The living conditions and health status of international immigrants in Chile: Comparisons among international immigrants, and between them and the Chilean-born Volume 1 of 2 Main document Baltica Beatriz Cabieses Valdes Submitted in accordance with the requirements for the degree of Doctor of Philosophy The University of York Department of Health Sciences August 2011 Cabieses B. (2011) Abstract The Republic of Chile is a middle-income South American country. In recent decades, Chile has faced a “new immigration” pattern, described as young immigrants, coming mostly from Latin American countries to work. This thesis is the first quantitative population-based study exploring the living conditions and health status of international immigrants in Chile. Secondary data analysis of a cross- sectional population-based survey carried out in 2006 is used (the CASEN survey 2006; 268,873 participants from 73,720 households). This study encompasses a large set of Social Determinants of Health (SDH) and analyses their relationship to several health outcomes among immigrants and the Chilean-born population. Those sets of SDH are the following: demographic, socioeconomic, material living standards, access to health care and migration related determinants. A wide range of statistical methods are used throughout this thesis in order to account for the great variability found in this dataset, as well as the complexity and co-linearity involved in most of its variables. Results show 1% of the sample report as international immigrants, coming mainly from Peru (28%), Argentina (26%), Bolivia (6%) and Ecuador (5%). An additional 0.7% chose not to report their migration-status (migration status missing values) and this group is more likely to live in socioeconomic derivation than immigrants. International immigrants are a heterogeneous group, with wide variation in socioeconomic status (SES). The "healthy migrant" effect appears within the total international immigrant population: this group has a lower prevalence of all health problems compared to the Chilean-born. However, when analyzing prevalence by SES, significant differences are found. Immigrants show clear gradients of health by SES, with different patterns according to the nature of the problem considered. Immigrants with low-SES show no "healthy migrant" effect and they have similar disease prevalence to the average Chilean-born, despite being younger. The “healthy migrant” effect also disappears among those living longer than 20 years in Chile. These key findings have direct policy implications for Chile and suggest relevant future research in this topic in the Latin American region. 1 Cabieses B. (2011) List of Contents in Volume 1 PAGES Abstract 1 List of Tables in Volume 1 10 List of Figures in Volume 1 13 List of Contents in Volume 2 – Appendix Book 25 Acknowledgements 39 Declaration 40 CHAPTER 1 INTRODUCTION 43 1.1 Why study the international immigrant population in Chile? International migration and the global agenda 45 1.2 Key concepts included in this thesis 46 1.2.1 Migration and international immigrants 46 1.2.2 Health and the “social” dimension of its definition 47 1.2.3 The Social Determinants of Health (SDH) 47 1.2.4 Health inequalities 48 1.2.5 Health equity 49 1.2.6 Social epidemiology 50 1.3 The context for including inequalities among immigrants as a key research topic in Chile 51 1.3.1 The context in Latin America: the development of Social Medicine 51 1.3.2 The national context for studying SDH in Chile 52 1.4 A personal statement about this research 58 1.5 How is this thesis structured? 59 CHAPTER 2 MIGRATION IN THE WORLD AND IN CHILE 62 2.1 The complex concept of migration 64 2.2 Classification of migration 65 2.3 Reasons for migration 66 2.4 Characteristics of migration 69 2.4.1 General approach: the most frequent characteristics of people who migrate 69 2 Cabieses B. (2011) 2.4.2 The issuer society: brain-drain and remittances between more developed and less developed countries 70 2.4.3 The receiver society: selectivity policies and discrimination in the context of economic liberalism and globalisation 72 2.5 Theories of Migration 73 2.5.1 Push-and-pull theory 73 2.5.2 Cumulative causation theory 75 2.5.3 Migration through globalization 76 2.5.4 Behavioural decision-making theory of migration 80 2.6 Description of migration in Chile 82 2.6.1 A general description of international migration in Latin America 82 2.6.2 International migration in Chile 82 2.7 Limitations and challenges of research on migration 87 CHAPTER 3 THE COMPLEX RELATIONSHIP BETWEEN MIGRATION AND HEALTH 88 3.1 A brief description of the search strategy considered in this literature review chapter 90 3.2 Key concepts in the relationship between migration and health 91 3.2.1 Selective