i determinanti delle migrazioni …. … le migrazioni come ......foresight: migration and global...
TRANSCRIPT
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I determinanti delle migrazioni ….… le migrazioni come determinante di salute
Prof. Francesco CASTELLI, MD, FRCP (London), FFTM RCPS (Glasg), FESCMID
Professore di Malattie Infettive
Direttore, Clinica di Malattie Infettive e Tropicali
UNESCO Chair Training and empowering human resources for health development in resources limited countries
Università di Brescia
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2017: 257.7 million
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Fonte: http://www.unhcr.org/figures-at-a-glance.html
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Source: UN DESA, 2015. www.un.org/en/development/desa/population/migration/data/estimates2/estimates15.shtml, modified
International migrants by region of residence, 2015
0
10
20
30
40
50
60
70
80
Africa Asia Europe Latin Americaand the
Carribean
NorternAmerica
Oceania
Million
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«Push» factors
«Pull» factors
«Choice» factors
Determinants of migration
or
«why do people migrate?»
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«Macro» factors
«Meso» factors
«Micro» factors
Determinants of migration
or
«why do people migrate?»
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Political
•Conflict, insecurity
•Discrimination
•Persecution
Demographic
•Population density
•Population structure
•Diseases prevalence
Economic
•Job opportunities
•Income
•Producer/consumer prices
Social
• Seeking education
• Family obligations
Environmental
• Exposure to hazard
• Food/water security
• Energy security
• Land productivity
Individual characteristics
•Age, sex, ethnicity
•Education, wealth
•Marital status•Religion, language
Obstacles/facilitators
•Political/legal framework
•Social networks/diasporic links
•Cost of moving
•Technology
Meso
Micro
Macro
Foresight: Migration and Global Environmental Change (2011) Final Project Report The Government Office for Science, London, modified
Complex drivers of migration: macro-, meso- and micro-factors
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1400 1600 1800 2000
1 billion
It took about 7 million years for the human
population to reach 1 billion. Then something
happened.
World population in year
1800
www.gapminder.org/teach Version: 12Free teaching material for a fact-based worldview
Sources: Biraben 1980; McEvedy & Jones 1978; UN World Pop. Prosp. 2012; combined by Gapminder.
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2 billion
1400 1600 1800 2000
In just 130 years it increased to
World population in year
1930
www.gapminder.org/teach Version: 12Free teaching material for a fact-based worldview
Sources: Biraben 1980; McEvedy & Jones 1978; UN World Pop. Prosp. 2012; combined by Gapminder.
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3 billion30 years later
1400 1600 1800 2000
World population in year
1960
www.gapminder.org/teach Version: 12Free teaching material for a fact-based worldview
Sources: Biraben 1980; McEvedy & Jones 1978; UN World Pop. Prosp. 2012; combined by Gapminder.
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4 billion14 years later
1400 1600 1800 2000
World population in year
1974
www.gapminder.org/teach Version: 12Free teaching material for a fact-based worldview
Sources: Biraben 1980; McEvedy & Jones 1978; UN World Pop. Prosp. 2012; combined by Gapminder.
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5 billion13 years later
1400 1600 1800 2000
World population in year
1987
www.gapminder.org/teach Version: 12Free teaching material for a fact-based worldview
Sources: Biraben 1980; McEvedy & Jones 1978; UN World Pop. Prosp. 2012; combined by Gapminder.
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1400 1600 1800 2000
6 billion12 years later
World population in year
1999
www.gapminder.org/teach Version: 12Free teaching material for a fact-based worldview
Sources: Biraben 1980; McEvedy & Jones 1978; UN World Pop. Prosp. 2012; combined by Gapminder.
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7 billion12 years later
World population in year
2011
1400 1600 1800 2000
www.gapminder.org/teach Version: 12Free teaching material for a fact-based worldview
Sources: Biraben 1980; McEvedy & Jones 1978; UN World Pop. Prosp. 2012; combined by Gapminder.
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1400 1600 1800 2000
UN World
Population
Forecast Billion people
2
4
6
8
10
12
1
3
5
7
9
11
www.gapminder.org/teach Version: 12Free teaching material for a fact-based worldview
Sources: Biraben 1980; McEvedy & Jones 1978; UN World Pop. Prosp. 2012; combined by Gapminder.
