Healthy ageing in a comparative perspective
Reus Pons, Matias
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Publication date: 2018
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Reus Pons, M. (2018). Healthy ageing in a comparative perspective: A study of the health of older migrants and non-migrants across Europe. University of Groningen.
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chapter 6
Chapter 6
6.1 InTroducTIon And rEsEArcH quEsTIons
This study aimed to provide crucial new knowledge on the health of older mi-grants and older non-mimi-grants in Europe. The overall objective was to assess differences in health and health transitions between older people with and with-out a migration background, and to explain these differences using a range of individual and contextual factors. The two general research questions that guided the thesis were as follows:
How does the health of older migrants and non-migrants differ across European countries, and how do these differences evolve over time and with age?
To what extent are the health differences between older migrants and non-migrants in Europe explained via individual and contextual factors?
Most previous research on the health inequalities between migrants and non-migrants was conducted within a single country, using a cross-sectional approach, and rarely focused on the older population. To gain a better understanding of how healthy ageing differs between migrants and non-migrants, studies are needed that go beyond the national level and beyond the use of a cross-sectional approach. This study combined cross-sectional and longitudinal approaches in comparing the health of migrants (of diverse origins) and non-migrants in different European countries, and considered the role of contextual effects of the country of residence. Furthermore, many earlier studies focused on a single dimension of health only, even though various health indicators may capture dif-ferent aspects of health or difdif-ferent stages in the disablement process (Jagger et al., 2011). Therefore, taking into account different dimensions of health, includ-ing mortality, as well as measures of both physical and mental health, is essential to gaining a better understanding of the pathways that lead to inequalities in health between migrants and non-migrants.
By doing so, this thesis aimed to overcome some of the gaps in the existing literature, and to add knowledge about whether and, if so, to what extent older migrants are in a specific and/or more precarious health situation than older non-migrants.
In the remainder of this concluding chapter, a summary of the results by chapter is provided, followed by a discussion of the main results in light of the existing theory. Finally, suggestions for future research are formulated, the implications
of the results for society are discussed, and recommendations for policymakers are made.
6.2 summAry of THE fIndIngs
Chapter 2 investigated whether there were differences in overall and cause-specific mortality between older migrants and non-migrants in Belgium during an eight-year mortality follow-up (2001–2009). More specifically, the goal of the analysis was to answer the following questions: Do migrants maintain an overall mortality advantage at older ages? How are the overall mortality differences between older migrants and non-migrants reflected in cause-specific mortality? The findings indicated that at older ages, migrants in Belgium seem to maintain an overall mortality advantage relative to non-migrants, despite their lower socio-economic status. This overall migrant mortality advantage was primarily explained by their lower levels of mortality from most cancers and cardiovascular diseases. However, the analysis also showed that older migrants were at higher risk than non-migrants of dying from infectious diseases and diabetes-related causes, and that older male migrants of western origin were at higher risk of dying from respiratory diseases than their non-migrant counterparts. The results further indicated that older fe-male migrants had mortality disadvantages relative to their non-migrant counter-parts for lung cancer (western migrants) and cardiovascular disease (non-western migrants). After controlling for socio-economic status, most of the cause-specific mortality disadvantages found among migrants disappeared.
Chapter 3 examined whether healthy life expectancy at age 50 (HLE50) differed
between migrants and non-migrants in Belgium, the Netherlands, and England and Wales; and evaluated how these differences evolved between 2001 and 2011 in the latter two countries. The specific research questions addressed in this chap-ter were as follows: In what ways does the HLE50 of migrants and non-migrants
differ? How have these differences evolved over time? To what extent are the differences in the HLE50 of older migrants and non-migrants, and the changes
in these differences over time, attributable to either mortality or general health? The findings of the analyses were very consistent across all three countries, and showed that regardless of whether migrants might had lived (or not) for a longer time period, older migrants in Europe – and especially older non-western mi-grants – could expect to spend fewer years in good health than their non-migrant counterparts, in both absolute and relative terms. Over time, the differences in HLE50 between migrants and non-migrants diminished in the Netherlands, but
Chapter 6
widened in England and Wales. The reduction of the inequalities in the Nether-lands was mainly explained by a substantial improvement in general health among those individuals with the lowest HLE50; i.e., non-western migrants. In contrast,
the changes in HLE50 in England and Wales were mainly driven by mortality
improvements, which led to increases among all groups in the share of years of life individuals could expect to live in poor health. Additionally, the differences in the development of mortality and morbidity led to an increase in the inequalities in HLE50 between (non-western) migrants and non-migrants.
