this issue are rare (for a state of the art see Chimienti et al. 2001; Weiss 2002; FOPH 2007). In order to fulfil this gap several qualitative and quantitative research projects have been carried out in the framework of the “Migration and Public Health Strategy 2002-2006”, which was adopted by the Federal Council in July 2002. One of the axes of this strategy is the research and monitoring within the field of migration (for the results of these different projects see FOPH 2006). The monitoring of the migrant population’s state of health in Switzerland (GMM) particularly targets populations who are under-represented in statistical sources and large researches (see Gabadinho 2007). This monitoring is based on a total sample of 19,797 persons of ten different backgrounds (Swiss, Italian, German, Austrian, French, Ex-Yugoslavian, Portuguese, Turkish, Sri Lankan and Kosovan). Notably absent are data for people from Asia, Africa and Latin America.

In brief, the different surveys on migrants’ health pointed out the following results :

• Migrants’ mental health is often worse than that of the Swiss.
• Certain groups of migrants encounter a higher prevalence of HIV/Aids, Tuberculosis, Hepatitis, Malaria and Sexually-transmitted diseases than the Swiss.
• Miscarriage, a lack of contraception during intercourse and female genital mutilation are more frequent among migrants than among the Swiss.
• Young migrants have inferior dental health.
• Certain groups of migrants are more likely than the average member of the population to have cancer (stomach cancer of Southern European migrants, rhinopharynx cancer of Chinese and liver cancer of Africans and Asians).
• Certain groups of migrants display a more risky attitude regarding tobacco consumption, their food and lack of exercise.

Let us now observe these results in detail, highlighting the indicators of variation and the differences among groups.

Contents 1 State of Health – general indicators of variation 2 Subjective health 3 Infectious disease 4 Mortality 5 Reproductive health 6 Occupational accident 7 Long-Term functional incapacity personally reported by the persons affected 8 Handicap reducing the professional or daily activities of persons 9 Health behaviour 10 References

State of Health – general indicators of variation

(based on Gabadinho 2007: pages 60-64 media:report.pdf

• Increasing risk for both sexes according to age regarding self-reported health, disability, long-term functional and physical disorders. The situation is more uniform regarding the psychical (stet) balance.
• The socio-economic situation also appears as a variable, particularly important with a systematic improvement of health when the social stratification is higher.
• The presence of a child under 15 years of age in the household is also associated with a systematic decreasing risk, except for the psychical (stet) balance. This can be linked to several factors, including the effect of selection, since men and women with a child under the age of 15 tend to be relatively young and healthy.
• The role of marital status is more diffuse, but the authors note that being married improves the emotional balance for both men and women, while the fact of being separated or divorced has a negative effect on health.
• Finally, even when the above factors are taking into account and equalised, nationality remains a significant marker of health status. Among the Italians in Switzerland, only the women present differences as compared with the Swiss, regarding the self-reported health and psychical balance, which is more often poor, as well as more frequent physical disorders.

For citizens and nationals of the former Yugoslavia and more so for those of Turkey, the situation is unfavourable for all indicators in comparison with the Swiss but also with other nationalities. This is also the case for Kosovan asylum-seekers and to a lesser extent, for Tamil. The probability of presenting poor self-reported health and emotional balance also increases for Portuguese women and men in comparison with their Swiss counterparts. However, the profile of female and male Sri Lankans is positive for all indicators and is even better than that of the Swiss, regarding functional disability, long-term physical disorders (men only) and handicaps limiting the exercise of professional or everyday activities (women only). The model taking into account only foreigners shows that the Sri Lankans have a better situation than the ex -Yugoslavs for all of the indicators, while on the contrary, the Turkish women encounter higher systematic risk. In addition, the Kosovan and Tamil asylum-seekers often face a poorer mental balance than the other groups. However, when the Tamil asylum-seekers (female and male) are compared solely to the former Yugoslavian asylum-seekers, rather than to the Swiss, they show a lower percentage of risk concerning all issues.

• Several indicators of integration also have an impact on health status. Arriving in Switzerland aged over 14 years old is associated with a worse subjective state of health (for women) and emotional balance (for women and men) than for the Swiss, as well as more frequent physical disorders (women).
• Not knowing one of the national languages of Switzerland represents an increased risk, which could also be related to the socio-economic status or the arrival in Switzerland. The victims of political repression or violence in the country of origin, both men and women, encounter worse mental health, whilst those facing discrimination in Switzerland present an increased risk for most indicators.

In brief, nationality remains an important factor in attempting to explain the variation in health status, even after taking account of important variables such as age, socio-economic level, the situation of life or region of residence. The authors ‘highlight the fact that the information used in this research report is from declarations of respondents themselves, possible variations in cultural perception of the symptoms and the disease cannot be excluded. However, many studies have shown that the condition of self-rated health is a reliable indicator for morbidity or mortality risk.

