Salutogenic health promotion program for migrant women at risk of social exclusion

Migration can negatively affect physical, mental and emotional health [6, 7]. It has a stressful effect on people because it begins with the hope of a new and better life but experiences at the new destination often cause unexpected loss and culture shock [8, 9]. Migrants must cope with these stressors until they can regain a sense of balance or adapt to the new situation [9, 10]. For these reasons, migrants are considered a vulnerable population [11].

Although migrant populations are among those most affected by health inequities, few health programs and policies focus specifically on reducing inequities in these vulnerable populations [12‐14]. Migrant women are especially at risk due to gender discrimination, stigmatization, and lack of resources [15]. Gender is a social determinant of health that triggers differences in the socialization of women and men. This implies distinctive values, attitudes, and behaviors that lead to gender-based differences in access to resources and jobs [16]. Moreover, migrant women usually work at home, so their work is unpaid, ignored, and not recognized by others [17].

In addition, they suffer from the stigmatization or discrimination [18, 19] to which the migrant population is especially vulnerable [20]. Migrant individuals are often targeted for their differentiating features, ethnic traits or cultural behaviors [21]. It is known that self-esteem helps to cope with stigmatization [22] and that a high level of self-esteem and self-confidence help to reduce perceived stress, allowing the individual to choose the most effective coping strategies [23]. A high level of self-esteem together with strong social support reduces vulnerability to stressors [24, 25], and social support is a protective determinant for adults to adapt to a new environment [26] and to cope with stressful situations [27].

Finally, lack of resources in migrant populations causes difficult life conditions and limits access to opportunities. In Spain, the unemployment rate is 19% in the native population, while it is 35% among migrants [28].

The aim of health promotion programs for migrant individuals are generally focused on covering their basic needs, such as food and housing [29], or on modifying lifestyle behaviors [30, 31]. Although necessary, these programs are not sufficient to overcome health inequities. New approaches and new strategies are needed. In Spain, the strategic goals of the national program in prevention and health promotion include a commitment to tackle health inequity and to facilitate the health empowerment of individuals [32]. Moreover, the Spanish Commission to Reduce Social Inequalities in Health was created in 2008 specifically to develop a nationwide proposal for interventions to reduce health inequities [33]. In accordance with national policy and strategies, the present study introduced the salutogenic model developed by Aaron Antonovsky into a health promotion program in an effort to explore new approaches that can be effective in reducing health inequities.

Antonovsky’s salutogenic model is based on a health-disease continuum between dis-ease and ease. Salutogenesis focuses on the origins of what creates health (strengths and resources) and focuses attention toward the development of health [34]. In contrast, the usual pathogenic approach considers health and disease as two mutually exclusive states and focuses on the risk factors associated with disease [35]. Salutogenesis suggests that stressors are common in daily life, generating tensions that can cause a landslide of health consequences if the individual succumbs to them, or a positive health effect if the tensions are overcome [34].

The key elements in Antonovsky’s theory of salutogenesis are generalized resistance resources (GRRs) and sense of coherence (SOC). GRRs are defined as “a property of a person, a collective or a situation which, as evidence or logic has indicated, facilitates successful coping with the inherent stressors of human existence”. SOC is defined as “the ability to understand the overall situation and the capacity to use available resources” [35]. Antonovsky described three SOC dimensions: comprehensibility, manageability and meaningfulness. Comprehensibility represents the person’s capacity to transform stimuli into information about what is being experienced or perceived as meaningful, orderly, consistent, structured, and clear. Manageability refers to the individual’s perception of the available resources and their adequacy to meet daily demands. Meaningfulness indicates the extent to which a person feels that life makes sense emotionally and is sufficiently motivated to put effort into confronting problems and difficulties [36].

The aim of health promotion programs with a salutogenic model of health is to increase the internal and external awareness of the GRRs and enhance the ability to use them in daily life [37] in order to improve health. These programs are focused not only on minimizing (disease) risks, but also on strengthening the existing GRRs of each participant, thus facilitating the participant’s progress towards health as described by Antonovsky. This study explored the effectiveness of a salutogenic health promotion program for migrant women at risk of social exclusion.

The main objective of this salutogenic health promotion program was to improve awareness of GRRs and increase self-esteem, physical and mental quality of life (QL), and SOC in the study population, and decrease their perception of stress. For this reason, program activities were planned with the aim of raising questions and encouraging the participants to help each other identify their own resources through the contributions of the group discussions. The role of the facilitator of the sessions was to enable the women to discover their GRRs.

