Hispano-Americans in Europe: what do we know about their health status and determinants? A scoping review

This scoping review synthesises existing knowledge about the heath status and determinants of HAs in Europe in order to inform a research agenda. The 193 studies reviewed focused mostly on the health status of this population and paid disproportionately little attention to the determinants of health. The majority of studies addressed communicable infections, followed by “maternal and child health” and a range of “psycho-pathologies”. Burgeoning research in the last few years has yielded some specific, consistent findings about the health status and determinants of HAs in Europe (Table 2). These suggest that this population has a tendency to overweight, is prone to deliver babies using Caesarean sections, is more likely to have post-birth complications than locals, is prone to be affected by allergies/asthma, utilises specialised services less than locals, and carries a disproportionate burden of communicable infections in specific sub-populations. However there are many inconsistent findings and some popular perceptions about “Hispano-American migrants” are not fully confirmed by the evidence reviewed (Table 3). Most studies adopted a vertical approach focusing on a particular disease but left unexplored the interlinkages between different pathologies and health conditions and how these relate to occupational, legislative, social and environmental factors. Many considered “HA migrants” as a homogeneous analytical category masking likely heterogeneities. This review describes these important research gaps and suggests specific avenues of inquiry to advance knowledge in this field.

It is now widely accepted that the conditions in which people are born, grow, live and work are crucial determinants of populations’ health [210] and amongst “ethnicity and health” scholars there is a high level of consensus on the need to move beyond an exclusive focus on behavioural and genetic determinants to account for broader contextual factors [211]. Still, this review illustrates that the greatest share of scientific production on the health of HAs in Europe is focused on the health status of this population and pays disproportionately little attention to the social, occupational and economic determinants of health. Research efforts have focused on communicable infections although these contribute only partially to the burden of disease in a population that is more commonly affected by gynaecological and obstetric conditions, traumatic accidents, headaches, back pain, depression and gastrointestinal disorders [179,180] (Table 3). This is in line with the wider body of literature addressing migrants’ and ethnic minorities’ health, where these tend to be portrayed as “sources of infection” in spite of being more commonly affected by similar diseases as locals [212,213].

A comprehensive understanding of HAs’ health requires a closer look at various layers of social determinants of health (SDH). We need to understand better the pathways through which the living and working conditions of HA populations in Europe influence their health status and behaviours. Beyond basic demographic characteristics and income indicators we need to account for neighbourhood characteristics such as ethnic density and social cohesion indicators, and consider legal status, religion, social class, employment status, working conditions and ethnicity as cross-cutting axis linking “migrant status” to health outcomes. The specificities of diverse HA populations should be examined, and greater policy attention paid to the “invisibility” of domestic and personal care work - commonly performed by HAs in Europe- and the “unseen” hazards related to it [214]. A careful evaluation of the achievements and pitfalls of policies designed to regularise domestic work, such as the voucher system in Belgium and France [215] and the recent failed attempt in Spain [216] could shed light into what should be done to address this issue.

The literature on migrants’ health reports wide heterogeneities in patterns of health service utilisation, depending on demographic factors, area of residence, country of origin and type of service [171,172,174,217-220]. In the case of HAs, the popular perception that they resort to health care services more often than locals- which is sometimes attributed to their “low tolerance to pain” [221]- is not fully confirmed by the existing evidence (Table 3). A more careful examination that accounts for a variety of demographic and socio-economic factors is needed to unpack the complex patterns and determinants of service use in diverse HA populations.

Cancer risks varied by area of origin and cancer typology [98]. We also identified substantial heterogeneities in cardiovascular mortality [105,107], morbidity [108] and risk factors [104,222]. Our findings mirror the inconsistent picture found for other migrant groups and support recent calls to develop “fine-grained monitoring systems” that account for different populations and health conditions [212]. Future research should investigate how rates of CVD in HAs in Europe compare to those of locally-born residents, HAs who never migrated, those residing in different European countries [223], and “second generation” migrants [103]. However, there are many methodological challenges to be faced, particularly in relation to the availability of ethnicity indicators and reliable comparable data [224].

Our findings do not support the popular belief that HAs exhibit higher rates of psychopathology than the locally born. The inconclusiveness of results in this field - with studies finding levels of psychopathology that are both above and below the rates found in locals- casts doubts on the widespread assumption that migration “per se” is a risk factor of mental disorders (Table 3). Along the same lines, previous reviews on the prevalence of mental illness in migrant populations have also found wide disparities [225]. While the vulnerabilities faced by HA migrants in Europe are well described in the literature, we don’t know enough about how these translate into prevalence of psycho-pathology and the specific factors that trigger or hinder the development of mental disorders. Beyond dissecting the relative influence of stressors directly related with the migration process from other more general strains that also affect the local populations, we need to examine the interlinks between different sources of stress including perceived discrimination, legal status, and interpersonal violence, and how these intersect with other factors such as sex, age, income, occupational status, reasons to migrate, sexual orientation, class and ethnicity [226-228].

In a context of rapidly changing population flows exacerbated by the economic recession, it becomes crucial to longitudinally explore patterns and determinants of health in HAs who initially settled in Spain but who decided to re-emigrate back home or moved to other European countries where the “cultural congruity” that has been described and questioned [134,229] as a “protective factor” in Spain, may not operate. Attention should also be paid to HAs who decide to stay in contexts of high unemployment and job insecurity - firmly established determinants of poor mental health [230-240]. Against the unstable macro-economic backdrop of many European countries, the role played by discrimination as a social determinant of health, and how it interlinks with broader societal attitudes including racism and class prejudices merits additional attention. Further research on the role of social support will help us to interpret the unexpected positive correlations found between poor mental health and indicators of “social integration” [139,143], contributing to current debates over the influence of neighbourhood characteristics on health indicators [241,242].

