**Introduction**

The world has changed during the last 60 or 70 years and not everything can be defined clearly as positive or negative; there are many contradictions. Most societies have profited from globalization, market economies, transnational free trade, and cheaper travelling, but some societies have been left behind. So have some people. On the one hand, there can be no doubt that in today's society, the methods of destruction have created *catastrophic risks* (Beck, 2009), for the environment and also for those who want to move or have to move in order to survive. Beck's theory of risk is fitting when looking at the statistics of the UNHCR: these risks are based on innovation and developing technologies. On the other hand, look‐ ing at the more positive issues of progress and modernization, time and space are converg‐ ing, people are better informed, longevity has improved, trade can take place via the Internet and travelling is more comfortable and faster. Most of all, the international stu‐ dents' movement is an encouraging new phenomenon: travelling, studying in a foreign country and experiencing different cultures usually lead to a widening of people's perspec‐ tive, creating tolerance and improving the understanding of foreign customs – the only re‐ striction being the economic resources of the parents. However, since international education is marketed worldwide by almost all universities and since the number of interna‐ tional students is rising continuously, there is optimism that the risks of destruction will be

This book is dedicated to all those who have lost their lives leaving their home country and seeking asylum somewhere else. It was written in the spirit of peace and hopefully will con‐

**Dr Ingrid Muenstermann**

School of Health Sciences

Australia

Discipline of Health and Exercise Sciences

Flinders University of South Australia

As the reader quite rightly perceives, I am an eternal optimist.

reduced.

VIII Preface

tribute to this sentiment.

## **Chapter 1**

**Provisional chapter**

## **Introductory Chapter Introductory Chapter**

## Ingrid Muenstermann Ingrid Muenstermann

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/67209

This book is edited by a social scientist, a humanist, cosmopolitan, who has the privilege to live in a so called civil society.1 I emigrated from Germany to Australia for the second time in 1973, a divorcee with two teenage daughters. Of course, the beginnings were not easy. Having been assured the position of secretary for the newly established Goethe Society in Melbourne, we had to come to Adelaide because a Lutheran Minister, Pastor Zinnbauer, was our guar‐ antor. Things went from bad to worse: The person who was meant to establish the Goethe Society in Melbourne was killed in an airplane crash, while we were on our way to Australia on board of the Flaminia. Not a good beginning in a new country—a time of self‐inflicted injury and great uncertainty. I decided to stay in Adelaide and make the most of the situation. Looking back now, memories persist, but bringing things into perspective and considering the circumstances faced by millions of people who flee today war torn Syria, try to escape persecution, or are forcibly displaced and reside in camps in the Middle East or in Europe, I consider myself very fortunate! I made it to and in Australia—professionally. Bob Holton [2] looks at his pursuit of academic employment in three different countries and reveals a similar attitude, pointing out that

This [moving from one country to another] represents only one of a range of global trajectories that individuals and families make in the contemporary world, one located within wealthier and more powerful settings. There are many far riskier and often tragic global trajectories for those who seek asylum, or for whom mobility in the search for employment and security is a day‐to‐day struggle for survival in the face of exploitation and danger. (p. viii)

The book is an attempt to provide a critical view of the present immigration and refugee situation. Today's globalized world has created winners and losers: Billions of dollars shift daily across invisible borders, welcomed by developed as well as by developing societies, and import and export influence the gross domestic product, but the movement of people is challenged, creating emotive debates. Migration is a contesting policy area in most countries,

<sup>1</sup> In a civil society, social connections, which include plenty of robust goodwill to sustain difference and debate, are of supreme importance [1].

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

and there is widespread public resistance to immigration that reaches large numbers. People are afraid, usually without justification, that migrants will take their jobs. There are also fears of terrorism, of Islamization, of the destruction of social norms, and of the loss of familiar cus‐ toms and common laws. While *peoples movements in the twenty-first century—Risks, challenges and benefits* deal directly with only some of these issues, the book should set the scene for further discussion. The chapters were written by authors in Canada, Germany, Italy, Japan, Norway, Portugal, The Netherlands, Turkey, UK, and USA; however, the writings do not always reflect problems of the countries they were written in. Scholars are flexible in today's *world at risk* [3] as chapters 2, 4, 13 show.

The book is divided into five parts, all of them capturing the objectives of risks, challenges, and benefits. **Part 1, Colonial history in a post‐colonial world**, consists of only one chap‐ ter, but *The immigrant experience* is the fascinating sociological analysis of two articles, *The Enigma of Arrival* by V. S. Naipaul, and *White Teeth* by Z. Smith. Chapter 2 addresses the chal‐ lenges immigrants face in the country of their destination. It looks at their expectations, dis‐ appointments, and struggles to integrate without losing their identity; it highlights power relations between the previously colonized and the previous colonizer in a post‐colonial era. The author uses the theories of hybridity, mimicry, orientalism, otherness, ambivalence, and cultural differentiation to explain the actions of the main characters. The author also looks at intergenerational challenges: The parents, being the first generation of immigrants, want to maintain old customs and values, while their children aim to be accepted by their friends in the host society, wanting to fit in, acculturate, which causes disquiet in the older and frustra‐ tion in the younger generation.

**Part 2**, **Settlement of Immigrants—Health Care Challenges**—contains five chapters. Chapter 3 looks at *Immigration and food insecurity: The Canadian experience*. In 2011, the immigrant popu‐ lation of Canada was 6.8 million (20.6% of the total population). This fact implies the chal‐ lenges for a government to anticipate risks, that is, how to keep new settlers healthy and prevent diseases. At arrival, migrants are generally healthier than the host population, and they display fewer chronic illnesses and lower levels of disability; however, this changes over time. There are several reasons for this: Migrants usually experience low socio‐economic sta‐ tus, indicating that their food choices are limited, and their lifestyle and diets change. They are often socially excluded which can lead to the consumption of unhealthy 'comfort' food which, in turn, leads to being overweight. The authors argue that the medical system is inept to deal with the diverse dietary needs of immigrants. They explain in some detail the meaning of food security and provide statistical evidence: The prevalence of food insecurity is higher among recent immigrants compared with non‐recent immigrants. They suggest that the cul‐ tural perspective of food be recognized as the fifth pillar for food security and that measure‐ ment tools be developed to capture availability, accessibility, utilization, stability as well as the cultural dimension of food. The authors also argue that addressing food security is critical for the integration of healthy Canadian immigrants.

Chapter 4 compares *health-related quality of life of elderly Turkish and Polish migrants with that of German natives: The role of age, gender, income, discrimination, and social support.* This chapter presents original research and contains a great deal of statistical data. Germany accommodates 15 million migrants (almost 19% of the population), and 1.4 million are aged 65 and above. Questionnaires (Sf‐36, plus queries regarding socio‐economic status, discrimination, social support) were distributed in Hamburg, Germany, to 100 Turkish, 103 Polish migrants and 101 native Germans. The authors were testing their hypotheses that age and gender influence health‐related quality of life, especially that of immigrants, that when income decreases and discrimination intensifies, quality of life decreases, and that social support improves the qual‐ ity of life. The findings were analyzed for each group, and the groups were compared. Most of their assumptions were confirmed; however, interestingly their notion that migrants (here Turkish and Polish) inevitably suffer poorer health‐related quality of life than natives (in this case Germans) could not be substantiated.

and there is widespread public resistance to immigration that reaches large numbers. People are afraid, usually without justification, that migrants will take their jobs. There are also fears of terrorism, of Islamization, of the destruction of social norms, and of the loss of familiar cus‐ toms and common laws. While *peoples movements in the twenty-first century—Risks, challenges and benefits* deal directly with only some of these issues, the book should set the scene for further discussion. The chapters were written by authors in Canada, Germany, Italy, Japan, Norway, Portugal, The Netherlands, Turkey, UK, and USA; however, the writings do not always reflect problems of the countries they were written in. Scholars are flexible in today's