Chapter 4 explored the differences in health transitions between older migrants and non-migrants in Europe during the 2004 to 2015 period. The specific research questions addressed in this chapter were as follows: Compared to non-migrants, are migrants more likely to experience a deterioration in health as compared to maintaining good health; and are they less likely to experience an improvement in health as compared to remaining in poor health? To what extent are the dif-ferences in the health transition patterns of older migrants and non-migrants explained by the differences in their socio-economic profile and health-related behaviours? The results showed that at older ages, both western and non-western migrants had a higher risk of health deterioration than non-migrants. Western (male and female) migrants and non-western female migrants were also found to be less likely than non-migrants to experience an improvement in health. In contrast, non-western male migrants were shown to be more likely than their non-migrant counterparts to experience an improvement in health. Having a low level of education, being unemployed or economically inactive, being overweight or obese, having ever smoked, and having poor exercise habits were identified as factors that increased the likelihood of experiencing health deterioration, and that decreased the risk of experiencing an improvement in health. However, the differences in the health transition patterns of older migrants and non-migrants remained largely unexplained after the inclusion of these individual-level covari-ates.
Finally, chapter 5 investigated differences in the overall health, the physical health, and the mental health of older migrants and non-migrants in Europe (2004–2015); and the extent to which individual factors and the context of the country of resi-dence (integration policies and public attitudes towards migration and migrants) explained these health inequalities. The specific research questions addressed in this chapter were as follows: In what ways do older migrants and non-migrants in Europe differ in their overall health, their physical health, and their mental health? To what extent do integration policies and public attitudes towards migration and
migrants explain the health differences between older migrants and non-migrants in Europe? To what extent is the association between health on the one hand and integration policies and public attitudes on the other dependent on the origin of the migrants? The results showed that older migrants in Europe, and especially those of non-western origin, had higher odds of having poor self-rated health, diabetes, and depression than their non-migrant counterparts. The association observed between migrant health and public attitudes towards migration and migrants reflected the expected pattern; i.e., the worst health outcomes among migrants were found in countries with less favourable attitudes towards migra-tion and migrants. This associamigra-tion was stronger among non-western migrants than among western migrants. For depression, the association was in the same direction, but not statistically significant. The association between integration policies and migrant health was, however, less clear. In general, inequalities in general, physical, and mental health persisted between older migrants and older non-migrants, even after the inclusion of individual- and context-level factors. 6.3 THEorETIcAl ImplIcATIons of THE fIndIngs
6.3.1 Differences in health and health transitions between older migrants and non-migrants in Europe
In general, the thesis showed that older migrants in Europe have poorer health than older non-migrants. At age 50, migrants in Belgium, the Netherlands, and England and Wales could expect to live a smaller number of years in good health than non-migrants. The share of remaining life years after age 50 that could be expected to be lived in good health was also found to be lower among migrants (chapter 3). Chapters 4 and 5 further investigated migrant health across 10 western and southern European countries: Austria, Belgium, Denmark, France, Germany, Italy, the Netherlands, Spain, Sweden, and Switzerland. Older migrants in Europe were found to be disadvantaged not only in terms of their general health (chapter 4), but also in terms of their physical and mental health (chapter 5). Migrants in Europe were shown to have higher risks of health deterioration and lower risks of health recovery with age than non-migrants. Thus, the analysis found that the health inequalities between migrants and non-migrants increased with age (chapter 4). Migrants in Belgium were also shown to be more likely to die from certain specific causes than non-migrants; most notably, infectious diseases and diabetes-related causes (chapter 2).
