Abstract

Background: The immigrant population living in Spain grew exponentially in the early 2000s but has been particularly affected by the economic crisis. This study aims to analyse health inequalities between immigrants born in middle- or low-income countries and natives in Spain, in 2006 and 2012, taking into account gender, year of arrival and socioeconomic exposures. Methods: Study of trends using two cross-sections, the 2006 and 2012 editions of the Spanish National Health Survey, including residents in Spain aged 15–64 years (20 810 natives and 2950 immigrants in 2006, 14 291 natives and 2448 immigrants in 2012). Fair/poor self-rated health, poor mental health (GHQ-12 > 2), chronic activity limitation and use of psychotropic drugs were compared between natives and immigrants who arrived in Spain before 2006, adjusting robust Poisson regression models for age and socioeconomic variables to obtain prevalence ratios (PR) and 95% confidence interval (CI). Results: Inequalities in poor self-rated health between immigrants and natives tend to increase among women (age-adjusted PR 2006 = 1.39; 95% CI: 1.24–1.56, PR 2012 = 1.56; 95% CI: 1.33–1.82). Among men, there is a new onset of inequalities in poor mental health (PR 2006 = 1.10; 95% CI: 0.86–1.40, PR 2012 = 1.34; 95% CI: 1.06–1.69) and an equalization of the previously lower use of psychotropic drugs (PR 2006 = 0.22; 95% CI: 0.11–0.43, PR 2012 = 1.20; 95% CI: 0.73–2.01). Conclusions: Between 2006 and 2012, immigrants who arrived in Spain before 2006 appeared to worsen their health status when compared with natives. The loss of the healthy immigrant effect in the context of a worse impact of the economic crisis on immigrants appears as potential explanation. Employment, social protection and re-universalization of healthcare would prevent further deterioration of immigrants’ health status.

Introduction

The immigrant population living in Spain grew exponentially in the early 2000s, from 1.5 million foreign-born individuals registered in municipal censuses in 2000 to 6 million in 2008. 1 This immigration phenomenon, predominantly of populations from low income countries, has played a fundamental role in the evolution of the Spanish economy, 2 its timing coinciding with a high demand for unskilled labour during the ‘boom’ period, especially in the sectors of construction, services and domestic help. 3 Studies of national and regional health surveys during those years generally found poorer socioeconomic conditions among immigrants from middle- and low-income countries, but lower rates of chronic conditions and use of medicines result for general self-rated health and mental health being more heterogeneous depending on the study, indicator, gender and country of birth. 4 The evolution of this situation deserves attention, given the deterioration of the healthy immigrant effect, which is extensively described in other countries and reflects their exposure to poor living and working conditions. 5,6

Moreover, since 2008, Spain has stood out as one of the countries most seriously affected by the recent economic crisis in Europe, with adverse effects on health determinants such as unemployment, 2 income and working conditions, 7 especially concentrated among the poor and vulnerable members of society, including immigrants. 8,9 Recent data show that the unemployment rate among immigrants was double that recorded among natives (in 2011, 39.1% and 18.4%, respectively). 10 Besides this greater exposure to detrimental determinants of health, austerity and exclusionist policies have also undermined immigrants’ access to social and health services. 9 Also, the recession has truncated the flow of immigrants arriving in Spain. This influx was observed to slow down, with the total immigrant population finally stabilizing around 6.6 millions between 2010 and 2013. 1

Apart from economic and social consequences, the recent economic crisis has also resulted in changes in population health overall. In Europe, some studies have found short-term effects on some health outcome, such as suicides, which are most noticeable when economic changes occur rapidly and in scenarios of low social protection. 7,11 In Spain, the effects seem to vary depending on the health outcomes studied, with mental health being more affected than self-rated health and all-cause mortality, 12,13 and according to social dimensions of inequality such as gender or socioeconomic position. 13,14

As for changes in the health of immigrants in Spain, one follow-up study of workers indicated an increased risk of poor mental health among those who experienced deterioration in their employment conditions. 7,15 However, we are not aware of general population studies analysing the evolution of immigrants' health in Spain or inequalities compared with native Spaniards. In this regard, the 2012 Spanish National Health Survey offers an excellent opportunity to assess this evolution, considering that both the decline of the healthy immigrant effect and the economic crisis may have had an influence on the patterns observed in the past decade. Therefore, this study aims to analyse inequalities in the distribution of different indicators of general and mental health between immigrants and natives in Spain, in years 2006 and 2012, taking into account gender and year of arrival and the contribution of socioeconomic exposures to these inequalities.