The book is divided into five parts, all of them capturing the objectives of risks, challenges, and benefits. **Part 1, Colonial history in a post‐colonial world**, consists of only one chap‐ ter, but *The immigrant experience* is the fascinating sociological analysis of two articles, *The Enigma of Arrival* by V. S. Naipaul, and *White Teeth* by Z. Smith. Chapter 2 addresses the chal‐ lenges immigrants face in the country of their destination. It looks at their expectations, dis‐ appointments, and struggles to integrate without losing their identity; it highlights power relations between the previously colonized and the previous colonizer in a post‐colonial era. The author uses the theories of hybridity, mimicry, orientalism, otherness, ambivalence, and cultural differentiation to explain the actions of the main characters. The author also looks at intergenerational challenges: The parents, being the first generation of immigrants, want to maintain old customs and values, while their children aim to be accepted by their friends in the host society, wanting to fit in, acculturate, which causes disquiet in the older and frustra‐

**Part 2**, **Settlement of Immigrants—Health Care Challenges**—contains five chapters. Chapter 3 looks at *Immigration and food insecurity: The Canadian experience*. In 2011, the immigrant popu‐ lation of Canada was 6.8 million (20.6% of the total population). This fact implies the chal‐ lenges for a government to anticipate risks, that is, how to keep new settlers healthy and prevent diseases. At arrival, migrants are generally healthier than the host population, and they display fewer chronic illnesses and lower levels of disability; however, this changes over time. There are several reasons for this: Migrants usually experience low socio‐economic sta‐ tus, indicating that their food choices are limited, and their lifestyle and diets change. They are often socially excluded which can lead to the consumption of unhealthy 'comfort' food which, in turn, leads to being overweight. The authors argue that the medical system is inept to deal with the diverse dietary needs of immigrants. They explain in some detail the meaning of food security and provide statistical evidence: The prevalence of food insecurity is higher among recent immigrants compared with non‐recent immigrants. They suggest that the cul‐ tural perspective of food be recognized as the fifth pillar for food security and that measure‐ ment tools be developed to capture availability, accessibility, utilization, stability as well as the cultural dimension of food. The authors also argue that addressing food security is critical

Chapter 4 compares *health-related quality of life of elderly Turkish and Polish migrants with that of German natives: The role of age, gender, income, discrimination, and social support.* This chapter presents original research and contains a great deal of statistical data. Germany accommodates

*world at risk* [3] as chapters 2, 4, 13 show.

4 People's Movements in the 21st Century - Risks, Challenges and Benefits

tion in the younger generation.

for the integration of healthy Canadian immigrants.

Chapter 5 looks at *Suicidal behaviors in patients admitted to emergency department for psychiatric consultation: A comparison of the migrant and native Italian populations between 2008 and 2015*. It is a long‐term (2006/2008 to 2015), qualitative and quantitative study carried out in a pub‐ lic hospital in the north of Italy (Novara, Piedmont). Eight authors have contributed to this chapter, and comparison is made between the Italian natives and the migrant population. In 2014, 5 million migrants (8.2% of the total population) lived in Italy. The authors observed that socio‐economic status and physiology of the two groups were different. They found that the immigrants were younger than the native Italian population, that they used the emer‐ gency department (rather than psychiatric outpatient services), and mainly attended because of self‐injury, substance abuse, and alcohol‐related disorders. The Italian natives were older, often retired, invalid, or disabled and were more commonly treated by psychiatric outpatient services and presented with a more diverse range of psychiatric symptoms than the migrants. The authors argue that migrants may experience a condition similar to bereavement: They usually lose the connection with their home country, experience exclusion, lose social status, feel inadequate because of language barriers, and are often unemployed. All of these issues lead to stress and can result in mental illness (i.e., substance abuse and self‐harm).

Chapter 6 is also written by an Italian author, dealing with *Migration and health from a public health perspective*. The author is especially interested in migration medicine and looks at Italy's public health policies. He argues that consideration of the social determinants of health (edu‐ cation, job, income, and accommodation) would be beneficial. He also finds that the health of migrants is of importance and that in order to establish their needs, qualitative and quan‐ titative research is necessary, involving a multi‐disciplinary team approach. An unhealthy population is costly, not only financially but also socially and publically. The author advo‐ cates that sanitary systems be more actively promoted—not all migrant women are familiar with the prevention of an oncological disease. Health services in industrialized countries are well established but are also expensive. Therefore, he promotes the creation of more reli‐ able databases, the introduction and maintenance of dependable sources of sanitary informa‐ tion, record linkages between different systems (personal background as well as health care information), and international identification of important indicators so that they can be used transnationally. The author is a supporter of the unconditional human rights of migrants (whether they are regular, legal, documented or irregular, illegal, undocumented) and argues that (a) more economic resources are needed to prevent rather than cure ill health in migrants, that (b) cultural barriers ought to be contested, and that (c) the training of staff incorporates a transcultural approach.

Chapter 7 is, again, written in Italy by a considerable group of authors. It is a review of the literature and statistical data and deals with the important issue of *the impact of tuberculosis among immigrants*. The authors find that according to official statistics, tuberculosis shows no signs of disappearing despite its decreased prevalence in high‐income countries. The group presents an overview of tuberculosis among immigrants in low‐TB burden countries and dif‐ ferent screening practices. They also look the risks of latent TB infection (LTBI) and argue that screening is important since early diagnosis and treatment prevent a prolonged disease. Different screening practices are discussed in relation to different countries. Other important issues in this chapter are the diagnosis and management of tuberculosis, including drug‐resis‐ tant TB among immigrants: The sputum smear microscopy is still effective, but today more advanced technologies are often used, including radiographic imaging, nucleic acid ampli‐ fication techniques, and new generation assays. In their concluding paragraphs, the authors look at the worldwide burden of tuberculosis. They consider the push and pull factors that influence people to migrant and argue that the health of immigrants is important, because ill health of the migrant population is costly to the host society. Overall, the authors find that TB transmission between immigrants and native populations is rare, but TB control is important. They recommend more resources be allocated so that "Global Action Framework for Research towards TB Elimination" for the period 2016–2015 can be achieved.

**Part 3 Settlement of Immigrants—Some Cultural Aspects**—consists of four chapters. Challenges faced by the newcomers as well as by researchers and policy makers are addressed. The most important issue for immigrants is to be able to communicate in their country of des‐ tination, which very often requires the learning of a new language. Chapter 8, *Socio-cultural models of second language learning of young immigrants in Canada*, addresses the problem. The authors find that both sociolinguistic and cognitive‐linguistic approaches are needed in order to understand second language teaching, learning and why many people maintain an accent. Acculturation, the distance from mother tongue to English, previous experience with other cultures, and the age of second language learning influence cognitive‐linguistic second lan‐ guage learning; the social context of the language learner affects the level of proficiency. The chapter contains an important discussion on the methodological challenges when searching for a consistent definition of acculturation, when conducting research on acculturation and language learning, and when determining the link between acculturation and language learn‐ ing. The authors sum it up like this: The more confident the immigrant is in speaking the language of the host society, the more positive interactions will occur which "in turn lead to a reinforcement of the immigrant to acculturate into the mainstream cultural group".