Chapter 6
The finding that older migrants in Europe tend to be in worse health than older non-migrants may well be attributable to the steeper rates of health decline with age among migrants than among non-migrants (e.g. Kim et al., 2013). Migrants may be exposed to a series of health risks over their life courses, which may in turn be responsible for their faster rates of deterioration in health with age, and for their health disadvantage relative to non-migrants at older ages. The ‘cumula-tive disadvantage’ theory (Angel et al., 2001; Dannefer, 2003) posits that migrants tend to suffer from the negative effects of having a lower socio-economic posi-tion throughout their life courses, which could have a detrimental effect on their health. Indeed, migration can be accompanied by a range of negative effects, including material deprivation, poor working conditions, social isolation, psycho-social stress, and limited access to services (Gushulak et al., 2010). Furthermore, ‘acculturation’ hypotheses suggest that over time, migrants may adopt unhealthy lifestyles from the host society which, in the long run, could have negative effects on their health (Abraído-Lanza et al., 2005; Kunst et al., 2011).
These results appear to contradict the general finding that younger adult migrants have a health advantage relative to non-migrants, especially shortly after arrival. Given that migrants tend to have lower socio-economic status than non-migrants, and that low socio-economic status is strongly associated with poor health and in-creased mortality, the overall mortality advantage of migrants over non-migrants has been described as the ‘migrant mortality paradox’ (Abraído-Lanza et al., 1999; Palloni & Arias, 2004). However, the adult migrant health advantage at arrival and shortly thereafter is reflected not only in reduced mortality, but also in better general, physical, and mental health (Goldman et al., 2014; Gubernskaya, 2015; Garcia & Reyes, 2017). Evidence showing that compared to non-migrants, migrants are more likely to follow healthy lifestyles, including having a healthier diet and drinking and smoking less (Abraído-Lanza et al., 2005), may explain their relative advantage in terms of most chronic conditions. In addition, improve-ments in socio-economic, sanitary, and health care conditions might have resulted in declines in the prevalence of and mortality from communicable diseases among certain groups of migrants (Razum & Twardella, 2002). In addition, the tendency of migrants to be in better health than non-migrants at the time of arrival and shortly thereafter has been explained by ‘positive health selection’ or the ‘healthy migrant effect’, which is based on the observation that individuals who decide to migrate are disproportionately young and healthy (Razum et al., 1998; Abraído-Lanza et al., 1999; Palloni & Arias, 2004; Rechel et al., 2013; Vandenheede et al., 2015).
However, the differences in health between migrants and non-migrants in Europe that were found in this and in previous studies depended not only on the ages of the individuals studied, but also on the dimension of health studied, and on the migrants’ countries of origin and countries of residence. First, the results of this study show that differences in health between migrants and non-migrants vary according to the dimension of health under study. In contrast with their general health disadvantage, older migrants in at least some European countries also had certain health advantages over non-migrants. Specifically, older migrants in Belgium were found to have an overall mortality advantage over non-migrants, which was reflected in their lower mortality from most cancers and cardiovascular diseases (chapters 2 and 3). In the literature, two plausible explanations have been offered for why older migrants maintain an overall mortality advantage even though they have a general health disadvantage relative to older non-migrants due to steeper rates of health deterioration. The ‘negative health selection’ or ‘salmon bias effect’ hypothesis argues that migrants tend to return to their country of origin later in life when their health declines, leaving behind a healthier migrant population in the country of destination (Razum et al., 1998; Palloni & Arias, 2004). However, previous studies have shown that negative health selection is not widespread in the European context. Because many older migrants come from countries with relatively poor living conditions and health care, they usually prefer to stay in Europe than to return, even though return migration is prevalent among some origin groups (Razum et al., 1998; Vandenheede et al., 2015). It thus appears likely that in the European context, the overall migrant mortality advantage at older ages is attributable to the rather long latency periods between the adoption of certain risk profiles and the clinical manifestation of the disease and subsequent mortality (Law & Wald, 1999; Razum & Twardella, 2002; Rechel et al., 2013).
