Bodø 10.09.2019 Samera Azeem Qureshi MD, PhD Migrasjonshelse, FHI, Content of Presentation

• What is

• Process of migration & Immigration to

• Integration

• Migration & Health , Health of immigrants in Norway

• Cancer Project

• Conclusions Immigration

According to the Wikipedia

“Immigration is the international movement of people into a destination country of which they are not natives or where they do not possess citizenship in order to settle or reside there, especially as permanent residents or become citizens, or to take up employment as a migrant worker or temporarily as a foreign worker” Global Migration

According to , the

• All-time high, estimated 244 million international migrants in 2015

• Main reasons Economic, political and social conflicts

• Immigration to the has increased considerably over the last decades Migration Process

Can be divided into three phases:

• Pre-migration

• Migration

• Post-migration Migration Process

• Pre migration conditions:

✓ Socio-cultural and political issues

✓ Oppression, militarization, war violence, torture, imprisonment with out trial

✓ Harrasment by authorities, disappearance of close family members, living in hiding Migration Process

• Migration

✓ Dangerous journey: imprisoment, abuse, rape, lost or kidnap; witnessing death or murder,

✓ Serious injury, lack of shelter, overcrowding, poor hygiene, poor medical care

✓ Disrupted education (children) lost or interrupted careers (adults) Migration Process

• Post migration ✓ Trauma ✓ Challenges of acculturation → identity problems ✓ Lack of social support, language problems ✓ Insecure residency status ✓ Stigma, discrimination Results of Migration

POSITIVE

• It gives rise to MULTI-CULTURAL societies

• Research suggests that migration is economically BENEFICIAL both to the RECEIVING and SENDING countries

• Development economists argue that REDUCING BARRIERS to labor mobility between developing countries and developed countries would be one of the MOST EFFICIENT TOOLS of POVERTY REDUCTION di Giovanni, Julian 2015; Andreas, Willenbockel,Dirk 2016 Results of Migration

NEGATIVE

However, research has found both in the and extensive evidence of DISCRIMINATION against foreign born and minority populations in

• Justice • business • the economy, • housing, media, politics and

• HEALTH CARE

di Giovanni, Julian 2015; Andreas, Willenbockel,Dirk 2016 What is Multi-culture?

According to the Cambridge dictionary multicultural is defined as

• Including people who have many different customs and beliefs

• A number of different cultures, esp to the traditions of people of different religions and races

• Or Including people from different cultures Is Norwegian society Multi-cultural? History of Immigration to Norway

• Historical immigration to Norway, started in the

• and academia

From the middle of 20th Century four phases of immigration1

• In 1960s labor migrant men from &

1Sandnes, Toril (2017). Innvandrere i Norge, 2017. Oslo-: Statistics Norway. History of Immigration to Norway

• In late 1970s -family members from former immigrants

• In mid 1980s- asylum seekers mainly from , , , and the former .

• Beginning of the 21st century – Liberal labor immigrants & strict towards asylum seekers

1Sandnes, Toril (2017). Innvandrere i Norge, 2017. Oslo-Kongsvinger: Statistics Norway.

MIGRATION to Norway from developing countries a fairly recent phenomenon with its origins in the late sixties. 1000000 Philipine Whole Period: , , , USA 800000 EU Whole Period: spouses, students, specialists 600000 Pakistan Pakistan Turkey Turkey 400000 Balkan Chile Vietnam 200000 Iran

0 1946 1950 1960 1970 1980 1990 2000 2010 2019

Refugees Family, Student Labor SSB 2019

Who are Immigrants?

According to SSB

“ Immigrants are persons born abroad of two foreign-born parents and four foreign-born grandparents”

“ Norwegian-born to Immigrant Parents are born in Norway of two parents born abroad and in addition have four grandparents born abroad” SSB 2019

Integration

Oberg’s 4 phases of cultural adjustment:

• Honeymoon phase In Theory • Crisis period (‘culture shock’). • Adjustment phase • Acceptance and Adaptation phase Oberg, K 1954 Cultural adjustment in theory Immigration & Health Immigration & Health

❑ The theory of Selectivity “which assumes that migration is a type of natural selection and explains who migrates when, where, and why”

“HEALTHY MIGRANT EFFECT” is a concept within the theory of selectivity

Im & Yang 2006;Grove N.J 2006,Organista 2003, Keefe&Padilla 1987, Berry 1980 The Negative effect theory

✓ New environment increases the risk of disease

✓ Increases the risk of illness and death when moving from low risk to high risk areas

✓ Change in lifestyle, both physical and psychosocial Family, friends, social network Status/profession Societal norms/ rules are different Changes in dietary habits, nutrient intake A process of urbanization or westernization

“EXHAUSTED MIGRANT EFFECT”

Grove N.J 2006,Organista 2003, Keefe&Padilla 1987, Berry 1980 Studies on Health of Immigrants in Norway

• Research on migrants’ health in Norway has a fairly recent history, being started in the mid-1990s.