Chapter 9, entitled *Acculturation, adaptation, and loneliness among Brazilian migrants living in Portugal,* addresses the risks individuals face when deciding to emigrate and the challenges for policy makers to provide some strategies to make the life of these people acceptable when losing their jobs or growing old. This is a mixed‐method study, involving 258 participates. In 2014, Portugal's population of 10,402,000 included 22% of immigrants (228,844), of these 87,493 (almost 8.5%) were of Brazilian origin. These people worked mainly in low‐skilled jobs, which made them vulnerable during the economic recession. This research is of importance, it establishes how Brazilian immigrants to Portugal fit into the overall structure of society and what challenges are needed to be addressed. The authors tested five hypotheses relating to loneliness of Brazilian migrants and concentrated on issues such as integration strategies, the influence of the immigrants' cultural identity, the effects of perceived discrimination, the importance of self‐worth, and the perception of others. They used W. J. Berry's explanation of acculturation as benchmark and utilized the ULS‐6 scale (revised UCLA Loneliness Scale) to establish loneliness and several other measures to determine acculturation strategies, cultural identity, prejudices, self‐esteem, and attitudes toward ethno‐cultural groups. The results sup‐ ported three of their hypotheses, but two were only partially supported. The most important finding was that Brazilians in Portugal choose to be integrated into society. This means that they would like to maintain their own cultural heritage but would like to develop close ties with the host society.

that (b) cultural barriers ought to be contested, and that (c) the training of staff incorporates a

Chapter 7 is, again, written in Italy by a considerable group of authors. It is a review of the literature and statistical data and deals with the important issue of *the impact of tuberculosis among immigrants*. The authors find that according to official statistics, tuberculosis shows no signs of disappearing despite its decreased prevalence in high‐income countries. The group presents an overview of tuberculosis among immigrants in low‐TB burden countries and dif‐ ferent screening practices. They also look the risks of latent TB infection (LTBI) and argue that screening is important since early diagnosis and treatment prevent a prolonged disease. Different screening practices are discussed in relation to different countries. Other important issues in this chapter are the diagnosis and management of tuberculosis, including drug‐resis‐ tant TB among immigrants: The sputum smear microscopy is still effective, but today more advanced technologies are often used, including radiographic imaging, nucleic acid ampli‐ fication techniques, and new generation assays. In their concluding paragraphs, the authors look at the worldwide burden of tuberculosis. They consider the push and pull factors that influence people to migrant and argue that the health of immigrants is important, because ill health of the migrant population is costly to the host society. Overall, the authors find that TB transmission between immigrants and native populations is rare, but TB control is important. They recommend more resources be allocated so that "Global Action Framework for Research

**Part 3 Settlement of Immigrants—Some Cultural Aspects**—consists of four chapters. Challenges faced by the newcomers as well as by researchers and policy makers are addressed. The most important issue for immigrants is to be able to communicate in their country of des‐ tination, which very often requires the learning of a new language. Chapter 8, *Socio-cultural models of second language learning of young immigrants in Canada*, addresses the problem. The authors find that both sociolinguistic and cognitive‐linguistic approaches are needed in order to understand second language teaching, learning and why many people maintain an accent. Acculturation, the distance from mother tongue to English, previous experience with other cultures, and the age of second language learning influence cognitive‐linguistic second lan‐ guage learning; the social context of the language learner affects the level of proficiency. The chapter contains an important discussion on the methodological challenges when searching for a consistent definition of acculturation, when conducting research on acculturation and language learning, and when determining the link between acculturation and language learn‐ ing. The authors sum it up like this: The more confident the immigrant is in speaking the language of the host society, the more positive interactions will occur which "in turn lead to a

reinforcement of the immigrant to acculturate into the mainstream cultural group".

Chapter 9, entitled *Acculturation, adaptation, and loneliness among Brazilian migrants living in Portugal,* addresses the risks individuals face when deciding to emigrate and the challenges for policy makers to provide some strategies to make the life of these people acceptable when losing their jobs or growing old. This is a mixed‐method study, involving 258 participates. In 2014, Portugal's population of 10,402,000 included 22% of immigrants (228,844), of these 87,493 (almost 8.5%) were of Brazilian origin. These people worked mainly in low‐skilled jobs,

towards TB Elimination" for the period 2016–2015 can be achieved.

transcultural approach.

6 People's Movements in the 21st Century - Risks, Challenges and Benefits

Chapter 10, *Asians as model minorities: A myth or reality among scientist and engineers in academia* takes a critical look at how Asians are perceived by society and analyzes this general senti‐ ment by looking at their personal experiences. The term 'model minority' emerged because Asians are high academic achievers and hold high socio‐economic status compared with African Americans and Hispanics. But, as the author points out, this group confronts ineq‐ uity in income and job opportunities when compared with their Caucasian counterparts. The first point the author makes is that 'Asians' are not a heterogeneous group but are made up of people from Cambodia, China, India, Indonesia, Japan, Korea, Malaysia, Pakistan, The Philippines, Singapore, South Korea, Taiwan, Thailand, and Vietnam. The author argues that most race/ethnicity research does not present a true picture because 'Asians' have been merged into one category. People of different ethnic backgrounds seem to follow certain career trajectories and are drawn to certain jobs in academia. For the purpose of this research, the author divides 'Asians' into (and here it gets a little complicated): 'Asian‐non‐US‐citizens' and 'Asian‐US‐citizens' to compare their experiences with those of 'other‐non‐US‐citizens' and 'other‐US‐citizens'. These differentiations are important in order to determine academic achievements, job satisfaction, and job productivity between groups. The author presents empirical evidence that these issues are influenced by citizenship and argues that high achiev‐ ers need to have the possibility of progress. If the US does not provide this sense, these people may return to their home countries creating not only a vacuum within the scientific commu‐ nity but also producing increasing costs for the government when retraining new academics. More research into and greater appreciation of 'Asian‐non‐US‐citizen' scientists is advocated.

The next contribution to this book, Chapter 11, asks the question: *Why do immigrants to Norway leave the country or move internally?* Important facts (empirical evidence) are provided by a group of scholars from the Research Department, Statistics Norway. The authors use statistical data of 2012 and 2013. They establish eight different groups of people, four different locations (they call it levels of centrality), and consider the two genders to determine the movement of migrants. In order to find answers to their question of why immigrants leave Norway or move within the country, they use variables such as age, duration of residence in Norway, labor market status, reasons for immigration, level of education, and family size and com‐ position. Their main findings are that (a) the probability of emigration or internal migration decreases with increased length of residence (integration effect over time) and that (b) labor force participation strengthens the relationship to the host country (decreasing the probability of moving). Interestingly, reasons provided to immigrate to Norway, such as 'work', 'family', and 'escape' are high indicators for staying at the same locality. This study also created some contradictions: On the one hand, it shows that those immigrants who are well integrated into the workforce are inclined to remain while those not in the work force have the highest rates of emigration. On the other hand, those with the highest rates of education are showing high rates of emigration. Overall, the four main reasons for return migration are weak integration into the host country, close attachment to the country of origin, return after accumulation of financial resources, and improved or new employment opportunities in the country of origin. The authors advocate further research in order to keep the population (workforce) steady.

**Part 4, The New Wave of Immigration—Foreign Students**—considers the present but also takes a look into the future. Risks? Challenges? Yes, of course, but the chapter *The new actors of international migration* demonstrates the benefits of foreign students to the host society, to native students, and to the foreign students themselves. The move of young people to complete their education in a different country offers countless opportunities to all involved. The title itself is of significance, that is, 'the new actors'—implying change, anticipation, and enthusiasm. The OECD reports that in 2012/13 5.4 million students were registered at an educational institu‐ tion outside their home country [4]. This quantitative study was undertaken at a university in Turkey. Previously, Turkey had sent students to other countries to complete their education; however, today increasing numbers of foreign students are attracted to Turkey. The author wanted to find out whether international students in Turkey experience prejudices, discrimi‐ nation, and racism. The author also wanted to determine the levels of adaptation to and satis‐ faction with their lives in Turkey, would they be prepared to promote Turkey to prospective visitors and/or students in their home countries, and what would be the avenues of promotion. Promoting university education in Turkey is an important issue to increase the foreign stu‐ dent population. One hundred and eighty‐two undergraduates, aged between 17 and 27, were researched using a survey that established demographic details as well as asked questions relating to the issues mentioned above. The students are from Africa and Asia, from regions of Europe/Balkan, Europe/Other, South Caucasus, and from the Middle East. The results of this study are interesting: prejudices and discrimination were faced (to a minor degree) by all stu‐ dents, but mainly off campus than on campus; and students from Africa and the Middle East experienced racism to a larger degree than students from other regions. The author provides some important explanations of why certain groups of students experience more prejudices than other groups. Overall, the results show that the biases experienced by the undergraduates did not affect their impressions of Turkey; there is evidence that they will promote university education in Turkey. And the means to do that? Positive social networking will encourage people to migrate, and this will boost the number of international students. The international‐ ization of education, growth of mass communication and transportation, and the relationship between present and potential immigrant students will have an encouraging effect on relocat‐ ing for educational purposes. Foreign students will be the new actors of immigration.