migration 91 3.2.2 The healthy migrant effect 91 3.2.3 The paradox of assimilation 93 3.2.4 The Latino paradox 93 3.2.3 The salmon bias 94 3.3 Health-related problems among immigrants 95 3.3.1 Recent health problems and infectious diseases 95 3.3.2 Chronic conditions (non-infectious diseases) and mortality rate 98 3.4 Summary of explanatory pathways in the relationship between migration and 104 health 3.5 Limitations and challenges of health and migration research in the world 107 3.6 Evidence, challenges and limitations of health and migration research in Latin America and Chile 110 CHAPTER 4 UNDERSTANDING MIGRATION IN THE CONTEXT OF THE SOCIAL DETERMINANTS OF HEALTH (SDH) 119 4.1 Models describing the Social Determinants of Health (SDH) and models explaining their connection with health 121 3 Cabieses B. (2011) 4.1.1 Models explaining the relationship between the SDH and health 121 4.1.2 The Models describing the SDH 127 4.2 Understanding migration in the context of the SDH 131 4.3 Research limitations and challenges when researching migration and the SDH in 134 Chile 4.3.1 Limitations when conducting research on migration and SDH in Chile 134 4.3.2 Challenges in research on migration and SDH in Chile: what has been 136 already recognised? CHAPTER 5 METHODOLOGICAL APPROACH 138 5.1 Type of research 140 5.2 Research questions 141 5.2.1 Overarching research question 141 5.2.2 Specific research questions 141 5.3 Methods 142 5.3.1 Type of study 142 5.3.2 Instrument 142 5.3.3 Sample 143 5.3.4 Recruitment and data collection 144 5.3.5 Primary and secondary outcomes 145 5.3.6 Variables selected from the CASEN survey (summarised in Appendix 5.1 and 5.2) 145 5.3.7 Data analysis 149 5.4 Ethical considerations 154 5.4.1 Access to the survey 154 5.4.2 Potential risks 154 5.4.3 Vulnerable groups 154 5.4.4 Potential benefits 154 5.4.5 Ethics Committee Approval 155 5.5 Survey limitations 155 CHAPTER 6 WHAT ARE THE DEMOGRAPHIC CHARACTERISTICS OF IMMIGRANTS IN CHILE AND HOW DO THEY COMPARE TO THE CHILEAN-BORN? 157 6.1 General migration patterns in Chile: study results 159 6.2 Demographic determinants of health: a literature review 161 6.2.1 What is known about age as a determinant of health? 161 4 Cabieses B. (2011) 6.2.2 Why include gender as a determinant of health? 161 6.2.3 Literature on ethnic minority status, migration and health 162 6.2.4 Urbanization and geographical determinants among immigrants 166 6.3 Demographic characteristics of international immigrants in Chile: study results 171 6.3.1 Summary of key findings 171 6.3.2 Age distribution of international immigrants in Chile 171 6.3.3 Gender patterns among immigrants in Chile 173 6.3.4 Marital status patterns among immigrants 173 6.3.5 Minority ethnic patterns among immigrants in Chile 173 6.3.6 Where do immigrants live? 174 6.4 Migration-related factors among international immigrants in Chile: study results 187 6.4.1 Years living in the country: temporary versus long-term immigration 187 6.4.2 Country of Origin: shaping distinctive patterns between immigrants 190 6.5 Discussion 196 6.5.1 Contrasting key findings with other studies and theories on migration 196 6.5.2 Strengths, limitations and future research in this area 200 CHAPTER 7 WHAT ARE THE SOCIOECONOMIC CONDITIONS OF IMMIGRANTS IN CHILE AND HOW DO THEY COMPARE TO THE CHILEAN-BORN? 209 7.1 Socioeconomic status (SES) of immigrants in Chile: literature review and study results 211 7.1.1 Income 211 7.1.2 Educational level 216 7.1.3 Occupation 218 7.1.4 Summary of key findings from this section 222 7.1.5 Clustering immigrants in Chile according to their socioeconomic status 224 7.2 Household material living standards 227 7.2.1 Literature review and specific methods used in this section 227 7.2.2 Findings from this study 228 7.3 Discussion 232 7.3.1 Methodological discussion 232 7.3.2 Comparing results of this chapter to international evidence 233 CHAPTER 8 DO IMMIGRANTS REPORT HAVING ACCESS TO THE CHILEAN HEALTH CARE SYSTEM AND HOW DOES THIS COMPARE TO THE CHILEAN-BORN? 243 5 Cabieses B. (2011) 8.1 Access to, need and use of health care 245 8.2 A further description of the Chilean health care system 247 8.3 A brief methodological explanation 250 8.3.1 Weighted multinomial regression models 250 8.3.2 Weighted logistic regression models 251 8.3.4 Summary graphs 251 8.4 Health care provision entitlement in Chile: Study results 254 8.4.1 Describing health care provision entitlement among the IIP in Chile 254 8.4.2 Factors associated with type of provision entitlement among immigrants in Chile 258 8.5 Exploring access to health care among immigrants with health needs: study results 266 8.5.1 Access to health care in Chile by immigrants with recent health events: any 266 health problem or accident (AHPA) in the past