• In 2000–2002, the first comprehensive population-based health surveys : the Oslo Health Study (HUBRO-2000/2001;Oslo Immigrant Health Study (Invandrer-HUBRO- 2002)

• These studies provided information about health status based on self-reported, physical and clinical examinations (detail on www.fhi.no)

• In addition, Statistics Norway (SSB) surveys in 1998, 2005 and 2015/2016 Health among immigrants in Norway

Survey on the health of immigrants report 2019

Analysis using data from the survey, the sample consisted of

• 4294 participants

• Aged 16–66 years

• 12 different countries Health among immigrants in Norway

• A significant proportion who drink alcohol in most groups

• Among women, the highest proportion of those who came as children / young people and those who have strong social networks

• High proportion of smokers in some groups (men) Turkey, Iran, Poland

• Increases with income (up to 40,000) and the highest proportion of men without a large network Health among immigrants in Norway

• Physical activity low in many groups

• Small correlation with health among women

• High proportion of obese women in many groups

• The proportion of overweight increases with men's residence time

• High prevalence of Diabetes among immigrants from South Mental Health

• Particularly high proportion of mental illnesses among immigrants from the

• Low proportion of immigrants from Somalia and Eritrea

• Surprisingly high proportion of Polish immigrants

• The highest proportion of mental health problems and sleep problems among the oldest immigrants, especially women

• Affinity, trust and social support are important Perceived discrimination among immigrants in Norway

• Around 27% of participants reported perceived discrimination

• PD associated with higher odds of mental health problems

• Sense of belonging and trust in others moderated the relationship

• Improved integration strategies could potentially improve the mental health of immigrants How to approach Health in Multicultural Society? Intervention to increase the participation of immigrant women in cervical cancer screening

2015-2018

Samera Azeem Qureshi MD, PhD Bernadette Kumar MD, PhD Esperanza Diaz MD, PhD Kathy Møen MD Abdi Gele PhD • To identify barriers that influence the interactions between immigrants and health care professionals

• To evaluate the effectiveness of two different community-based strategies

• Comparison of the effect measured by analyses of registry data Focus groups health Professionals in Oslo

26 GP, 3 gynecologist og 3 midwives, total 32 Main Issues Raised

General factors Specific factors • Language barrier • Routines • Knowledge • Responsibility • Cultural • Gender of GP • Organizational structure Health Providers Strategies

• Using an interpreter • Models and drawings • On the woman's premises • Show confidence • Help with scheduling (8Double time) • Take cell sample when they come for other things Suggestions for the System

• Simplify the reminder letter

• Take the "lower level" test

• Info about cell sample on introduction program, health station

• Info on the web in different languages Suggestions for The System

• Promotions

• Brochures in different languages delivered to women (health station, schools, medical offices)

• The GP sends a letter to the women with an hour for cell testing

• IT solutions Focus Groups (Pakistani & Somali women)

Six FGDs in Oslo with 35 women (Feb.-April 2016)

Main Issues Raised • General Practitioner • Not by males • Nature of the test • Letters from Kreftregisteret difficult to understand • Time and place and obligatory • Religious belief has become more of a taboo How to increase participation- Interventions

Immigrant Women Health care professionals Health care professionals

Bergen: 40 GP clinics

Target Group: - GPs - Nurses - Midwives

Method - Posters - Post- cards - Meetings Health care professionals Immigrant Women

Oslo:

Target Group Pakistani and Somali women Place: Lørenskog Bærum Asker Drammen

Method: Information meetings

Conclusions

• Working as a health professional in a multi-cultural society is challenging. In Norway, a recently published study among General Practitioners showed a lack of specific strategies to deal with cross-cultural consultations

• To bridge the gap between theory and practice and attain equity in health care, it is, therefore, necessary to ensure adequate cultural awareness, knowledge on migration and health and cross-cultural competencies among health care professionals Conclusions

• Intercultural challenges should not be attributed to the immigrant patients alone

• Responsibility of health professionals in initiating, maintaining or inadequately tackling these challenges cannot be ignored The Process of Cultural Competence in the Delivery of Health Care Services

JOSEPHA CAMPINHA-BACOTE 2002 Samera Azeem Qureshi: [email protected]

Migrasjonshelse; FHI