**Part 5, Emigration and Gender**, consists of a very important chapter, dealing with an issue that has so far lacked research: *The voice of trailing women in the decision to relocate. Is it really*  *a choice?* Research suggests that trailing spouses play an important part during expatria‐ tion: a successful outcome of the private and professional life of all involved depends on the willingness of the spouse to move, on assignment completion, expatriate adjustment, and expatriate performance. Between 2015 and 2016, the author undertook a phenomenological study interviewing 12 wives and mothers (27–42 years of age) in the Netherlands and in the United States regarding their experiences of being a 'relationship partner' of a 'highly skilled spouse'. The author wanted to determine their degree of agency. All women were academi‐ cally educated and employed prior to relocation. The emerging themes included support of the husband's career, economic considerations, the well‐being of the children, and solving a problem at their place of work. Most women placed their husband's professional progress as the main reason to relocate; however, it was often the only conceivable path, precluding an open discussion on the decision to relocate. The author concludes that for most women, relo‐ cation is not a real choice but that sacrifices are required in order for their partner to practice a real choice. Analyzing the situation from a sociological point of view, the author looks at powerlessness and gender‐role ideologies that depict women as the primary care giver and men as the primary provider. Therefore, trailing women in this study made the choice to relocate based on the viewpoint that their role in the family, that is, in the reproductive realm, is subordinate to their husband's role in the working world, the productive realm. There are some very interesting arguments presented during the interviews with the researcher.

Putting the last touches to this book a fortnight before Christmas 2016 and living in a nice, albeit very run‐down house with a lovely garden in South Australia, I cannot help but thinking of my (and all other children's) childhood during World War II, at times of danger and great uncer‐ tainty. Today's troubles, Syria and Aleppo, are a constant reminder. CNN news [5] reports that:

Syrian government troops now control most of the neighborhoods in the old city of Aleppo after days of fierce fighting against rebel forces, with only small pockets remaining in opposi‐ tion hands.

Another news item from Beirut, Lebanon [6], reports:

decreases with increased length of residence (integration effect over time) and that (b) labor force participation strengthens the relationship to the host country (decreasing the probability of moving). Interestingly, reasons provided to immigrate to Norway, such as 'work', 'family', and 'escape' are high indicators for staying at the same locality. This study also created some contradictions: On the one hand, it shows that those immigrants who are well integrated into the workforce are inclined to remain while those not in the work force have the highest rates of emigration. On the other hand, those with the highest rates of education are showing high rates of emigration. Overall, the four main reasons for return migration are weak integration into the host country, close attachment to the country of origin, return after accumulation of financial resources, and improved or new employment opportunities in the country of origin. The authors advocate further research in order to keep the population (workforce) steady.

8 People's Movements in the 21st Century - Risks, Challenges and Benefits

**Part 4, The New Wave of Immigration—Foreign Students**—considers the present but also takes a look into the future. Risks? Challenges? Yes, of course, but the chapter *The new actors of international migration* demonstrates the benefits of foreign students to the host society, to native students, and to the foreign students themselves. The move of young people to complete their education in a different country offers countless opportunities to all involved. The title itself is of significance, that is, 'the new actors'—implying change, anticipation, and enthusiasm. The OECD reports that in 2012/13 5.4 million students were registered at an educational institu‐ tion outside their home country [4]. This quantitative study was undertaken at a university in Turkey. Previously, Turkey had sent students to other countries to complete their education; however, today increasing numbers of foreign students are attracted to Turkey. The author wanted to find out whether international students in Turkey experience prejudices, discrimi‐ nation, and racism. The author also wanted to determine the levels of adaptation to and satis‐ faction with their lives in Turkey, would they be prepared to promote Turkey to prospective visitors and/or students in their home countries, and what would be the avenues of promotion. Promoting university education in Turkey is an important issue to increase the foreign stu‐ dent population. One hundred and eighty‐two undergraduates, aged between 17 and 27, were researched using a survey that established demographic details as well as asked questions relating to the issues mentioned above. The students are from Africa and Asia, from regions of Europe/Balkan, Europe/Other, South Caucasus, and from the Middle East. The results of this study are interesting: prejudices and discrimination were faced (to a minor degree) by all stu‐ dents, but mainly off campus than on campus; and students from Africa and the Middle East experienced racism to a larger degree than students from other regions. The author provides some important explanations of why certain groups of students experience more prejudices than other groups. Overall, the results show that the biases experienced by the undergraduates did not affect their impressions of Turkey; there is evidence that they will promote university education in Turkey. And the means to do that? Positive social networking will encourage people to migrate, and this will boost the number of international students. The international‐ ization of education, growth of mass communication and transportation, and the relationship between present and potential immigrant students will have an encouraging effect on relocat‐

ing for educational purposes. Foreign students will be the new actors of immigration.

**Part 5, Emigration and Gender**, consists of a very important chapter, dealing with an issue that has so far lacked research: *The voice of trailing women in the decision to relocate. Is it really*  Hundreds of Syrian men who escaped rebel‐held areas of eastern Aleppo to reach govern‐ ment‐controlled parts of the city are missing, United Nations officials said on Friday [9.12.16], adding that they had received reports of government reprisals, including numerous arrests and several cases of summary killings of suspected supporters of the opposition. At the same time, the officials said, some rebel groups have prevented civilians from leaving and even killed or kidnapped those who demanded that insurgents leave their neighborhoods.

After 5 years of war, will there be peace? How soon will there be some peace? The reports and images provided by the media cast doubt on my hope, so world leaders, governments, policy makers as well as ordinary citizens will have to further consider how to make this world a better place to live in, how to prevent risks and circumvent challenges.

It is believed that this book provides some important insights into the complexities of people's movements in the twenty‐first century. Every chapter looks at the risks involved in leav‐ ing one's home country: It is not only the loss of old familiar places, family, and friends but involves uncertainty and often the loss of prestige and status. These are challenges that need to be conquered by the individual migrant; they involve push and pull factors, integration, and acculturation, followed by assimilation. Looking at people's movements from a govern‐ ment perspective, settlement plans, healthcare programs, and language teaching curricula are strategies that need to be in place in order to create a society where people feel safe and have the opportunity to advance. Beck [7] points to the challenges faced by individuals as well as by governments to adjust to present circumstances: "Today's world of global crises and dangers produced by civilization, and the old differentiations between internal and external, national and international, us and them, [need to] lose their validity and a new cosmopolitan realism becomes essential to survival" (p. 14). Easier said than done.