Methods

Design, study population and information sources

This is a study of trends using two cross-sections, performed using data from the 2006 and 2012 editions of the Spanish National Health Survey. The study population consisted of non-institutionalized men and women, aged 16 years and over, who lived in Spain in the year in which they participated in the survey. Subjects were selected by means of a stratified multistage sampling design and personally interviewed at their home. The response rate of the two surveys was approximately 71%. 16 For the purposes of this study, considering the small share of elderly immigrants, people in the economically active age range (16–64 years) were selected. Persons born in countries classified by the International Monetary Fund as advanced economies 17 (representing about 2% of the samples of foreign-born individuals in both years) were excluded from the analyses, in light of previous studies showing their relatively advantaged socioeconomic position and health. 4,18 The final sample included 23 760 individuals interviewed in 2006 and 16 616 in 2012.

Variables

Health outcomes

Included as dependent variables were two indicators of general health status and two of mental health:

  • Self-rated health assessed using the question ‘Within the last 12 months would you say your health was very good, good, fair, bad or very bad?’ and categorizing answers as good (good or very good) and poor (fair, bad or very bad). 19

  • Chronic activity limitation due to a health problem assessed using the question ‘During the last six months, to what extent have you been limited to perform activities that people normally do, due to a health problem? Severely limited, limited, not limited’ and categorizing answers as limited or not limited.

  • Mental health assessed using the 12-item version of the General Health Questionnaire (GHQ), with three or more points indicating poor mental health. 20 The GHQ questions refer to the last weeks.

  • Use of psychotropic drugs assessed using the question: ‘During the past two weeks, have you used tranquilizers, anxiolytics, sleeping pills, antidepressants and/or stimulants?’ (yes/no).

Main independent variable

Immigrant status was defined based on country of birth: Spain or abroad. For the 2012 survey, which collected information on year of arrival, we have further separated those immigrants who arrived before 2006 from those arriving since, considering the former group more similar to immigrants in the 2006 survey.

Adjustment variables

The adjustment variables used in the analysis were age as a continuous variable, educational level (no education, primary, secondary, university), employment status (working, unemployed, homemaker, other), social class (based on the current or last occupation of the person, or of the head of the household for never employed respondents, categorized following the Spanish Society of Epidemiology proposal 21 as: SC I-II: professionals, managers, directors; SC III: administrative workers, clerks, safety and security workers and self-employed; SC IV: skilled and semi-skilled manual occupations; SC V: unskilled manual occupations), marital status (single, married, other), social support (Duke-UNC Functional Social Support Questionnaire, considering scores below the 15% percentile as poor social support) and overcrowding (more than three household members per bedroom or less than 14 m 2 per person). 22

Data analysis

First, socio-demographic characteristics and the age-standardized proportions of health outcomes [plus associated 95% confidence interval (CI)] were described by country of birth, time since arrival (before/since 2006 only in survey of 2012), sex and year of survey. For standardization, we used the direct method taking the foreign-born population in the 2012 National Statistics Institute continuous register as the reference. Then, immigrants who had arrived since 2006 were excluded and both surveys were analyzed jointly. Robust Poisson regression models 23 were fitted to obtain for each survey year the prevalence ratios (PR) for health outcomes of immigrants compared with natives, adjusting for age and then, sequentially adding as explanatory factors (starting with more distal ones) social class, employment status, marital status, overcrowding and social support. Interaction between country of birth and year of survey was included, and sampling weights derived from the sample design were applied. Analyses were performed using Stata version 11.