Subjective health

• The results of the last two Swiss health surveys (Vranjes et al. 1996; Abelin 2001) showed that immigrants’ (Italians’) subjective well-being is worse than the subjective well-being of autochthones and that they often encounter an episode of illness.

• The recent monitoring on health of migrants (Gabadinho et al. 2007]) gives more information on specific groups not targeted in the former health surveys. It shows that migrants judge their state of health as markedly worse than the native Swiss population does. Female immigrants, in particular, feel far more ill than Swiss women. The percentage of Swiss or foreign people interviewed, having indicated bad or very bad subjective health, is 2% among men and 3% among women. The repartition is different according to the nationalities but with the same structure of age showing a stronger proportion of people feeling bad among foreigners than among Swiss, both for male and female: 2.1% of Swiss men declared feeling bad or very bad, compared with 14% of Turks or 16.5% of former-Yugoslavians, and even about 20% of Kosovan asylum-seekers.

• Most of the studies on immigrants’ mental health are focused on asylum-seekers. The authors assume that, because of difficulties experienced in the country of origin and during migration, people with an asylum background encounter more psychological disturbances. An empirical survey showed that 25% of the refugees living in Switzerland have been tortured (Wicker, 1993), while another described the mental consequences particularly problematic for them (Wicker, 1993; Moser et al. 2001).

• Other studies deal with the difficulty of screening psychological disturbances. The study of Gilgen et al. (2003) in the framework of the PNR 39 with a sample of 146 patients (where 36 were refugees from Bosnia, 62 immigrant workers from Turkey and 48 Swiss ‘intern migrants’) found that 41% did not mention their most important problem spontaneously. They declared a somatic problem first, whilst they, in fact, were suffering from psychological disturbances.

Infectious disease

• Different studies have noted a higher prevalence of Tuberculosis among asylum seekers and refugee groups (Zelwegger et al. 1993; Loutan et al. 1994; Bischoff et al. 1997).

• Although the prevalence of HIV-infected immigrants is similar to autochthonous rates overall, some important differences exist between countries of origin. There is a higher prevalence among those hailing from African countries, mostly of asylum background, than others (Wanner et al. 2000; Zuppinger et al. 2000).

• Other infectious diseases, such as Hepatitis B, Malaria and intestinal parasites are more often diagnosed in asylum-seekers from Asia and Africa (Loutan et al. 1994).

• Number of studies concerning infectious diseases have highlighted significant differences. Diabetes, inflammatory and allergy problems (Loutan et al. 1994) and stomach cancer (Wanner et al. 2000) are diseases diagnosed more often among immigrant than autochthonous groups. The causes of these diseases are often linked to risky health-related behaviour (see below), such as unhealthy nutritional habits, tobacco and alcohol consumption as well as lack of exercise (Wanner et al. 1996).

Mortality

• Although mortality is a common indicator in monitoring the state of a population’s health, few studies have used this indicator in order to compare the health of immigrants and autochthones. The scarce research that does exist on this topic is based on statistical causes of death and national census data. That which has been done has observed that Southern European immigrants are characterised by lower mortality rates in terms of cardio-vascular problems and lung and colon cancers and higher mortality rates in terms of stomach cancer (Wanner et al. 2000; Wanner 2001). However, the authors stress that mortality is not a good indicator as most diseases diagnosed among immigrant groups are not lethal. Furthermore, immigrants who suffer from a potentially fatal disease generally tend to return to their country of origin prior to death (return bias).

• The results of infant mortality are clearer and contain less bias. Ackerman-Liebrich (1990; 1998) and Lehman et al. (1990) showed that immigrant women, when compared to their autochthonous counterparts, encounter a higher risk of premature birth, which is often caused by heavy working conditions and a lack of follow-up health care during the pregnancy. Infant mortality is also higher among those of foreign mothers, especially those from the former Yugoslavia and from Turkey that recently arrived in Switzerland (Wanner, 1996).

Reproductive health

(based on Bollini, Wanner et al. 2006 media:report06.pdf).

• The study carried out by Bollini, Wanner et al. combines three types of analysis (2006: 9-10): 1) an exhaustive review of quantitative studies on the pregnancy outcome of immigrant and native women in European receiving countries; 2) an analysis of pregnancy data in Switzerland, from 1972 to 2001; 3) a qualitative study exploring the interaction between immigrant women and the health care system around reproductive health issues in Switzerland.

• The analysis of Swiss data focuses on results of low birth weight, stillbirth, infant mortality, neo-natal and post neonatal mortality data for all deliveries, which took place in Switzerland from 1972 to 2001, by nationality. The results showed that all the indicators of pregnancy outcome have improved over the last 30 years in Switzerland. However, for some groups like Turks, Sri-Lankans and Africans the improvement was less important, and a sizeable gap in comparison with Swiss nationals remained. The authors highlight that merging was only possible for the period 1987-1996. Furthermore, no adjustment for social class or parents’ education was possible with the available data.