Second, we observed that in general, older migrants from non-western countries had the worst overall health, physical health, and mental health outcomes (chap-ters 3–5); as well as increased risks of experiencing a deterioration in health with age (chapter 4). These findings illustrate the importance of the context of origin. Migrants’ baseline health status is affected by the context of origin through the country’s physical, socio-economic, and political environment; and through the country’s role in shaping health-related behaviours and practices (Razum & Twardella, 2002; Abraído-Lanza et al., 2005; Deboosere & Gadeyne, 2005). These findings suggest that over the life course, non-western migrants might be exposed to more health risks than western migrants (greater ‘cumulative disadvantage’). Indeed, the analyses presented in chapters 4 and 5 showed that compared to
Chapter 6
non-migrants, migrants in Europe, and especially those of non-western origin, were more likely to be unemployed or economically inactive, less likely to exercise regularly, and more likely to be obese. However, older male migrants of non-western origin were also more likely than non-migrants to experience an improve-ment in health with age (chapter 4). Therefore, the findings seem to suggest that compared to migrants of western origin, migrants of non-western origin were not only exposed to more health risks over their life courses, but also that they exhibited a wider range of healthy lifestyles and strategies. It has, for example, been shown that non-western migrants have low rates of smoking and drinking (Abraído-Lanza et al., 2005), and strong social networks and spiritual resources (Kristiansen et al., 2016).
Third, differences in the health situations of migrants were also found depend-ing on the country of residence. While migrants – and especially those of non-western origin – were shown to have lower healthy life expectancies at age 50 than non-migrants in the Netherlands and in England and Wales, the trends in these two contexts were found to differ over time (chapter 3). The findings indicated that over time, the inequalities decreased in the Netherlands, but increased in England and Wales. Furthermore, the results of this study differed from those of studies conducted outside of Europe. For instance, whereas analyses in this thesis showed that older migrants in Europe tend to be in poorer health than non-migrants, this was not found to be the case in studies performed in the United States (e.g. Gubernskaya, 2014; Garcia & Reyes, 2017). It therefore appears that differences in health between (older) migrants and non-migrants vary depending on the characteristics of the migrants, including their specific countries of origin and their migration histories; the specific context in the country of reception; and the interaction between the characteristics in the contexts of origin and reception.
6.3.2 Factors that explain the differences in health and health transitions between older migrants and non-migrants in Europe
The previous section discussed the main findings regarding the differences in health between older migrants and non-migrants in Europe, and introduced the main theories that seek to explain such inequalities. Analyses in this thesis also tested some of the mechanisms cited in these theories to explain health inequalities, including individual-level factors (socio-economic status, health-related behaviours) and context-level factors (integration policies, public attitudes towards migration and migrants). After all, the health of migrants is the result of a complex interplay of exposures (legal, social, economic, cultural, behavioural)
over their life courses, including health challenges specifically related to migration (International Organization for Migration, 2006).
According to the ‘cumulative disadvantage’ theory and the ‘acculturation’ theory, having low socio-economic status over the life course and having adopted health-damaging behaviours earlier in life are the main mechanisms that underlie the poorer health among migrants at older ages. Analyses in this thesis provided evidence that having low socio-economic status and engaging in health-damaging behaviours partially explained migrants’ disadvantages in overall health, physical health, and mental health (chapter 5); and in mortality from specific causes of death (chapter 2). The longitudinal perspective taken in chapter 4 allowed to draw some stronger (causal) conclusions regarding the effects of a series of individual-level determinants of health in explaining the inequalities in the health transition patterns of older migrants and non-migrants in Europe. Factors that increased the likelihood of experiencing health deterioration, and decreased the risk of experiencing health improvement, included having a low level of education, being unemployed or economically inactive, being overweight or obese, having ever smoked, and having poor exercise habits. These associations were evident for both migrants and non-migrants, although migrants were generally found to have lower socio-economic status, to exercise less, and to have higher rates of obesity. The policy and the societal context in the country of residence create the situa-tions and the condisitua-tions in which socio-economic, behavioural, and other factors shape health inequalities across various population groups (Solar & Irwin, 2010). Specific aspects of a given context may affect migrants and non-migrants differ-ently, and contribute to situations and conditions in which migrants are exposed to factors that could affect their health after they settle in the destination country. In this thesis, we studied the extent to which integration policies and public attitudes affected the health of older migrants and non-migrants (chapter 5). Non-western migrants were found to have relatively poor general health and physical health outcomes in countries with both less inclusive and more inclusive integration policies. The latter finding was rather unexpected. Previous studies have raised concerns about whether implementing highly inclusive policies – with the no-table exception of anti-discrimination policies – is an efficient way to integrate non-western migrants into society and into the labour market (Koopmans, 2010; Ziller, 2017). This observation might explain why health inequalities between migrants and non-migrants were not found to be smaller in countries with more inclusive policies. Nevertheless, it is important to acknowledge that the data on these policies referred to the policy situation in 2007; whereas older migrants,
Chapter 6
most of whom arrived many years ago, have been exposed to wide and varying policy contexts over their lives.