This program consisted of 4 group sessions, each lasting 2 h for a total of 8 h, a duration similar to analogous programs in other studies [38] (Fig. 1). The specific activities carried out in each session were as follows:

Participants in the study were migrant women at risk of social exclusion who were participating in the Ecosol and Avancem Santa Clara programs of Caritas Diocesana. The 6-month programs focus on strengthening professional skills through a personalized itinerary, with the aim of helping these women join the job market. Participants were divided into 4 groups of 7 women each. The groups were intentionally heterogeneous, with participants of different ethnic origins, religious and cultural backgrounds, and languages.

The effectiveness of the intervention was measured by comparing the results of a questionnaire before and after the 6-month salutogenic health promotion program.

The questionnaire included the following information:

A descriptive analysis of the sociodemographic variables was carried out. The binary relationship between variables was calculated using Pearson’s chi-square test/Pearson’s correlation, Student t-test and one-way ANOVA test. The bivariate effectiveness of the program was evaluated by Student paired t-test or Wilcoxon test. Normal distribution was assumed with the Kolmogorov-Smirnov and Shapiro-Wilk tests.

A sequential multiple regression analysis was used to predict the factors associated with the effectiveness of the program. Initially, the model included as independent variables the factors with published evidence of statistically significant bivariate association with the selected program.

The Statistical Package for the Social Sciences (SPSS) v.20.0 for Windows was used for data processing and analysis. The level of significance (p) was established as p < 0.05.

The results of the pretest questionnaire according to the social demographic data are shown in Additional file 1. On one hand, women from Sub-Saharan African countries had higher self-esteem compared to women from Morocco and Latin-American countries. On the other hand, participants who reported their socioeconomic situation as “bad” or “very bad” had higher levels of perceived stress than participants who considered their socioeconomic status to be “good”. Furthermore, participants from rural environments had higher scores in the mental dimension of quality of life, compared to those from urban areas.

After their participation in the health promotion program, participants showed a remarkable decrease in the SOC dimension of comprehensibility and in their perceived stress [see Table 2]. They also had an increased physical QL and showed a trend toward increased self-esteem.

Changes in the dependent variables between the pretest and posttest in relationship with the sociodemographic data are shown in Additional file 2. A greater increase in SOC can be observed in the women from Latin-American countries who were not living within a family setting at the moment of the study. Mean values for self-esteem increased more among participants from Latin-American countries, compared to those from Sub-Saharan African countries. In contrast, a decrease in self-esteem was observed among the women from Morocco. Participants with responsibility for dependent family members experienced a decrease in the mean value of perceived stress. Women younger than 35 years increased their mean physical QL score, while the older participants showed a decrease. In contrast, the younger women reported a decrease in the mean quality of mental health, while participants older than 35 years reported an increase.

Findings presented in Additional file 3 showed that all variations in mean values were inversely related to participants’ own initial value. In addition, an inverse relationship between the change in perceived stress and initial mental health QL was observed (− 0.426; p < 0.05). Thus, the decline in perceived stress was greater in women who initially reported a lower mental QL. On the other hand, the initial physical QL scores (0.466; p < 0.05) were positively correlated with changes in self-esteem.

Multiple regression analysis was carried out to examine the relationship between the change in each construct and the various potential predictive factors. Additional file 4 summarizes the initial model (model 1), which compiled all independent variables, and the final model (model 2), which assembled the variables having a statistically significant correlation with the change in each construct after the health promotion program [see Fig. 2].

The health promotion program contributed to a greater increase in SOC in participants with a higher social support score and lower SOC at baseline, compared to the mean. The greatest change in perceived social support was observed in participants with a low initial score who were living within a family setting.

Higher perceived social support and mental QL at baseline were correlated with an increase in self-esteem at follow-up. In contrast, the higher the initial self-esteem values, the less change was observed. Eventually, a greater change in perceived stress was noted in participants with lower initial values for perceived stress, mental QL, and social support.

In reference to the quality of mental and physical health, greater change in physical QL was detected in younger women (< 35 years old) and in participants with lower initial physical QL scores. In contrast, greater change in mental QL was observed in older women and participants coming from Latin-American countries.