Benefits of people moving or relocating relate to their overall well‐being and to the well‐being of the receiving society: Immigrants are the 'reserve army of labor', that is, competing for jobs depresses wages. There is also the logic of demand and supply. Giovanni Peri [8] makes the point that "by taking the manual jobs that natives progressively leave, immigrants push a reorganization of production along specialization lines that may increase the effectiveness and efficiency of labor". He looks at the mobility of migrants and finds that "highly edu‐ cated immigrants account for about one‐third of US innovations". He sustains this argument by providing some figures: "In 2006, immigrants founded 25% of new high‐tech companies with more than \$1 million in sales, generating income and employment for the whole coun‐ try". Mark Wooden [9] argues that "in the longer term, immigration gives rise to govern‐ ment revenues, which more than pay for the expenditure that immigration also gives rise to" (p. 153). Apart from these few economic benefits, migration, moving between countries, has other advantages: It will broaden the outlook of the traveler, change their perspective of other people, of their cultures and countries, and it will provide a better understanding of human‐ ity. Closing this chapter, here is a thought on what it means to be enlightened:

What is enlightenment? To have the courage to make use of one's cosmopolitan vision and to acknowledge one's multiple identities—to combine forms of life founded on language, skin color, nationality, or religion with the awareness that, in a radically insecure world, all are equal and everyone is different. [7]

## **Author details**

#### Ingrid Muenstermann

Address all correspondence to: ingrid.muenstermann@flinders.edu.au, imuenstermann@bigpond.com

Discipline of Health and Exercise Sciences, School of Health Sciences, Flinders University of South Australia, Australia

## **References**


[3] Beck, Ulrich (2009). *World at Risk*. Cambridge, UK: Polity Press.

and acculturation, followed by assimilation. Looking at people's movements from a govern‐ ment perspective, settlement plans, healthcare programs, and language teaching curricula are strategies that need to be in place in order to create a society where people feel safe and have the opportunity to advance. Beck [7] points to the challenges faced by individuals as well as by governments to adjust to present circumstances: "Today's world of global crises and dangers produced by civilization, and the old differentiations between internal and external, national and international, us and them, [need to] lose their validity and a new cosmopolitan

Benefits of people moving or relocating relate to their overall well‐being and to the well‐being of the receiving society: Immigrants are the 'reserve army of labor', that is, competing for jobs depresses wages. There is also the logic of demand and supply. Giovanni Peri [8] makes the point that "by taking the manual jobs that natives progressively leave, immigrants push a reorganization of production along specialization lines that may increase the effectiveness and efficiency of labor". He looks at the mobility of migrants and finds that "highly edu‐ cated immigrants account for about one‐third of US innovations". He sustains this argument by providing some figures: "In 2006, immigrants founded 25% of new high‐tech companies with more than \$1 million in sales, generating income and employment for the whole coun‐ try". Mark Wooden [9] argues that "in the longer term, immigration gives rise to govern‐ ment revenues, which more than pay for the expenditure that immigration also gives rise to" (p. 153). Apart from these few economic benefits, migration, moving between countries, has other advantages: It will broaden the outlook of the traveler, change their perspective of other people, of their cultures and countries, and it will provide a better understanding of human‐

realism becomes essential to survival" (p. 14). Easier said than done.

10 People's Movements in the 21st Century - Risks, Challenges and Benefits

ity. Closing this chapter, here is a thought on what it means to be enlightened:

Address all correspondence to: ingrid.muenstermann@flinders.edu.au,

equal and everyone is different. [7]

**Author details**

Ingrid Muenstermann

imuenstermann@bigpond.com

Palgrave Macmillan.

South Australia, Australia

**References**

What is enlightenment? To have the courage to make use of one's cosmopolitan vision and to acknowledge one's multiple identities—to combine forms of life founded on language, skin color, nationality, or religion with the awareness that, in a radically insecure world, all are

Discipline of Health and Exercise Sciences, School of Health Sciences, Flinders University of

[1] Cox, Eva (1995). *A truly civil society. The 1995 Boyer Lectures*. GPO Box 9994, Sydney, NSW

[2] Holton, Robert J. (2005) *Making Globalization*. Houndmills, Basingstoke, Hampshire, UK:

2001: Australian Broadcasting Corporation—A Roadmap for Collingwood?


**Colonial History in a Post-Colonial World**

**Chapter 2 Provisional chapter**

#### **The Immigrant Experience in V.S. Naipaul's** *The Enigma of Arrival and Z. Smith's White Teeth***: An Exploration of Homi Bhabha's Postcolonial Theory The Immigrant Experience in V.S. Naipaul's** *The Enigma of Arrival and Z. Smith's White Teeth***: An Exploration of Homi Bhabha's Postcolonial Theory**

Berna Köseoğlu Berna Köseoğlu

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/66969

#### **Abstract**

V.S. Naipaul and Z. Smith, prominent postcolonial authors, reflect the condition of the immigrants suffering from cultural shock, hybridity, fragmentation and mimicry in the postcolonial Western societies in their novels, *The Enigma of Arrival* and *White Teeth*. The former portrays the desperate condition of an author doing his best to create his work in the post‐war West, in London and New York, trying to overcome his hybridity and adaptation problems due to his cultural background, and the latter sheds light on the cultural distress of two families from Bangladesh, immigrating to London, by stress‐ ing the conflicts between the Westerners and the Easterners and between the first and the second generations of immigrants. Thus, these two novels highlight the immigrant experience illustrating the impact of power relations between the former colonized and the former colonizer upon their relationship in the postcolonial era. In this study, the problems of immigrants in the post‐war West in these novels will be analysed in the light of Homi Bhabha's postcolonial theory, which puts forward such concepts as hybridity, mimicry, ambivalence, cultural differentiation and otherness. In this regard, Bhabha's theory will be adapted into these novels to identify cultural problems of immi‐ grants in these works.

**Keywords:** V.S. Naipaul, Z. Smith, Homi Bhabha, postcolonialism, immigration, orientalism, other, otherness, hybridity, mimicry, adaptation, multiculturalism

## **1. Introduction**

Colonialism, determining the political, economic and social structure of countries from the beginning of the sixteenth century, had a great influence upon the social position and the

and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

cultural values of the colonized. It is undeniable that England played a very significant role as the colonizer by controlling many Asian, African and American nations during the colonial age; so England, socially, economically and politically, dominated different countries whose social and cultural notions were replaced with the English norms. The personal identity of the colonized experienced a radical transformation, which resulted in otherness, fragmentation, hybridity and mimicry as a consequence of multiculturalism as put forward by the postco‐ lonial theorist Homi Bhabha. In this respect, the power of the English nation as the colonizer was dominant not only in the colonial era but also in the postcolonial period. In this sense, even after the independence of the colonies ruled by England, the conflicts between the for‐ mer colonized and the former colonizer could still be recognized, particularly when these two opposite groups came together in the postcolonial age as a result of the former colonized's immigration to England.

In order to identify these conflicts in the light of Homi Bhabha's postcolonial theory, two postcolonial novels will be analysed in this chapter. One of them is, Vidiadhar Surajprasad Naipaul's the autobiographical novel, *The Enigma of Arrival* (1987), which portrays the cul‐ tural trauma of an immigrant from Trinidad, especially in England but also in New York by referring to the enigma the novelist himself experienced when he immigrated from Trinidad to England. The character's dilemma due to his Trinidadian background in English culture clearly shows the author's inner conflict because of his hybridity. In this sense, the influence of Naipaul's own Trinidadian background and education in England upon the protagonist in his novel is obvious.

Zadie Smith's *White Teeth* (2000) also reflects the condition of the former colonized, the immi‐ grants coming from Bangladesh to England by revealing the psychological trauma and the cul‐ tural conflicts these immigrants experienced in England in the post‐war age. Especially Smith's coming from a multicultural family, her being torn between Jamaican and English heritage due to her mother's Jamaican nationality and her father's English origin, their years in the post‐war England, contributed much to her effective portrayal of the immigrant trauma in her novel *White Teeth*. While dealing with the struggles of the in‐between immigrants in these two works, Homi Bhabha's postcolonial philosophy will be explored and adapted into these novels.