In contrast, the effects of public attitudes towards migration and migrants clearly reflected the expected pattern: migrants had the poorest general health and physi-cal health outcomes in countries with less favourable attitudes, followed by in countries with intermediate levels of attitudes, and finally by in countries with more favourable attitudes. Thus, less favourable attitudes towards migration and migrants were found to be an important predictor of migrant health inequali-ties. This finding has important implications. On the one hand, positive views of migration and migrants may provide a more favourable context for the social and economic integration of migrants into society, which might in turn lead to better health outcomes among migrants (Berry, 2005). On the other hand, nega-tive perceptions of migration and migrants, and especially when coupled by acts of racism or discrimination, could have very negative effects on migrants’ health (Paradies, 2006; Johnston & Lordan, 2012).
Nevertheless, the policy and societal contexts in the country of residence might not be as important in determining migrant mental health inequalities. Although they were not statistically significant, the associations found between policies and attitudes and the mental health inequalities observed between older migrants and non-migrants followed a pattern similar to those of general health and physical health. It could be the case that migrants’ experiences before and during the migration process – especially if the migration was forced and traumatic – are more important in determining migrants’ mental health than the context in the country of residence. Indeed, poor mental health among migrants has been shown to be strongly associated with the context and the conditions during the pre-departure and movement phases of the migration process, and with the dif-ficulties the individual faces in starting a new life in a new environment, including the threat of material deprivation and social isolation (Gushulak et al., 2010). Large differences between migrant origin groups are therefore possible. Although the findings revealed no significant association between the context and mental health, these results may hide group diversity, with both positive and negative effects for different individuals or migrant groups.
Finally, it is important to note that the effects of the country of residence may not be independent of the effects of the country of origin. For instance, public attitudes towards migrants or integration policies may affect migrants differently depending on their country origin. The findings of this study showed that the
association between public attitudes and migrants’ health was stronger among non-western than among western migrants (chapter 5). Indeed, attitudes towards migrants tend to be more negative with increasing cultural (Schneider, 2008) and religious (Coenders et al., 2008) distance. In turn, the stress migrants experience from potentially threatening public attitudes towards migrants may negatively affect their health through a range of diseases (Cohen et al., 2007). The results also showed that western migrants and non-migrants had similar health outcome patterns regardless of the integration policies in the country of residence (chapter 5). This finding was expected because most of the western migrants studied are of European origin, and thus have residency, social, and political rights that many non-western migrants lack (European Commission, 2015).
6.4 rEflEcTIon on THE ApproAcH
6.4.1 Main strengths of the approach and innovativeness of the study
This thesis used a novel, multidisciplinary, and cross-country comparative ap-proach to study differences in health between migrants and non-migrants, with a specific focus on the older population. Both cross-sectional and longitudinal perspectives were taken, and various dimensions of health were considered: namely, mortality, general health, physical health, and mental health. The extent to which both individual and contextual factors explain the health inequalities between older migrants and non-migrants in Europe was considered. This novel approach generated new insights regarding the health inequalities between older migrants and non-migrants in Europe.