• There is little reliable data on the sexuality of migrants (Rommel et al. 2006). It is known, however, that deficient contraception is responsible for a higher number of abortions and unwanted pregnancies among foreign women (Addor et al. 2003; Bollini / Wanner 2005; Wolff et al. 2005). Termination of pregnancy is almost three times more prevalent among foreigners than among Swiss citizens.

• Centres of Planned Parenthood attribute the reasons for a large number of unwanted pregnancies to the precarious status of stay (Sieber 2001). As a cause of failed contraception, there are financial difficulties, prejudice against the contraceptive pill or psychological pressure related to the status of residence or exercised by the partner (OFSP 2006a; Wolff et al. 2005).

• Foreign sex workers, especially women from Sub-Saharan Africa, are much more vulnerable to HIV and AIDS. Another typical problem for migrant women from some regions is excision, abbreviated to FGM (Female Genital Mutilation). Most circumcised women and girls at risk of being so come from Somalia, Ethiopia and Eritrea. In this context, migrants from sub-Saharan Africa are considered in Switzerland to be the most vulnerable. The number of women affected by this practice in Switzerland has been estimated at approximately 6,700 cases in the year 2001 (UNICEF 2005).

Occupational accident

• Although many studies agree that immigrants are often involved in low-skilled work that entails health risks, little research has analysed the occupational accidents of immigrants as compared to autochthones. Egger et al. (1990) showed that this rate is significantly higher among immigrant than autochthonous groups. Using the results of several European studies, Bollini and Siem (1995) concluded that the duration of stay leads to health degradation among some immigrant groups because of their poor living and working conditions, which they termed the ‘exhausted migrant effect’.

Long-Term functional incapacity personally reported by the persons affected

(based on Gabadinho 2007: 53-55 media:report.pdf))

• Portuguese inhabitants in Switzerland reported a higher long-term incapacity in comparison with Swiss inhabitants: 22% (men) and 28% (women) versus 14% and 17% respectively for Swiss men and women, of equivalent age groups. This difference is no longer significant after taking into account other variable of influence. The authors deduce that this gap is primarily due to differences in socio-economic profile and most likely in the type of work involved (57% and 63% respectively of Portuguese men and women belong to the lower socio-economic strata, against 12% and 21% respectively of Swiss men and women).

• After having a controlled age and socio-economic position, Sri Lankan (asylum-seekers and stable residents) declare a lower functional disability compared to ex-Yugoslavian (OR between 0.20 and 0.31). In contrast, Turkish women encounter such an incapacity more often.

Handicap reducing the professional or daily activities of persons

(based on Gabadinho 2007: 59-60 media:report.pdf)

• The frequency of disability among the Swiss and the different migrant groups in Switzerland is 4% for both sexes. About 3% of Swiss men and 4% of Swiss women are affected by such a handicap, but the proportion is higher for Italian men and women (7% and 8%, respectively) and more than twice (at least 10%) for ex-Yugoslavian, Portuguese and Turks as well as for asylum-seekers from Kosovo, both men and women. The variation related to age is also important.

• Once factors such as age, socio-economic situation and having a child under 15 years of age are taken into consideration, nationality still has a significant effect regarding the variation on handicaps. For ex-Yugoslavian and Turkish men and women, as well as for Kosovan asylum seekers, the reported risk is higher.

Health behaviour

• Certain groups of migrants, and especially the young, are showing a more risky behaviour by smoking more, by failing to maintain their physical fitness and by ignoring a balanced diet (Ferron et al. 1997).

• Tobacco consumption is more prevalent among certain groups of migrants than within the Swiss population. The percentage of smokers is higher among Turks, whilst it is very low among Sri Lankans, living in Switzerland (Rommel et al. 2006). In all groups, men smoke more than women (SFO 2004b).

• Foreigners, all nationalities merged are much less likely to consume alcohol more frequently than the Swiss. Again, in all groups, men are less abstinent than women. Regarding alcohol-related problems, no significant difference is noticed between the different groups of migrants (Weiss 2003). However, the mortality rate from diseases related to alcohol consumption is higher in those from Eastern Europe (Wanner et al. 2000).

• Compared to the Swiss, certain groups of migrants (Turkish women and Kosovan asylum-seekers) use drugs more frequently, mainly painkillers and sedatives administered by medical prescription (Rommel et al. 2006).

According to the Swiss survey on health, young foreign men consume more addictive substances (tobacco, cocaine, heroin) than young Swiss men. There is no difference in this respect between foreign and Swiss young women (Gmel / Müller 2001). The reliability of data regarding drug use is questionable, as it is very difficult to obtain reliable data regarding illegal practices that are carried out by persons in precarious residency status (Rommel et al. 2006).

