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Bodø 10.09.2019
Samera Azeem Qureshi MD, PhD
Migrasjonshelse, FHI, Oslo
• What is Immigration
• Process of migration & Immigration to Norway
• Integration
• Migration & Health , Health of immigrants in Norway
• Cancer Project
• Conclusions
Content of Presentation
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 United Nations, the
• All-time high, estimated 244 million international migrants in 2015
• Main reasons Economic, political and social conflicts
• Immigration to the Nordic countries 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 outtrial
✓ Harrasment by authorities, disappearance of close family members, livingin hiding
Migration Process
• Migration
✓ Dangerous journey: imprisoment, abuse, rape, lost or kidnap; witnessingdeath 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 United States and Europe extensive evidence ofDISCRIMINATION against foreign born and minority populations in
• Justice• business• the economy, • housing, media, politics and
• HEALTH CAREdi 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 customsand 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?
• Historical immigration to Norway, started in the Viking Age
• Trade and academia
From the middle of 20th Century four phases of immigration1
• In 1960s labor migrant men from Pakistan & Turkey
1Sandnes, Toril (2017). Innvandrere i Norge, 2017. Oslo-Kongsvinger: Statistics Norway.
History of Immigration to Norway
• In late 1970s -family members from former immigrants
• In mid 1980s- asylum seekers mainly from Iran, Chile, Vietnam, Sri Lanka and the former Yugoslavia.
• Beginning of the 21st century – Liberal labor immigrants & strict towards asylum seekers
1Sandnes, Toril (2017). Innvandrere i Norge, 2017. Oslo-Kongsvinger: Statistics Norway.
History of Immigration to Norway
MIGRATION to Norway from developing
countries a fairly recent phenomenon with its
origins in the late sixties.
0
200000
400000
600000
800000
1000000
1946 1950 1960 1970 1980 1990 2000 2010 2019
Balkan
ChileVietnam
PakistanTurkey
PakistanTurkey
Hungary
SomaliaIraqAfghanistan
EritreaSyria
Iran
EUPolandLithuania
Whole Period: spouses, students, specialists
Whole Period: Denmark, Sweden, Germany, USA
PhilipineThailand
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
Oberg’s 4 phases of cultural adjustment:
• Honeymoon phase
• Crisis period (‘culture shock’).
• Adjustment phase
• Acceptance and Adaptation
phase
In Theory
Integration
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
Grove N.J 2006,Organista 2003, Keefe&Padilla 1987, Berry 1980
✓ 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 psychosocialFamily, friends, social networkStatus/professionSocietal norms/ rules are differentChanges in dietary habits, nutrient intake
A process of urbanization or westernization
“EXHAUSTED MIGRANT EFFECT”
The Negative effect theory
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
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 Asia
Health among immigrants in Norway
• Particularly high proportion of mental illnesses among immigrants from the Middle East
• 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
Mental Health
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
Main Issues Raised
• Routines
• Responsibility
• Gender of GP
• Language barrier
• Knowledge
• Cultural
• Organizational structure
General factors Specific factors
26 GP, 3 gynecologist og 3 midwives, total 32
• 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
Health Providers Strategies
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
Immigrant Women Health care professionals
How to increase participation- Interventions
Bergen: 40 GP clinics
Target Group:- GPs- Nurses- Midwives
Method- Posters- Post- cards- Meetings
Health care professionals
Health care professionals
Immigrant Women
Oslo:
Target GroupPakistani and Somali womenPlace:LørenskogBærumAskerDrammen
Method:Information meetings
•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
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
JOSEPHA CAMPINHA-BACOTE 2002
The Process of Cultural Competence in the Delivery of Health Care Services