First, because the analyses focused specifically on the older population, the results differed from those of studies on the younger adult population. This highlights the importance of the ‘cumulative disadvantage’ over the life course (Angel et al., 2001; Dannefer, 2003), as well as of the ‘time lag’ explanation (Law & Wald, 1999). Second, by incorporating a longitudinal approach, the analyses were able to show how cumulative exposure to various health risks over the life course results in a migrant health disadvantage at older ages; i.e., migrants were found to be at greater risk of health deterioration with age than non-migrants. Third, the incorporation of a series of dimensions of health and the cross-country comparative perspective allowed to observe a general health disadvantage among older migrants in Europe, but also to discern important differences in this pattern of disadvantage according to the health dimension or the country of residence studied. For instance, because the inequalities in mortality do not necessarily
Chapter 6
follow the same pattern as the inequalities in general health, a measure that com-bined the two provided additional insights. It was also found that the inequalities in healthy life expectancy declined over time in the Netherlands, but increased in England and Wales. Fourth, the further exploration of the context in the country of residence generated additional insights about the extent to which the policy and the societal context explain the health differences between migrants and non-migrants.
6.4.2 Main challenges and suggestions for future research
A series limitations of the present study should be mentioned. The availability and the quality of the data, especially for older migrant populations, made it challenging to study migrant health across countries and over time, between various migrant groups, and over the life courses of migrants. First, the use of census- and register-based data in different countries led to comparability issues across space and time. For instance, changes in the phrasing of the question on general health hindered the comparison of healthy life expectancy at age 50 for certain groups (e.g., non-western migrants) in different countries and over time. Second, censuses and registers often provide little information, and might be af-fected by return bias (Kristiansen et al., 2016). By contrast, surveys provide both more detailed information and enhanced comparability across space and time. However, most of these surveys are not designed to adequately study migrant populations, as they tend to have relatively small samples of migrants (Rechel et al., 2013; Kristiansen et al., 2016). This limitation prevented the categorisation of migrants according to their country of origin, beyond making a broad distinction between western and non-western migrants. Third, a major limitation of this and other studies is the limited availability of comparable longitudinal, preferably lifelong, data (Sauzet & Leyland, 2017).
In conclusion, because survey data contain more detailed information and are more comparable across space and time than census- or register-based data, these data offer more options for analysis. However, greater efforts are needed to col-lect survey data, preferably over the life course, with oversampling of migrants to ensure representativeness. The greater availability of this type of data would al-low future research to draw more nuanced conclusions regarding the role of the context of origin and the role of exposures over the life course in the health
outcomes of (older) migrants, and would improve the comparability of findings across space and time. While making a broad distinction between western and non-western migrants provided important insights, a more detailed analysis that compares countries or regions of origin could lead to more nuanced
conclu-sions. For instance, analyses on census-linked mortality register data have shown that mortality patterns differ substantially according to the specific country of origin, beyond the western versus non-western classification (chapter 2). Having access to longitudinal data that span the life course would allow researchers to study the effects of exposures over the life courses of individuals on current health inequalities, and to disentangle the effects of the exposures migrants face before, during, and after migration. Furthermore, panel survey data may have an additional advantage over register data; while migrants do not always de-register when leaving the country (and thus remain counted as residents), it is possible to identify the individuals who could not be reached in a panel survey (and are thus counted as ‘no information’). Having access to such data could allow for a more precise quantification of exposures (person-years), and for a more precise tracking of changes over time. For instance, it might become easier to distinguish between cases in which a certain characteristic did not change (e.g., self-rated health remained ‘good’) and cases in which the individual died, emigrated, or was simply lost to follow-up (unreachable).
By examining the extent to which both individual and contextual factors explain the health inequalities between older migrants and non-migrants in Europe, this study provided new insights. First, this study showed that integration policies and public attitudes were strongly associated with the health inequalities between older migrants and non-migrants across Europe. However, further research is needed to better understand the effects of integration policies and public at-titudes on migrant health. Additional insights on the role of the context of destination in the health inequalities between (older) migrants and non-migrants
may be gained by investigating the effects of specific policy domains (e.g., anti-discrimination policies, health-related policies, economic integration policies), as well as the effects of specific public attitudes that are more or less dominant in a society. Second, it is important to note that although the results of our analyses showed that individual and contextual factors had strong effects on health, the health inequalities between older migrants and non-migrants remained largely un-explained. This observation highlights that several key explanatory factors that contribute to these inequalities have yet to be addressed. Further research
should investigate the extent to which events that take place before and during the migration process explain the differences in health and in health transitions between older migrants and non-migrants. More specifically, the reasons for migration – including whether migration was voluntary – and the conditions dur-ing migration might be important determinants of migrant health. Research that focuses on the health differences between migrants and individuals having not
Chapter 6
migrated in their region of origin would also allow for a more nuanced conclu-sions on the risks and the benefits associated with migration, including potential socio-economic and behavioural changes and later life health outcomes. Specific conditions may in turn be shown to be related to the development of specific diseases and health needs, which could prove useful when formulating policies and interventions.