Results

Socioeconomic and demographic variables

Table 1 presents the socioeconomic and demographic description of the study population by country of birth, sex and year of survey. In both surveys and in both sexes, it may be seen that the immigrants tend to be younger than natives, to have less university studies and to be more likely to belong to the more disadvantaged social classes (IV and V) and to live in overcrowding. Immigrants are more often unemployed than natives, the corresponding percentages and differences being greater for the 2012 edition of the survey. Finally, low social support is more common in the immigrant population compared with natives, although the differences are smaller in 2012.

Table 1

Socioeconomic description of the study population by country of birth, sex and year of survey. Residents in Spain aged 16 to 64

  2006
 
2012
 
Men
 
Women
 
Men
 
Women
 
Spain
 
Immigrants
 
Spain
 
Immigrants
 
Spain
 
Immigrants arrived before 2006
 
Immigrants arrived after 2006
 
Spain
 
Immigrants arrived before 2006
 
Immigrants arrived after 2006
 
n n n n n n n n n n 
Total 10325 88.1 1395 11.9 9901 86.4 1555 13.6 6996 85.9 911 11.2 240 2.9 6771 84.2 907 11.3 361 4.5 
Age (years)                     
    15–24 1550 15.0 288 20.7 1468 14.8 285 18.3 965 13.8 118 12.9 63 26.1 894 13.2 134 14.8 81 22.3 
    25–34 2519 24.4 490 35.1 2198 22.2 630 40.5 1481 21.2 273 29.9 102 42.7 1379 20.4 249 27.4 170 47.1 
    35–44 2445 23.7 389 27.9 2385 24.1 340 21.9 1735 24.8 293 32.1 45 18.9 1635 24.2 309 34.1 66 18.2 
    45–54 2096 20.3 179 12.8 2059 20.8 223 14.3 1556 22.3 170 18.6 18 7.7 1573 23.2 155 17.0 30 8.4 
    55–64 1716 16.6 49 3.5 1792 18.1 77 5.0 1258 18.0 58 6.4 11 4.6 1289 19.0 61 6.7 15 4.1 
Educational level                     
    No education 448 4.4 113 8.1 548 5.6 75 4.9 282 4.0 83 9.1 2.2 302 4.5 52 5.7 2.1 
    Primary 5108 49.9 620 44.6 5062 51.7 620 40.2 4048 57.9 453 49.7 138 57.6 3644 53.8 416 45.9 158 43.8 
    Secondary 2644 25.8 495 35.6 2225 22.7 581 37.7 1460 20.9 272 29.8 65 27.1 1376 20.3 339 37.4 134 37.1 
    University 2042 19.9 163 11.7 1961 20.0 265 17.2 1206 17.2 103 11.3 31 13.1 1449 21.4 100 11.0 61 17.0 
Social class                     
    CS I II 2284 22.3 107 7.7 1775 18.1 109 7.1 1419 20.4 47 5.3 14 6.0 1304 19.7 38 4.3 31 8.9 
    CS III 2513 24.5 135 9.7 2395 24.4 153 10.0 1269 18.3 96 10.7 15 6.4 1683 25.4 92 10.4 24 7.0 
    CS IV 4212 41.1 724 52.2 3845 39.3 690 44.9 3448 49.7 518 57.8 144 61.5 2412 36.4 343 38.7 160 46.2 
    CS V 1228 12.0 421 30.4 1782 18.2 583 38.0 806 11.6 236 26.2 61 26.0 1232 18.6 413 46.6 131 37.9 
Employment status                     
    Working 7599 73.7 1161 83.3 5008 50.7 953 61.5 4371 62.5 460 50.5 127 52.8 3454 51.0 485 53.5 165 45.7 
    Unemployed 767 7.4 136 9.8 1007 10.2 164 10.5 1305 18.7 326 35.8 63 26.3 1032 15.2 186 20.6 66 18.4 
    Homemaker 16 0.2 0.0 0.0 2518 25.5 345 22.2 43 0.6 13 1.4 2.9 1226 18.1 149 16.4 83 23.0 
    Other 1926 18.7 97 6.9 1349 13.7 90 5.8 1277 18.3 112 12.3 43 18.1 1059 15.6 86 9.5 47 12.9 
Marital status                     
    Single 4346 42.2 661 47.4 3089 31.3 583 37.6 2890 41.3 328 36.2 132 55.0 2326 34.4 330 36.4 178 49.2 
    Married 5499 53.4 666 47.7 5981 60.6 846 54.5 3770 53.9 533 58.8 106 44.4 3802 56.2 495 54.6 149 41.3 
    Other 463 4.5 68 4.9 806 8.2 123 7.9 332 4.7 45 5.0 0.6 638 9.4 82 9.0 34 9.5 
Overcrowding 373 3.9 158 12.9 319 3.5 178 14.4 142 2.3 88 13.7 27 16.9 166 2.9 94 14.9 26 13.4 
    Low social support (P15) 1026 10.8 322 25.7 917 9.8 300 21.9 800 11.9 164 18.7 33 15.2 730 11.1 155 17.8 65 19.4 
  2006
 