• With the exception of those from Austria, France and Germany, migrants from other origins do not play sport as much as the Swiss (Rommel et al. 2006). It is important to point out that the migrants of this group are more often employed in physical occupations (SFO 2004).

• Different trends tend to emerge from the data related to food. On the one hand, a lower mortality caused by cardiovascular diseases is recorded among migrants, which could be related to healthier eating habits (Wanner et al. 2000). Among certain groups of migrants these habits change so that they are likely to face serious health problems (Kruseman 2005). However, the percentage of migrants suffering from overweight or obesity is higher than among the Swiss. School-aged children and 51 to 60 year-old migrants are particularly affected by obesity (Oehling et al 2005, Rommel et al. 2006).

There is little reliable data on the sexuality of migrants (Rommel et al. 2006). It is known, however, that contraception is deficient and responsible for a high number of abortions and unwanted pregnancies among foreign women (Addor Et al. 2003; Bollini / Wanner 2005; Wolff et al. 2005). Terminations are almost three times more prevalent among foreigners compared to Swiss citizens. Centres for Planned Parenthood reported the precarious status of stay as the reason for a large number of unwanted pregnancies (Sieber 2001). Health care consumption

• Although migrants reported a worse state of well-being than the Swiss, the differences regarding the use of health services does not show greater differences among migrants than among the Swiss (Rommel et al. 2006). The foreign population, however, consults more GPs than medical specialists, and does so more often for a disease or an accident rather than for a preventive examination (Vranjes et al. 1996; Calmonte et al. 2000). Turks and Sri-Lankan asylum-seekers use health services a little more than the Swiss, while people from former Yugoslavia use them less (Rommel Et al. 2006).

• Compared to the Swiss, the Portuguese, Austrian, French and German migrants use the services of gynaecologists more, whilst Tamil and Kosovan women are less likely to consult a specialist. Female and middle-aged migrants tend to make greater use of medical services than the Swiss (Rommel Et al. 2006).

• Migrants, especially Portuguese and Turks, as well as asylum-seekers, more often make use of treatment provided by hospitals as outpatients. (Santos-Eggimann 2002). The Swiss, as well as Italian, Austrian, German and French migrants are hospitalized longer on average than other nationalities.

• Foreigners in Switzerland use less psychiatric hospital treatments. Rather than use psychological or psychiatric care services, they use clinical or social services (Frick et al. 2005; Zemp 2001). Foreigners, however, do use more mental health outpatient services than the Swiss.

• Enforced admission to psychiatric services occurs more often to migrants than to the Swiss (on the order of a judge or a health authority). They are sent there more often in an emergency but are hospitalized for less time (Frick et al. 2005).

• The use of preventive examinations varies greatly depending on the type of examination (Rommel et al. 2006). The survey on the health of migrants shows that the frequency of medical checks for prevention of cancer (prostate, cervical smears, breast examinations) is relatively low among Sri Lankan and the former Yugoslavian migrants. It is known, however, that women with higher education are more often the subject of mammograms. In general, female foreigner workers were fewer than Swiss to indicate that they had received advice from their gynaecologist or other health professional on breast cancer screening. This indicator shows that the ability to practise self-examination with regard to breast care is far less developed among migrant women (Rommel et al. 2006). As for HIV testing, all groups of migrants have lower rates than the Swiss. Tamil, former-Yugoslavian and Turkish migrants have the lowest rate of HIV testing. Finally, vaccination coverage is mediocre amongst migrants (Weiss 2003). However, the rate of vaccination amongst young foreign children is higher than that of young Swiss children (ISPM 2005). In general, migrants benefit from prevention (Vranjes et al. 1995). Their rates of peri-natal morbidity and mortality is higher, whilst their rate of immunization is weaker and their recourse to preventive medicine less frequent. These results seem to indicate that the migrants have less access to the health system (Weiss 2003).

• Testa et al. (2003), analysing the data of psychiatric consultations in a Tessin hospital within the framework of the PNR 39, found that the percentage of asylum-seekers consulting ambulatory psychiatric services is 40% higher than that of Italians. Other studies found similar rates of psychiatric consultations for asylum-seekers in other regions (Wicker et al. 1999). This means that asylum-seekers have not only replaced labour immigrants in the labour market but also that they have re-produced the same psychological disturbances (Wicker 2003).

• The difficulty in rapidly screening for mental disturbances is problematic as an important number of refugees who have experienced traumatic events suffer from psychological disorders (Subilia, 1995; Wicker, 1993). The long term consequences and the lack of immediate treatment of these disturbances are still unknown because of the lack of cohort studies.

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