This thesis separately addressed how health inequalities evolved with increasing age, and over time. The results showed that migrants were less likely than non-migrants to age in good health; and that, at least in certain countries, the health inequalities between older migrants and non-migrants seem to be widening over time. This thesis provided no evidence to link these two outcomes, which arose from different datasets, different geographical contexts, and different time peri-ods. Nevertheless, it is possible to speculate that as the shares of older migrants in European populations increase (Lanzieri, 2011), and the health inequalities be-tween migrants and non-migrants widen with age, the health inequalities bebe-tween (older) migrants and non-migrants will grow over time. Further research is needed to investigate to what extent the failure to promote healthy ageing among migrants explains the widening health inequalities between migrants and non-migrants over time. It could also be interesting to study whether the
widen-ing of (relative) health inequalities between socio-economic groups (Hu et al., 2016; Mackenbach et al., 2016) is partly responsible for the increase in the health inequalities between migrants and non-migrants over time.
Finally, it is important to mention that certain groups of migrants, such as ir-regular migrants, are rarely included in datasets. Irir-regular migrants often live and work in very precarious situations, and tend to be denied access to social and health services (Rechel et al., 2013). The findings presented in this study only cov-ered migrants who were registcov-ered or participated in surveys. Because the most disadvantaged group of migrants was not taken into consideration, the study’s conclusions regarding migrant health might be too optimistic. Further research could investigate to what extent the health outcomes of irregular migrants, who are often excluded from datasets, differ from those of regularised migrants. Additional insight is needed into the extent to which excluding certain
groups of migrants affects the outcomes of research on migrant health based on survey, census, or register data.
6.5 ImplIcATIons for polIcy And socIETy
This study provided evidence that despite the potential existence of a migrant health advantage shortly after migration, migrants experience steeper rates of health decline with age that lead to a health disadvantage relative to non-migrants at older ages. Thus, healthy ageing does not seem to be as prevalent among mi-grants as among non-mimi-grants.
Given the increasing proportions of older migrants in European populations (Lanzieri, 2011), this pattern raises some important public health issues. Promot-ing healthy agePromot-ing and improvPromot-ing the health outcomes of (older) migrants will be essential to efforts to improve the overall health of the population. Europe’s current migration and demographic trends, which have recently been altered by waves of refugees arriving on the continent, will no doubt pose economic and social challenges for European societies. These countries therefore need to pre-pare their educational, economic, and health care systems to deal with these new and varied demands (England & Azzopardi-Muscat, 2017; Schilling et al., 2017). The findings of this thesis (the persistence of inequalities) suggest that poli-cies aimed at promoting healthy ageing may not be adequately targeting certain disadvantaged population subgroups, including migrants, and especially migrants of non-western origin. Based on the findings of this study, a series of policy recommendations for providing equal opportunities to maintain good health are presented. These interventions could lead to better health outcomes for all older individuals, and thus to a reduction in health inequalities at older ages. However, these policy recommendations can be applied not just to health policy, but to multiple sectors. After all, the health of migrants is the result of a complex inter-play of exposures (legal, social, economic, cultural, behavioural) during their life courses (International Organization for Migration, 2006).