2012
 
Men
 
Women
 
Men
 
Women
 
Spain
 
Immigrants
 
Spain
 
Immigrants
 
Spain
 
Immigrants arrived before 2006
 
Immigrants arrived after 2006
 
Spain
 
Immigrants arrived before 2006
 
Immigrants arrived after 2006
 
n n n n n n n n n n 
Total 10325 88.1 1395 11.9 9901 86.4 1555 13.6 6996 85.9 911 11.2 240 2.9 6771 84.2 907 11.3 361 4.5 
Age (years)                     
    15–24 1550 15.0 288 20.7 1468 14.8 285 18.3 965 13.8 118 12.9 63 26.1 894 13.2 134 14.8 81 22.3 
    25–34 2519 24.4 490 35.1 2198 22.2 630 40.5 1481 21.2 273 29.9 102 42.7 1379 20.4 249 27.4 170 47.1 
    35–44 2445 23.7 389 27.9 2385 24.1 340 21.9 1735 24.8 293 32.1 45 18.9 1635 24.2 309 34.1 66 18.2 
    45–54 2096 20.3 179 12.8 2059 20.8 223 14.3 1556 22.3 170 18.6 18 7.7 1573 23.2 155 17.0 30 8.4 
    55–64 1716 16.6 49 3.5 1792 18.1 77 5.0 1258 18.0 58 6.4 11 4.6 1289 19.0 61 6.7 15 4.1 
Educational level                     
    No education 448 4.4 113 8.1 548 5.6 75 4.9 282 4.0 83 9.1 2.2 302 4.5 52 5.7 2.1 
    Primary 5108 49.9 620 44.6 5062 51.7 620 40.2 4048 57.9 453 49.7 138 57.6 3644 53.8 416 45.9 158 43.8 
    Secondary 2644 25.8 495 35.6 2225 22.7 581 37.7 1460 20.9 272 29.8 65 27.1 1376 20.3 339 37.4 134 37.1 
    University 2042 19.9 163 11.7 1961 20.0 265 17.2 1206 17.2 103 11.3 31 13.1 1449 21.4 100 11.0 61 17.0 
Social class                     
    CS I II 2284 22.3 107 7.7 1775 18.1 109 7.1 1419 20.4 47 5.3 14 6.0 1304 19.7 38 4.3 31 8.9 
    CS III 2513 24.5 135 9.7 2395 24.4 153 10.0 1269 18.3 96 10.7 15 6.4 1683 25.4 92 10.4 24 7.0 
    CS IV 4212 41.1 724 52.2 3845 39.3 690 44.9 3448 49.7 518 57.8 144 61.5 2412 36.4 343 38.7 160 46.2 
    CS V 1228 12.0 421 30.4 1782 18.2 583 38.0 806 11.6 236 26.2 61 26.0 1232 18.6 413 46.6 131 37.9 
Employment status                     
    Working 7599 73.7 1161 83.3 5008 50.7 953 61.5 4371 62.5 460 50.5 127 52.8 3454 51.0 485 53.5 165 45.7 
    Unemployed 767 7.4 136 9.8 1007 10.2 164 10.5 1305 18.7 326 35.8 63 26.3 1032 15.2 186 20.6 66 18.4 
    Homemaker 16 0.2 0.0 0.0 2518 25.5 345 22.2 43 0.6 13 1.4 2.9 1226 18.1 149 16.4 83 23.0 
    Other 1926 18.7 97 6.9 1349 13.7 90 5.8 1277 18.3 112 12.3 43 18.1 1059 15.6 86 9.5 47 12.9 
Marital status                     
    Single 4346 42.2 661 47.4 3089 31.3 583 37.6 2890 41.3 328 36.2 132 55.0 2326 34.4 330 36.4 178 49.2 
    Married 5499 53.4 666 47.7 5981 60.6 846 54.5 3770 53.9 533 58.8 106 44.4 3802 56.2 495 54.6 149 41.3 
    Other 463 4.5 68 4.9 806 8.2 123 7.9 332 4.7 45 5.0 0.6 638 9.4 82 9.0 34 9.5 
Overcrowding 373 3.9 158 12.9 319 3.5 178 14.4 142 2.3 88 13.7 27 16.9 166 2.9 94 14.9 26 13.4 
    Low social support (P15) 1026 10.8 322 25.7 917 9.8 300 21.9 800 11.9 164 18.7 33 15.2 730 11.1 155 17.8 65 19.4 