In 2100 there will probably be somewhere around 11
billion people
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https://www.gapminder.org/videos/will-saving-poor-children-lead-to-overpopulation/
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Health force working in the world
http://www.worldmapper.org/display.php?selected=219
Physicians:
Italy (2014) 394/100.000USA (2013): 255/100.000Tanzania (2012: 3/100.000
Nurses/midwifes:
USA (2004): 988/100.000Italy (2014) 647/100.000Tanzania (2012: 43/100.000
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Rural-urban distribution of healthcare providers
Source: WHO, 2006http://www.who.int/whr/2006/whr06_en.pdf
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In the year 2000, climate changes have caused more than 150.000 deaths, alloccurring in the poorest part of the world population, producing only 3% of greenhouse emissions
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Lake Chad was about 25,000 square kilometers in surface area back in 1963. Now the lake is about one-twentieth the size it was in the mid 1960s
According to the United Nations, in Africa alone, climaticchanges may force 70 million people to migrate by the year2030
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Two hours walk to the Health Center …
Economic migrants, refugees, asylum seekers… whom are we speaking about? Migration patterns over time
Outline spectrum of health needs and variation by migrant group
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Courtesy Eng. G. Guariso
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Political
•Conflict, insecurity
•Discrimination
•Persecution
Demographic
•Population density
•Population structure
•Diseases prevalence
Economic
•Job opportunities
•Income
•Producer/consumer prices
Social
• Seeking education
• Family obligations
Environmental
• Exposure to hazard
• Food/water security
• Energy security
• Land productivity
Individual characteristics
•Age, sex, ethnicity
•Education, wealth
•Marital status•Religion, language
Obstacles/facilitators
•Political/legal framework
•Social networks/diasporic links
•Cost of moving
•Technology
Meso
Micro
Macro
Migrate
Stay
Finaldecision
Foresight: Migration and Global Environmental Change (2011) Final Project Report The Government Office for Science, London, modified
Complex drivers of migration: macro-, meso- and micro-factors
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https://www.google.it/search?q=enea&espv=2&biw=1440&bih=849&site=webhp&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjAwo_amo3KAhXHXhoKHb8IBLIQ_AUIBygC&dpr=1.5#imgrc=i1EFXq0ervCM4M%3A
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Arrivi via mare in Italia
Marzo 2016, Accordo UE-Turchia
Febbraio 2017, Accordo di Malta
Fonte: UNHCR (visitato il 13.3.2018)
http://data2.unhcr.org/en/situations/mediterranean
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Variazione annuale della popolazione residente di cittadinanza italiana e straniera – Italia Dati ISTAT 1 gennaio 2008-2018, valori in migliaia
Fonte: ISTAT, Indicatori demografici, 2017, 8 febbraio 2018, pagina 10, http://www.istat.it/it/archivio/208951 (accesso il 13.3.2018)
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Stranieri residenti in Italia
• N = 5.065.000 (8,4% della popolazione residente)
• Genere femminile = 52,4%
• Provenienza europea = 51,7%
• Primi 5 paesi:
• Romania, Albania, Marocco, Cina, Ucraina
• Religione = cristiana 53,3%, musulmana 32,6%
Fonte: Centro Studi e Ricerche IDOS, Dossier statistico immigrazione, 2017, pagina 13
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http://ec.europa.eu/eurostat/statistics-explained/index.php/Migration_and_migrant_population_statistics
Age structure of the national and non-national populations, EU-28, 1 January 2016 (%)
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Non communicable diseases in migrants
• Prevalence of risk factors and disease in the country of origin
• Genetic factors
• Lifestyle and behavior
• Cultural factors
• Access to prevention and care
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Determinanti di salute
Determinanti prossimali
Determinanti sociali
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Determinanti di salute
Determinanti sociali
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11%
44%
35%
10%
39%
44%
15%
2%
16%
46%
30%
9%
0% 20% 40% 60% 80% 100%
laurea
media superiore
media inferiore
nessuna/elementare
ITA
PSA
PFPM
PSA = paese di sviluppo avanzato
PFPM = paese a forte pressione migratoria
Istruzione Sistema PASSI 2008-2016
334.567 interviste a persone tra 18 e
69 anni di età di cui 15.277 a stranieri
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0 1 2 3 4 5 6 7 8 9 10
Difficoltà economiche
(su tutti i lavoratori italiani e stranieri)
35-49 anni
50-69 anni
Donne
Sc. Medie inf
Dip sup.