Thus, one can clearly observe the same cultural torment, isolation and alienation the formerly colonized people suffered from during the colonial age and also in post‐WWII England, the postcolonial West, in these two works. Therefore, the aim of this chapter is to question the metaphorical practices of colonialism in the postcolonial era and its impact upon the immi‐ grants in the postcolonial age by analysing the condition of the immigrant characters in *The Enigma of Arrival* and in *White Teeth.*

## **2. Homi Bhabha's postcolonial theory**

Analysing Homi Bhabha's postcolonial theory, it should be stated that his emphasis, in his work, *The Location of Culture*, on concepts such as hybridity, ambivalence, otherness, cultural difference and mimicry played a significant role in refiguring postcolonial theory. In Bhabha's postcolonial theory, the influence of Edward Said's postcolonial approach can‐ not be ignored. Said pays special attention to the discrepancies between the culture of the West and the East by introducing the term "Other" for the Easterners, which illustrates the gap between the "metropolitan culture" and the culture of the "Other." In other words, he asserts that the differences between the "centre" and the "peripheries" can effectively be explored by a "hybrid," who can combine his/her non‐Western culture with the Western norms, so in his work *Orientalism*, Said defines "Orientalism" as a way of understanding the traditions and the habits practised in the Orient and accepting its distinctive position in the rise of Europe [1].

cultural values of the colonized. It is undeniable that England played a very significant role as the colonizer by controlling many Asian, African and American nations during the colonial age; so England, socially, economically and politically, dominated different countries whose social and cultural notions were replaced with the English norms. The personal identity of the colonized experienced a radical transformation, which resulted in otherness, fragmentation, hybridity and mimicry as a consequence of multiculturalism as put forward by the postco‐ lonial theorist Homi Bhabha. In this respect, the power of the English nation as the colonizer was dominant not only in the colonial era but also in the postcolonial period. In this sense, even after the independence of the colonies ruled by England, the conflicts between the for‐ mer colonized and the former colonizer could still be recognized, particularly when these two opposite groups came together in the postcolonial age as a result of the former colonized's

16 People's Movements in the 21st Century - Risks, Challenges and Benefits

In order to identify these conflicts in the light of Homi Bhabha's postcolonial theory, two postcolonial novels will be analysed in this chapter. One of them is, Vidiadhar Surajprasad Naipaul's the autobiographical novel, *The Enigma of Arrival* (1987), which portrays the cul‐ tural trauma of an immigrant from Trinidad, especially in England but also in New York by referring to the enigma the novelist himself experienced when he immigrated from Trinidad to England. The character's dilemma due to his Trinidadian background in English culture clearly shows the author's inner conflict because of his hybridity. In this sense, the influence of Naipaul's own Trinidadian background and education in England upon the protagonist in

Zadie Smith's *White Teeth* (2000) also reflects the condition of the former colonized, the immi‐ grants coming from Bangladesh to England by revealing the psychological trauma and the cul‐ tural conflicts these immigrants experienced in England in the post‐war age. Especially Smith's coming from a multicultural family, her being torn between Jamaican and English heritage due to her mother's Jamaican nationality and her father's English origin, their years in the post‐war England, contributed much to her effective portrayal of the immigrant trauma in her novel *White Teeth*. While dealing with the struggles of the in‐between immigrants in these two works, Homi Bhabha's postcolonial philosophy will be explored and adapted into these novels.

Thus, one can clearly observe the same cultural torment, isolation and alienation the formerly colonized people suffered from during the colonial age and also in post‐WWII England, the postcolonial West, in these two works. Therefore, the aim of this chapter is to question the metaphorical practices of colonialism in the postcolonial era and its impact upon the immi‐ grants in the postcolonial age by analysing the condition of the immigrant characters in *The* 

Analysing Homi Bhabha's postcolonial theory, it should be stated that his emphasis, in his work, *The Location of Culture*, on concepts such as hybridity, ambivalence, otherness, cultural difference and mimicry played a significant role in refiguring postcolonial theory.

immigration to England.

his novel is obvious.

*Enigma of Arrival* and in *White Teeth.*

**2. Homi Bhabha's postcolonial theory**

According to Said, the West should not ignore the special cultural position of the non‐ Westerners; the non‐Westerners should not be defined as the "Other" and they should live in harmony together. The close interaction between the Orient and the Occident during the colonial period led to the diversity of cultures and brought different cultures together in an environment; however, it also caused the separation between these groups. Said's analysis of these cultural conflicts brought about his theory, "Orientalism," which is also explained by the author himself as the distinction between "the Orient" and "the Occident" [1].

The discrepancies between the Orient and the Occident, which have been discussed in lit‐ erary, philosophical and political texts, were regarded as problematic issues causing the strict distinction between the East and the West. Analysing the living styles, social norms, daily habits and viewpoints of the Easterners, many writers questioned the gap between the two parts. Said's emphasis on these concepts influenced Bhabha and he elaborated his postcolonial theory owing to Said's philosophy, accordingly Bhabha also contributed so much to revising postcolonial philosophy. First of all, the term "hybridity" is put forward by Bhabha, in *The Location of Culture*. According to his remarks, "split‐space" emerging in the postcolonial era led to an "international culture" [2]. When one considers the term "international culture," it can be asserted that it does not signify the official concept of multiculturalism, but diversity, plurality of cultures and cultural hybridity. Hybridity here refers to the "in‐between space," in which contradictory cultures come together and clash. Thus, this concept may suggest a new position for the postcolonial subjects. Instead of just celebrating the mysterious sense of cultural plurality, Bhabha tries to understand the feel‐ ings of people, who are in‐between hybrids, and identify their relationship with society in the postcolonial period.

Another term he suggests is ambivalence to emphasize the status of the postcolonial people in multicultural societies. The contradictory status of the immigrants in the postcolonial West and their conflicts due to their hybridity caused them to suffer from ambivalence. According to Bhabha, owing to ambivalence, colonial stereotype appears and the colonized's duality of iden‐ tity comes to the fore [2]. The "colonial stereotype," the powerful position of the colonizer and the powerless status of the colonized, comes to the fore as a result of ambivalence, which deter‐ mines the position of identities, their relationships with each other and their attitudes towards one another. Therefore, the contradictory approach portrayed towards the former colonized in the postcolonial era can also be defined as one of the reasons leading the immigrants, the ex‐col‐ onized, to cultural trauma. In this manner, the former colonized were also exposed to otherness as Bhabha points out: "[…] colonial discourse produces the colonized as a social reality which is at once an "other" and yet entirely knowable and visible" [1]. In other words, the colonized, during the colonial and even in the postcolonial period, were considered to be the "other," the stranger, the alien and the isolated, who suffered from their secondary position because of their cultural differences. These cultural differences brought about stereotyped roles, which intensi‐ fied the trauma of the ex‐colonized. In order to be accepted by the former colonizer in the post‐ colonial epoch, they had no choice but to mimic, imitate the manners of Westerners. Bhabha suggests that mimicry refers to the other's inappropriate and complex situation when he/she tries to be appropriate among the colonizer and it leads to the conflicts between the colonized and the colonizer due to the differences emerging between the two sides [2].

In this regard, the colonized people's mimicking the colonizer was a sign of rejecting their own identities and cultural values for the sake of acceptance in the postcolonial West, and consequently, they felt inappropriate due to their otherness and hybridity. Ironically enough, the more they tried to get rid of their personal identities, the more they suffered because of this rejection. Their being torn between their origins and the norms of the ex‐colonizer turned out to be contradictory in this sense, as consequence Bhabha, in the "Introduction" part of *Nation and Narration,* asks: When did we become "a people"? When did we stop being one? [3], which proves that he supports cultural unity and rejects othering individuals due to their cultural differences.