Before moving on to the specific policy recommendations, the target popula-tion will be briefly discussed. Should policymakers target migrant communities in particular or disadvantaged individuals in general, regardless of whether they are migrants? The findings of the thesis indicate that policy approaches aimed at tackling health inequalities should target the general population, irrespective of migrant status or other individual characteristics. However, it is also important to note that general approaches might need to be tailored to reach a given target population, and particularly migrants. Informal barriers, such as language, culture, or knowledge about health care and rights, could interfere with the realisation
Chapter 6
of policy goals. For instance, cultural values and low levels of knowledge about health-related issues seem to explain why relatively small shares of non-western female migrants undergo breast cancer screening (Nørredam & Krasnik, 2011). First, socio-economic inequalities between (non-western) migrants and non-migrants must be addressed to reduce the health inequalities between
these groups. This thesis showed that education, job status, and housing status are among the factors that explain the health inequalities between older migrants and non-migrants in Europe (chapters 2, 4, and 5). The effects of living and working conditions on migrant health outcomes have been discussed elsewhere as well (e.g., Gushulak et al., 2010). Thus, policies aimed at socio-economic re-distribution are needed, and efforts should be made to disseminate knowledge to less educated groups. Promoting health literacy is essential to ensuring that all members of society understand how to prevent disease and adhere to treatments. In particular, efforts should be made to promote the use of preventive health ser-vices, which tends to be rather low among migrants (Nørredam & Krasnik, 2011). To adequately reach migrants, these efforts to promote health literacy and the use of preventive services will need to be tailored to the languages and cultural sensi-tivities of specific migrant groups. Improving the multicultural competencies of workers in the health sector is therefore crucial to implementing these strategies (Rechel et al., 2013). In addition, migrants could be provided with information about the health care and social systems and about their rights by health workers. This information could also be disseminated at courses or workshops migrants attend, such as language classes or courses on residency requirements and labour market incorporation.
Second, policies aimed at reducing the health inequalities between (non-western) migrants and non-migrants should address health-related be-haviours. Chapters 4 and 5 showed how diet, exercise, and smoking are strong
predictors of health inequalities between older migrants and non-migrants in Europe. The influence of health-related behaviours on migrant health has also been discussed elsewhere (e.g., Abraído-Lanza et al., 2005). Therefore, interven-tions that promote eating in a healthy manner, exercising regularly, drinking in moderation, and stopping smoking might be key to achieving equality in health at older ages. Among older migrants in particular, and especially among older non-western female migrants, diet and exercise seem to be the most important risk factors. As was mentioned above, to adequately reach migrants, these inter-ventions may need to be tailored to the languages and cultural sensitivities of specific groups.
Third, to improve migrant health outcomes, policymakers should also take into consideration the effects of public attitudes towards migration and migrants, as these attitudes have been shown to be an important predictor of
migrant health inequalities (chapter 5). These concerns might be even more rel-evant in the current European context, where anti-immigrant political parties are gaining support. Therefore, taking action to promote favourable public attitudes towards migration and migrants could be an effective way to reduce health in-equalities between migrants and non-migrants in Europe. This could be achieved by adopting a more migrant-friendly (and inclusive) discourse at the policy and political levels, and by ensuring that this migrant-friendly discourse is reflected in actual rights (policy level). Furthermore, campaigns to promote more inclusive attitudes could be created and spread by the (national) media. The evidence suggests that on balance, migration has a positive impact on the economy and wellbeing of the societies in the countries of reception (e.g., Di Giovanni et al., 2015). Thus, it is important to ensure that information and counter-arguments to anti-immigrant discourses are easily accessible to the population, regardless of their level of education or other individual characteristics. In addition to these top-down approaches, bottom-up interventions should also be considered. For instance, governments may fund organisations that provide settings or organise activities where migrants and non-migrants can meet and interact with each other. After all, having contacts and friends from minority groups has been shown to be associated with more favourable attitudes towards migrants (Schneider, 2008). Fourth, to reduce the health inequalities between migrants and non-migrants at older ages, policymakers should not limit their focus to the older population.
Policymakers should target the younger population as well. Indeed, if the
aim is to reduce health inequalities at older ages, it will be necessary to address the needs of the older population. It has, for example, been shown that socio-economic and lifestyle changes at ages 50–60 are beneficial for health outcomes in later life (Hessel & Avendano, 2016; Berstad et al., 2017). However, this thesis clearly showed that poor health outcomes at older ages are frequently the result of cumulative disadvantages over the life course. Consequently, policymakers will need to target the younger population, including migrants from the moment of arrival (England & Azzopardi-Muscat, 2017). After all, the younger population of today will become the older population of tomorrow.
Chapter 6
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