In spite of unfavourable economic and social contexts, this review has found some promising prospects related to the effective mobilisation of coping strategies in this population [128,142]. The potential benefits (and limitations) of self-esteem and self-efficacy as health-protective factors [243-245] should be further examined and empirical data collected to inform the vulnerability-resilience debate [246].

The inconclusiveness of results in the field of mental health could be partly explained by the difficulty of diagnosing psychiatric disorders in populations of diverse cultural backgrounds with possible differing conceptualisations of mental health and ways to communicate distress [247]. Future studies should consider how psychopathology is defined at the countries of origin [247,248] and investigate further the cultural sensitivity of diagnostic instruments used [225].

Additional research is needed to monitor patterns of substance use and its determinants. We also need to understand better how maternal and child health indicators and determinants vary along the migration experience. The birth weight advantage of children born to HA mother identified in several studies [159,160,166] has led researchers to suggest that a “healthy migrant effect” or selected migration of healthier individuals might operate [159]. We consistently identified poor indicators for other birth outcomes [158,161,163,164] including perinatal mortality [151], which underscores the need to further investigate the nature, extent and duration of the “healthy migrant effect” [249] as well as perceived barriers and facilitators to accessing/providing good quality antenatal care from both users’ and providers’ perspectives. The extremely high rates of unwanted pregnancies [170] reported in the mid 2000s amongst undocumented HA migrants calls for additional up-to-date research in this field.

The majority of studies identified through our search strategy focused on communicable infections with a marked predominance of research focused on Chagas disease. This is not surprising given the particularly high prevalence of this disease amongst HAs, specially Bolivians [5], and the fact that public health policies known to be effective to prevent infection through blood transfusions and from mother-to-child are yet to be adopted by most European countries [250]. Other infectious diseases such as TB and STIs have received less research attention but the available evidence consistently points to a high proportion of HAs amongst TB cases identified in migrants (>40%), with frequent post-migration infection (Table 3). Besides considering how the conditions of migration influence reactivation of latent TB, the extent and mechanisms through which recent, post-migration TB infection occurs within host countries, and how these relate to social networking patterns with the autonomous populations and other migrant groups will further understanding of the nature and extent of the bidirectional transmission patterns reported in the literature [60,63]. Particular focus should also be placed on MSM and transsexual females of HA origin, consistently found to bear a disproportionate burden of HIV. Epidemiological, cost-effectiveness and qualitative studies are needed to assess the value of screening migrants for STIs and other communicable infections. These studies should be framed within broader ethical debates and should consider the fundamental principles of ethnic health research to ensure that besides addressing a public health concern, the evidence generated does actually revert into better health-care experiences and outcomes for minority populations [211].

Most of the studies reviewed adopted a cross-sectional approach based on data collected at a single receiving country with only 3 studies collecting data both at sending and reception countries. The paucity of trans-national and longitudinal studies is partly due to methodological challenges. Further research efforts, coupled with adequate funding should be directed to address these so both pre-migration and post-migration influences can be properly accounted for [251]. Differing reasons for migration should be considered as potential determinants of health and due attention should be paid to the health of migrants who return to their country of origin after a “failed” migration experience.

Amongst the studies that disaggregated data by sex, many found diverging results for women and men, suggesting that sex and gender should be further examined as factors influencing health outcomes in this population. Besides advancing knowledge on the often overlapping vulnerabilities that affect many migrant women, the finding that Bolivian men had some poorer health outcomes than their female counterparts [137] underscores the need to also investigate the reasons behind the health disadvantage described in some HA men. Changes in gender roles and relations resulting from migration processes- and its implications for health- deserve additional research. Moving yet one step further, a broad spectrum of gender identities including those of transgender females should be considered. By accounting for a plurality of “masculinities” and “feminities” future research should contribute to disentangle the often neglected interlink between sex and gender, and how these two variables intersect with other factors, including socioeconomic status and ethnicity, to influence health.

Hispano-Americans share a common language, but they can’t be categorised as a homogeneous “ethnic group”. The wide spectrum of ethnicities across HA populations, very often mixed, is just the most visible of an array of heterogeneities that characterises a population with differing reasons to migrate as well as educational, occupational, and social class backgrounds. Still, many of the studies reviewed grouped together “Latin-Americans” as an analytical category neglecting within-group differences. The diversity of results in the remarkable cases where data was disaggregated by country of origin and sex indicates that more refined analysis are needed so the commonalities and differences vs locals, other migrant populations, and within the HA migrant population itself can be better described and understood. To counter the “colour-blind” approach [252] prevailing in the literature, due attention should be paid to “whiteness” [242] and how ethnicity intertwines with migrant and socio-economic status to potentially influence health inequities. The ethnic diversity of the HA population in Europe provides a good opportunity to advance towards a more nuanced understanding of the interlinks between ethnicity, income, migrant status, and social status as determinants of health.

It has been argued that ethnicity and migration have been neglected in the “Social Determinants of Health” agenda [252]. This review illustrates the disproportionately little attention that the social determinants have received in European research addressing Hispano-Americans’ health. We call for continued increasing attention to this field of research, and make specific suggestions on how to readdress the balance. Conceptual models that go beyond categorizing individuals by broad regions of origin and that account for different potential sources of inequities [242,253] should underpin future studies in this field, so over-simplifications and over-generalisations likely to reinforce stigmatising clichés are avoided [252] and the interest of minority groups are better served by health research [211].