## **3. V.S. Naipaul's** *The Enigma of Arrival*

V.S. Naipaul, as a hybrid novelist, portrays the influence of colonialism on the ex‐colonized even in the postcolonial epoch in his novel, *The Enigma of Arrival*. In the novel, the impact of Naipaul's own background upon the reflection of the protagonist's sufferings because of his hybridity can be realized. Considering the biography of the author, it is clear that his own experiences dominate his novel. Trinidadian author, having an Indian immigrant family, receiving his uni‐ versity education at University College, Oxford, suffered from hybridity. On the one side, as he was familiar with his environment and people in his homeland, it was easier for him to lead his life there. On the other side, since there was no opportunity for him to broaden his mind and enlarge his vision in his homeland, he wanted to move to England [4]. But, in the West, he was exposed to cultural trauma and adaptation problems because of his in‐between status.

In this sense, one of the most significant novels of Naipaul, *The Enigma of Arrival*, is a striking reflection of his own hybridity and his experience of otherness and multiculturalism, the aspects that can be observed in Bhabha's postcolonial theory. In the autobiographical novel of the author, the protagonist trying to discover his personal identity through writing makes him recognize his own hybridity, otherness and dilemma due to his immigration from Trinidad to London and New York. Thus, in the novel, it is apparent that Naipaul reflects his own experiences as Barnouw highlights:

*Quintessentially a traveler, Naipaul has inhabited a large part of the world, looking at its amazing variety and trying to imagine the strangeness of people in different places and times. The experience*  *of cultural plurality moved him to seek out other's stories, and the symbiosis of recording and writing found already in his early texts reflects the responsibilities of writing out of others' articulated experiences, of transforming something already formed [5].*

as Bhabha points out: "[…] colonial discourse produces the colonized as a social reality which is at once an "other" and yet entirely knowable and visible" [1]. In other words, the colonized, during the colonial and even in the postcolonial period, were considered to be the "other," the stranger, the alien and the isolated, who suffered from their secondary position because of their cultural differences. These cultural differences brought about stereotyped roles, which intensi‐ fied the trauma of the ex‐colonized. In order to be accepted by the former colonizer in the post‐ colonial epoch, they had no choice but to mimic, imitate the manners of Westerners. Bhabha suggests that mimicry refers to the other's inappropriate and complex situation when he/she tries to be appropriate among the colonizer and it leads to the conflicts between the colonized

In this regard, the colonized people's mimicking the colonizer was a sign of rejecting their own identities and cultural values for the sake of acceptance in the postcolonial West, and consequently, they felt inappropriate due to their otherness and hybridity. Ironically enough, the more they tried to get rid of their personal identities, the more they suffered because of this rejection. Their being torn between their origins and the norms of the ex‐colonizer turned out to be contradictory in this sense, as consequence Bhabha, in the "Introduction" part of *Nation and Narration,* asks: When did we become "a people"? When did we stop being one? [3], which proves that he supports cultural unity and rejects othering individuals due

V.S. Naipaul, as a hybrid novelist, portrays the influence of colonialism on the ex‐colonized even in the postcolonial epoch in his novel, *The Enigma of Arrival*. In the novel, the impact of Naipaul's own background upon the reflection of the protagonist's sufferings because of his hybridity can be realized. Considering the biography of the author, it is clear that his own experiences dominate his novel. Trinidadian author, having an Indian immigrant family, receiving his uni‐ versity education at University College, Oxford, suffered from hybridity. On the one side, as he was familiar with his environment and people in his homeland, it was easier for him to lead his life there. On the other side, since there was no opportunity for him to broaden his mind and enlarge his vision in his homeland, he wanted to move to England [4]. But, in the West, he was

exposed to cultural trauma and adaptation problems because of his in‐between status.

In this sense, one of the most significant novels of Naipaul, *The Enigma of Arrival*, is a striking reflection of his own hybridity and his experience of otherness and multiculturalism, the aspects that can be observed in Bhabha's postcolonial theory. In the autobiographical novel of the author, the protagonist trying to discover his personal identity through writing makes him recognize his own hybridity, otherness and dilemma due to his immigration from Trinidad to London and New York. Thus, in the novel, it is apparent that Naipaul reflects his own experiences as

*Quintessentially a traveler, Naipaul has inhabited a large part of the world, looking at its amazing variety and trying to imagine the strangeness of people in different places and times. The experience* 

and the colonizer due to the differences emerging between the two sides [2].

to their cultural differences.

Barnouw highlights:

**3. V.S. Naipaul's** *The Enigma of Arrival*

18 People's Movements in the 21st Century - Risks, Challenges and Benefits

Naipaul's recognizing "variety" of people and "strangeness" of each individual in a plural and multicultural world shows that he achieved identifying the stories of different people in different cultures during his life and bringing them together with his own story. In the same manner, the protagonist in *The Enigma of Arrival*, like Naipaul himself, and those he observed throughout his life, can also be regarded as appropriate examples reflecting the sufferings of the postcolonial subjects. In the novel, the way how the protagonist describes his feelings when he first arrives in England shows that he does not belong to the land as a stranger and his "strangeness" makes him uncomfortable [6]. In this respect, in the very beginning, he is aware of his "strangeness" and the difficulty to adapt into the new environment as observed through his own words: "The idea of ruin and dereliction, of out‐of‐placeness, was something I felt about myself, attached to myself: a man from another hemisphere, another background. […]. I felt unanchored and strange" [6]. The character referring to "out‐of‐placeness" and his emphasis on his "unanchored and strange" position prove that he is in a cultural shock and thinks that his position in England is improper and absurd due to his Trinidadian back‐ ground. The reason why problems between the immigrants and the natives occurred in the postcolonial age was that the native people in the West regarded the position of immigrants as a threat to cultural unity. In this respect, Bhabha's concept of hybridity can be defined as a challenge to authority, to the Westerners [7]. Because of their cultural differences, the hybrids would bring their own cultural values to the West and undergo cultural clash with the Westerners, so it might be regarded as a risk by the Western society; although the pro‐ tagonist in the novel has not experienced a negative reaction from the English in this part of the novel, he assumes that his cultural norms and the living style he has adopted in Trinidad cannot be reconciled with those in England. As a result, when the character experiences the oddity of his own cultural values, together with his environment and its norms, he realizes that the process of adaptation will be hard to overcome. The more he feels inappropriate in the West, the more he begins to feel inferior, so even the house he begins to lead his life, in his own eyes, comes into view as the symbol of perfection, which is not suitable for an immigrant like him, as he emphasizes: "It could have been said that the perfection of the house in whose grounds I lived had been arrived at forty of fifty years before […]. Fifty years ago there would have been no room for me on the estate; even now my presence was a little likely" [6].

The house the protagonist begins to lead his life is perceived very magnificent by him, so he believes that the builder and the designer of the house could not have imagined that an immigrant from Trinidad with Indian heritage would stay in such a kind of splendid house. Fifty years ago, before the independence of the colonies, it could not have been possible for the former colonized to move to the West and live in houses in good conditions. Thus, it is not wrong to assert that the condition of the former colonies in the postcolonial period cannot be defined as totally good and this situation "would allow us to include people geographically displaced by colonialism such as African Americans or people of Asian or Caribbean ori‐ gin in Britain as 'postcolonial' subjects although they live within metropolitan cultures" [8]. Here Bhabha's emphasis on the contradictory impact of cultural differences and otherness upon the colonized can be recognized. The protagonist's feeling as the "other" in the postco‐ lonial West because of his cultural difference is obvious in the novel. In this regard, Bhabha "argues that colonial discourse is agonistic, split and contradictory, so that it never fully man‐ ages to assert a fixed and stereotypical knowledge of the colonial Other as it sets out to do" [9]. This uncertainty leads the protagonist in the novel to feel uncomfortable. As a result, he feels like a "stranger" [6] despite the opportunities he has after his immigration to England. In this sense, it is hardly possible for an immigrant to forget his colonial past and the difficulties he/ she was subjected to because of his position as the colonized during the colonial era. As the protagonist is aware of the impossibility to get rid of his former position, as the colonized, he indicates that his Trinidadian colonial past prevents him from achieving his ambition in writing and from being appreciated by the English [6].