Laurea
Lavoro non regolare
Centro Italia
Sud Italia
PSA
PFPM UE
PFPM Altra Europa
PFPM Nord Africa
PFPM sub-Sahara
PFPM Asia
PFPM America
0 1 2 3 4 5 6 7 8 9 10
35-49 anni
50-69 anni
Donne
Sc. Medie inf
Dip sup.
Laurea
Centro Italia
Sud Italia
PSA
PFPM UE
PFPM Altra Europa
PFPM Nord Africa
PFPM sub-Sahara
PFPM Asia
PFPM America
Paura di perdere il lavoro
(su tutti i lavoratori regolari italiani e stranieri)
Lavoro
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Lavoro
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2%
25%
48%
26%
13%
42%
35%
10%
6%
39%
41%
14%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
molto facilmente
abbastanza facilmente
con qualche difficoltà
con molte difficoltà
ITAPSAPFPM
PSA = paese di sviluppo avanzato
PFPM = paese a forte pressione migratoria
Situazione economica
Arriva a fine mese
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Determinanti di salute
Determinanti prossimali
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Cosa mangiano gli immigrati?
, Fonte: Alessio Petrelli Anteo Di Napoli, Alessandra Rossi, Daniele Spizzichino, Gianfranco Costanzo, Monica Perez, Sovrappeso e obesità nella popolazione immigrata adulta residente in Italia, Epidemiol Prev 2017; 41 (3-4) Suppl 1: 26-32.
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Fumo
0 1 2 3 4 5 6 7 8 9 10
35-49 anni
50-69 anni
Donne
Sc. Medie inf
Dip superiore
Laurea
Abb. Facilmente*
Qualche difficoltà
Molte difficoltà
Lavoro non regolare
Non lavoro
Centro Italia
Sud Italia
PSA
PFPM Europa
PFPM Nord Africa
PFPM sub-Sahara
PFPM America
PFPM Asia
0 1 2 3 4 5 6 7 8 9 10
* non significativo
Alcool
0 1 2 3 4 5 6 7 8 9 10
Sedentarietà
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0 1 2 3 4 5 6 7 8 9 10
35-49 anni
50-69 anni
Donne
Sc. Medie inf
Dip superiore
Laurea
Abb. facilmente
Qualche difficoltà
Molte difficoltà
Centro Italia
Sud Italia
PSA
PFPM Europa
PFPM Nord Africa
PFPM sub-Sahara
PFPM America
PFPM Asia
Restringendo l’analisi ai soli stranieri PFPM restano significative:
l’età, il genere, la scolarità (alta)
• Vivere in Centro Italia diventa un fattore protettivo
• Aver vissuto in Italia per almeno 10 anni è un aspetto che
accresce la probabilità di essere sovrappeso/obesi
58%
69%
60%55%
59%
64%68%
32%
24%
30%34%
31%28% 27%
10%7%
10% 11% 10% 8%5%
0%
20%
40%
60%
80%
100%
Italiani PSA PFPM-Europa PFPM-Nord Africa PFPM-Africa sub-
Sahara
PFPM-America PFPM-Asia
sotto/normopeso sovrappeso obeso
Eccesso ponderale
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Impact of migration on coronary heart disease risk factors: comparison of Gujaratis in Britain and their contemporaries in
villages of origin in India
Randomly sampled Gujaratis aged 25–79 yrs living in Sandwell (n = 242) age-, gender- and caste-matched remaining in their villages of origin in Navsari, India (n = 295).
Patel et al Atherosclerosis 185 (2006) 297–306
Economic migrants, refugees, asylum seekers… whom are we speaking about? Migration patterns over time
Outline spectrum of health needs and variation by migrant group
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Ethnic origin and cardiovascular risk
Anand SS et al. Differences in risk factors, atherosclerosis, and cardiovascular disease between ethnic groups in Canada: the Study of Health Assessment and Risk in Ethnic groups (SHARE)
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Coronary artery disease
*Harding S, Rosato M. Heart 2008;94:463–470.
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Ethnicity and Blood Pressure in Europe
Modesti PA et al. (2016) PLoS ONE 11(1): e0147601.