Total may differ from the sum of categories because of the sample weight.

Self-rated health

In both survey years, the immigrant population having arrived before 2006 presents worse self-rated health than natives (men: PR 2006 = 1.32, PR 2012 = 1.28 and women: PR 2006 = 1.39, PR 2012 = 1.56). After adjustment for the other variables, this probability attenuates in men but remains significant in women. The probability of poor self-rated health in immigrant women, with respect to native women, was greater in 2012 than in 2006 (in all models), the interaction being significant when overcrowding ( P value = 0.02) and social support ( P value = 0.021) are introduced. Finally, it should be noted that in 2012, immigrant men who arrived in Spain since 2006 present better self-rated health (8.8%) than Spanish men (15.1%) ( figures 1 A and 2 A).

Figure 1

Age-standardized prevalence of health outcomes by place of birth, sex and survey year. Residents in Spain aged 16–64 years

Figure 1

Age-standardized prevalence of health outcomes by place of birth, sex and survey year. Residents in Spain aged 16–64 years

Figure 2

Multivariate-adjusted PR and 95% confidence interval for health outcomes of immigrants in 2006 and of immigrants who arrived before 2006 in 2012 with respect to the Spanish population by sex and survey year. Residents in Spain aged 16 to 64 years. PR are obtained through the fitting of different multivariate models

Figure 2

Multivariate-adjusted PR and 95% confidence interval for health outcomes of immigrants in 2006 and of immigrants who arrived before 2006 in 2012 with respect to the Spanish population by sex and survey year. Residents in Spain aged 16 to 64 years. PR are obtained through the fitting of different multivariate models

Chronic activity limitation for a health problem

A higher proportion of native Spanish men present some type of limitation, compared with immigrant men, although the difference is not significant in 2012 (PR 2006 = 0.55; 95% CI: 0.39–0.77, PR 2012 = 0.73; 95% CI: 0.49–1.10). In contrast, in women, there are no significant differences in terms of country of birth, although the probability for immigrant women who arrived before 2006 tends to increase in 2012. In this year, most recent immigrants present a lower proportion of any limitation (10.0% in women and 3.7% in men) than natives (15.2% in women and 11.5% in men) ( figures 1 B and 2 B).

Mental health

In 2006, immigrant women presented worse mental health (30.5%) than Spanish women (22.8%), but this association is attenuated when overcrowding is added to the model and disappears when social support is also introduced. In men, there is no association between mental health and country of birth. However, in the 2012 survey, immigrant men who arrived before 2006 present a higher probability when the model is adjusted for age (PR = 1.34; 95% CI: 1.06–1.69) and when social class is subsequently introduced (PR = 1.31; 95% CI: 1.04–1.66), but the association disappears when employment status is introduced. Among women, this association persists even in the model which includes all adjustment variables (PR = 1.38; 95% CI: 1.13–1.67). Finally, it is noteworthy that immigrant men who arrived since 2006 present better mental health (10.0%) than native men (16.1%) ( figures 1 C and 2 C).