South Asian
SubsaharanAfrica
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Low adherence to anti-hypertensive treatment Database Regione Lombardia
Mancia G et al J Hypertens 2014, 32:1708–1716
• Younger age• Women• Depression• Co-morbidities (cancer, dementia, respiratory and rheumatologic diseases)
• Immigrants• No relationship with income
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Disparities in type 2 diabetes prevalence among ethnicminority groups resident in Europe:
a systematic review and meta-analysis
SubSaharian Africa
Meeks K et al Intern Emerg Med (2016) 11:327–340
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Mortality rate ratios (MRRs) combined for men and women in 6 European countries,
by region of origin and cause of death
Eur J Epidemiol (2016) 31:655–665
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31%
52%
39%
54%
27%
47%
40% 40%
21%
41%
26%
47%
15%
35%
20%
45%
16%
29%
21%
34%
26%
48%
32%
40%
16%
30%
18%
38%
0%
20%
40%
60%
80%
100%
Attività fisica Perdere peso (in eccesso ponderale) Attività fisica (in eccesso ponderale) Smettere fumare (fumatori)
Italiani PSAPFPM-Europa PFPM-Nord AfricaPFPM-Africa sub-Sahara PFPM-AmericaPFPM-Asia
Consigli degli operatori sanitari per cittadinanza
• Al netto di età, genere, istruzione, situazione economica e luogo di residenza la cittadinanza ha un effetto rispetto ai consigli che gli operatori sanitari danno alle persone.
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Increased risk of virological failure to the first antiretroviral regimen in HIV-infected migrants
Saracino A et al, CMI, 2016
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Casi di tubercolosi in Italia - anni 1955-2015
Source Ministero della salute 2017.http://www.salute.gov.it/portale/news/p3_2_1_1_1.jsp?lingua=italiano&menu=notizie&p=dalministero&id=2873
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Source ECDC/EURO TB report 2014
Numero di casi di TB in Italia 2007 - 2012
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KAP survey on malaria preventive measures of migrants
Scolari et al., JTM, 2002
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In sintesi…
• Stranieri PFPM svantaggiati dal punto di vista socio-economico
• Stili di vita:
• Maggiore sedentarietà
• Stranieri Est-Europa: maggiore fumo
• No differenza o minore consumo di alcol
• Modesto aumento del rischio per eccesso ponderale
• Complessivamente, determinanti di salute meno favorevoli
• Meno consigli su stili di vita da parte degli operatori sanitari
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Tuttavia, salute percepita positivamente …
0 1 2 3 4 5 6 7 8 9 10
35-49 anni
50-69 anni
Donne
Sc. Medie inf
Dip superiore
Laurea
Abb. facilmente
Qualche difficoltà
Molte difficoltà
Lavoro non regolare
Non lavoro
Centro Italia
Sud Italia*
Presenza patologie
PSA
PFPM Europa
PFPM Nord Africa
PFPM sub-Sahara
PFPM Asia/ America
* non significativo
Controllando per età, genere, istruzione,
situazione economica, situazione lavorativa,
luogo di residenza e presenza di patologie, la
cittadinanza influenza la percezione della
propria salute
I cittadini stranieri (PSA e PFPM) hanno
maggiore probabilità di “sentirsi molto
bene o bene” rispetto ai cittadini italiani
Restringendo l’analisi ai solo stranieri PFPM
restano significative: l’età, il genere, la scolarità
(laurea), la situazione economica, il lavoro non
continuativo, il vivere in Centro Italia e la
presenza di patologie
Non influisce il numero di anni vissuti in Italia
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Petrelli A. et al. Lo stato di salute percepito della popolazione immigrata in Italia, Epidemiol Prev 2017; 41 (3-4) Suppl 1: 11-17
Probabilità di avere una peggiore salute fisica
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Probabilità di avere una peggiore salute mentale
Petrelli A. et al. Lo stato di salute percepito della popolazione immigrata in Italia, Epidemiol Prev 2017; 41 (3-4) Suppl 1: 11-17
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I determinanti delle migrazioni- Fenomeno complesso e multifattoriale- Fattori controllabili e non controllabili- Migrante economico o forzato
Le migrazioni come determinante di salute- Effetto migrante sano effetto migrante esausto- Determinanti di salute sfavorevoli per stranieri- Transizione epidemiologica – malattie croniche