Use of psychotropic drugs

In 2006, the use of psychotropic drugs among immigrant men was lower (1.6%) than among native men (5.9%). In the adjusted models, this difference increases notably when social support is introduced (PR = 0.07; 95% CI: 0.03–0.16). In 2012, we observe an increase in use of psychotropic drugs in all groups, the increase being most important among immigrant men, whose use reaches the same levels as that of native men, in this case with a significant interaction between survey year and country of birth ( P value < 0.001). In 2006, immigrant women present lower use of psychotropic drugs than native Spanish women after adjusting for social support (PR = 0.73; 95% CI: 0.54–1.00); this association disappears in 2012 ( figures 1 D and 2 D).

Discussion

This study shows how between 2006 and 2012, the health status of immigrants arrived before 2006 appears to evolve less favourably than that of natives. There is a new onset of inequalities in mental health, and an equalization of the previously lower use of psychotropic drugs, especially among men. Likelihood of reporting chronic activity limitation, compared with natives, tends to increase among both sexes and among women for poor self-rated health. This unfavourable evolution may be interpreted as a result of the loss of the ‘healthy immigrant effect’ in a population increasingly settled (as shown by the increase in marriages and social support) in a context of economic crisis, increase in unemployment and persisting occupational segregation.

Existing research on immigrants' health in advanced countries has extensively reported a health advantage, which is frequently observed to diminish or even reverse with increasing time of residence. 4,5 In the case of Spain, the exponential growth of the immigrant population over the past decade may imply that most subjects interviewed in the 2006 edition had still spent only a few years in the host country, and we may be observing a cohort effect, with a relatively fast deterioration of the health of immigrants—once we exclude immigrants who arrived after 2006, and who actually report better health than natives; this is especially the case among men. The context of crisis may enhance this deterioration, which previous authors have attributed to cumulative hazardous socio-economic exposures, 18,24,25 including poor neighbourhood and housing conditions, 26 that affect immigrants' health in the long term. 9

Some studies have reported that life expectancy and self-rated health have continued to improve overall in the Spanish population during the first four years of the current economic recession 12 but also that mental health has deteriorated among adult men, especially among those of lower socioeconomic positions, 13 and, more recently, socioeconomic inequalities in mortality have been reported to be rising. 27 The worse evolution of health indicators of settled immigrants compared with natives adds to these results, where less socioeconomically advantaged groups experience the worst effects of the crisis, 8,14 emphasizing the importance of analyzing the health impact of the economic crisis in different population groups defined by axes of inequality. 14

Looking at specific variables, it is the indicators of mental health, i.e. GHQ-12 score and use of psychotropic drugs, which have worsened among immigrants between the two surveys, especially in men. This confirms findings from other studies of selected immigrant-worker cohorts. 7,15 Immigrant men have been affected by a disproportionate increase in unemployment, a well-established determinant of mental health especially in men, 28 which contributes to the onset of inequalities in mental health in 2012 (actually adjustment for employment status renders differences not significant). This ‘recession immigrant effect’ could be a result of the combination of acculturative stress 29 and an anticipated or actual loss of employment, since this is a crucial factor for the success or failure of their migratory project and for their role as breadwinner for the family and relatives in the country of origin. 30 The narrowing observed in the gap in psychotropic drug use occurs in a time where immigrants maintain access to services and prescriptions of the Spanish National Health System, 31 until in July 2012 a new law entered into force restricting healthcare access to immigrants with residence authorization. 32 Conversely, prevalence of poor self-rated health and chronic activity limitation have both decreased among immigrants, although less than they have for the Spanish population as a whole, 12 especially among women. As physical disorders are the main drivers for these indicators, 33 this trend may reflect an incipient loss of a ‘healthy immigrant effect’ that could account for immigrants' health advantage in 2006. Actually, in 2012, these two variables had a consistent, graded association with duration of residence (see Supplementary table ).

Gender-specific risks of poor self-perceived health and mental health

In both years, immigrant status is associated with poorer self-rated health and mental health in the case of women but not in the case of men, once having controlled for other socioeconomic variables. One potential explanation may be found in the gendered expression of distress resulting from low status and adverse living conditions; while immigrant men may respond by increasing smoking and/or heavy drinking—though this is not evident from Spanish data 34 —women may present psychological disorders such as depression and anxiety. 9,35 The higher likelihood of withdrawing socially of depressed men in comparison with depressed women 36 might explain why socioeconomic circumstances account for the higher risk of reporting poor self-perceived and mental health of immigrant men.

Another explanation could be related to the labour market insertion of immigrant women in services sector jobs such as domestic service, dependent care and hospitality. In these settings, labour relations are affected by a number of practices involving discrimination and social class domination. 37 In this sense, power relations between gender, class and immigrant status determine an intersection of disadvantages in the position of women. 38

Limitations and strengths

The main limitation of this study is the lower participation rate of immigrants compared with natives in the two surveys. Through the application of sample weights, the share of immigrant population approaches the actual weight of the population, according to the Municipal Register of Inhabitants. However, immigrants with language difficulties and from some countries of origin remain under-represented. 39 Furthermore, because of limited sample size, we treated the immigrant population as a single group, omitting the heterogeneity that can be observed in analyses by regions of origin. 34 Through the availability in the 2012 survey of the year of immigration, we could identify those immigrants who had arrived before the penultimate survey edition. This allowed us to better assess the loss of the ‘healthy immigrant effect’ in the same population group. However, some immigrants, present in 2006, may have left Spain partly as a result of the economic crisis. A recent study has challenged the view that sick immigrants are more likely to remigrate. 40 In this case, it could be possible that those who left were, at least physically, fitter to search for new job opportunities.

A strength of this study is that the variables chosen allow an overview of the health of the population. Self-rated health is considered a reliable indicator and a comprehensive assessment of a person's wellbeing. Chronic activity limitation is the only general question dealing with burden of chronic disease that has been asked in both surveys. Mental health as measured with the GHQ-12 questionnaire and psychotropic drug use are more sensitive to sudden environmental changes such as job loss or declining purchasing power.

Conclusions and recommendations

The immigrant population that arrived in Spain before 2006 appears to be losing its health advantage compared with the local native population. We explain these findings in the light of a potential ‘cohort effect’, which the economic crisis may have enhanced—with a determinant of health like unemployment especially affecting immigrants.

Serial population-wide health surveys constitute a crucial instrument to monitor the health status of immigrants when compared with the general population. Nevertheless, strategies to improve participation and representativeness of immigrants would increase validity, and the results need to be integrated with surveys targeting vulnerable and hidden groups.

Policies to protect the unemployed from poverty, to increase employability and to restore employment opportunities are much needed to prevent the deterioration of the population’s health. Accessibility must be ensured for immigrant populations, who are particularly exposed and vulnerable to the effects of the economic recession. At the same time, Spanish authorities should reconsider the Royal Decree 16/2012, which jeopardizes access to the National Health Service for this group in special need, immigrants—and their families—who have lost both their jobs and residence permits.

Acknowledgements

The authors thank Elena Ronda and Jordi Casabona for supporting the work and Dave MacFarlane for professional English edition.

Funding

This research was partially supported by the CIBER Epidemiología y Salud Pública Subprogram on Immigration and Health and the European Community's Seventh Framework Programme (FP7/2007-2013) under grant agreement 278173 (SOPHIE project).

Conflicts of Interest : None declared.

Supplementary data

Supplementary data are available at EURPUB online.

Key points

  • We compare the health status of natives and immigrants in Spain in 2006 (when most immigrants had arrived relatively recently) and 2012 (when they were facing high unemployment rates and financial strain).

  • The health status of immigrants arrived before 2006 shows a less favourable evolution than that of natives, especially for mental health and with differences by gender.

  • This accelerated health deterioration might be buffered by active and passive labour market policies and restoring universal healthcare access.

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Author notes

*The first two authors are joint first authors.

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