His referring to his "peasant India, colonial Trinidad" shows that he is still under the influ‐ ence of his Indian and Trinidadian background, which follows him even in the postcolonial period; even if he tries to begin a new life in England after the colonial age, it is hard for him to adapt into the new environment, which is defined "unaccommodating." However, in spite of his discomfort in England after immigration, he reveals his ambition to immigrate to England before his immigration and the dilemma he suffers from after his arrival: "I had dreamed of coming to England. But my life in England had been savorless, and much of it mean. I had taken to England all the rawness of my colonial's nerves […]" [6]. What he underlines is that the problem here is not with the English people but with his crisis of personal identity due to his cultural problems. Bhabha's focus on the identity crisis and otherness of the hybrid colo‐ nized in Western societies among the Westerners, the colonizer, comes into view in this part. In this respect, "[…] cultural hybridity has become instead a reflexive moral battleground between cultural purists and cultural innovators, a cultural 'thing' in itself, defined in a field of contestation" [10]; therefore, in this battleground, the protagonist is in a cultural conflict and tries to adapt into the culture of the host country.

The disillusionment of the protagonist after feeling lonely, isolated and alienated in England can also be linked with his cultural and racial difference and it can be observed in the novel; what he expects about England before his arrival turns out to be disappointment after his arrival, because he does not feel that he belongs to the country; the social life and traditions in the country are not compatible with his own, and therefore, he assumes that he is a stranger in a foreign land in which he is frustrated when reality and fantasy contradict with one another: "I had come too late to find the England, the heart of empire, which (like a provincial, from a far corner of the empire) I had created in my fantasy" [6].

His searching for size in England proves that he wants to discover a more magnificent and powerful country than his own. Since he is isolated in a small island like Trinidad, he wants to explore a glorious country in which he aims at discovering splendid places he has never seen. Nevertheless, when he observes the power of the Westerners, he feels inferior, so it would be worth mentioning that with the onset of migration, power relations between the ex‐colonized and ex‐colonizer dominated the Western societies [11]; consequently, after his visit, the pro‐ tagonist becomes disappointed when he realizes that even if London is better than Trinidad, it is not as splendid as he imagined before his visit, and particularly, his cultural trauma and loneliness cause him to define the city and his condition with negative phrases; therefore, he expresses his disillusionment by stating that he is "ignorant, joyless […], lonely" in London because of the cultural gap between himself and the English [6].

upon the colonized can be recognized. The protagonist's feeling as the "other" in the postco‐ lonial West because of his cultural difference is obvious in the novel. In this regard, Bhabha "argues that colonial discourse is agonistic, split and contradictory, so that it never fully man‐ ages to assert a fixed and stereotypical knowledge of the colonial Other as it sets out to do" [9]. This uncertainty leads the protagonist in the novel to feel uncomfortable. As a result, he feels like a "stranger" [6] despite the opportunities he has after his immigration to England. In this sense, it is hardly possible for an immigrant to forget his colonial past and the difficulties he/ she was subjected to because of his position as the colonized during the colonial era. As the protagonist is aware of the impossibility to get rid of his former position, as the colonized, he indicates that his Trinidadian colonial past prevents him from achieving his ambition in writing

His referring to his "peasant India, colonial Trinidad" shows that he is still under the influ‐ ence of his Indian and Trinidadian background, which follows him even in the postcolonial period; even if he tries to begin a new life in England after the colonial age, it is hard for him to adapt into the new environment, which is defined "unaccommodating." However, in spite of his discomfort in England after immigration, he reveals his ambition to immigrate to England before his immigration and the dilemma he suffers from after his arrival: "I had dreamed of coming to England. But my life in England had been savorless, and much of it mean. I had taken to England all the rawness of my colonial's nerves […]" [6]. What he underlines is that the problem here is not with the English people but with his crisis of personal identity due to his cultural problems. Bhabha's focus on the identity crisis and otherness of the hybrid colo‐ nized in Western societies among the Westerners, the colonizer, comes into view in this part. In this respect, "[…] cultural hybridity has become instead a reflexive moral battleground between cultural purists and cultural innovators, a cultural 'thing' in itself, defined in a field of contestation" [10]; therefore, in this battleground, the protagonist is in a cultural conflict

The disillusionment of the protagonist after feeling lonely, isolated and alienated in England can also be linked with his cultural and racial difference and it can be observed in the novel; what he expects about England before his arrival turns out to be disappointment after his arrival, because he does not feel that he belongs to the country; the social life and traditions in the country are not compatible with his own, and therefore, he assumes that he is a stranger in a foreign land in which he is frustrated when reality and fantasy contradict with one another: "I had come too late to find the England, the heart of empire, which (like a provincial, from a

His searching for size in England proves that he wants to discover a more magnificent and powerful country than his own. Since he is isolated in a small island like Trinidad, he wants to explore a glorious country in which he aims at discovering splendid places he has never seen. Nevertheless, when he observes the power of the Westerners, he feels inferior, so it would be worth mentioning that with the onset of migration, power relations between the ex‐colonized and ex‐colonizer dominated the Western societies [11]; consequently, after his visit, the pro‐ tagonist becomes disappointed when he realizes that even if London is better than Trinidad, it is not as splendid as he imagined before his visit, and particularly, his cultural trauma and

and from being appreciated by the English [6].

20 People's Movements in the 21st Century - Risks, Challenges and Benefits

and tries to adapt into the culture of the host country.

far corner of the empire) I had created in my fantasy" [6].

The reason why he feels so lonely is that he does not have anyone with whom he can share his feelings in London; in other words, he cannot find the society he can familiarize with due to his cultural background. This proves that problems occur when the cultural values of the immigrants are "transferred from small, closed societies, to large and complex ones" [12]. In this respect, Bhabha's referring to ambivalence in the colonial and postcolonial texts comes to the fore as Malpas and Wake also state: "Even in the most confident colonial text, Bhabha suggests that there are moments of ambivalence: moments when it is possible to discern that the argument is contradictory" [9]. Even if the ex‐colonies achieved their independence, when they came together with the ex‐colonizer, the identities of the former colonized could not exactly be defined.

Although the protagonist longs for being a part of the Western society, what he experiences is just frustration as he cannot get on well with the English as a consequence of cultural differ‐ ences. One of the reasons why he cannot adapt into the culture of the English and feels infe‐ rior is his educational level, so he says: "But in spite of my education, I was under‐read. What did I know of London?" [6]. No matter how much he has received education in Trinidad, he feels that it is not enough for him to prove himself among the qualified English. The more he has an interaction with them, the more he assumes that it is hardly possible for him to become familiar with the English, who are more qualified, talented and educated than himself, so he indicates: "I found a city that was strange and unknown" [6]. In this respect, he is torn between his illusionary world and real world that he really encounters; even if it is a fantasy for him to move to England, to improve himself and to make use of the opportunities in the West, after his immigration he is really disappointed because of his fragmentation, hybridity and cultural background as observed: "I lost a faculty that had been part of me and precious to me for years. I lost the gift of fantasy, the dream of the future, the far‐off place where I was going" [6]. Ironically enough, though the world of fantasy that the protagonist expects to find in London is the greatest ambition for him, after leading his life there for a period of time he gets bored and feels exhausted due to his cultural shock and hybridity, and therefore, he stresses that he is under the "weariness" of his "social, racial, financial […] insecurity" in England [6]. Throughout the process of writing his work, the protagonist is bored not only because of his efforts to create his book, but also as a consequence of his adaptation prob‐ lems in a multicultural society, London. In this perspective, Bhabha's portrayal of the conflicts experienced by the colonized because of their cultural differences can be described as one of the reasons bringing about adaptation problems of the immigrants in the postcolonial West. Therefore, it is obvious that "[d]escriptions of multiplicity of the self usually stress its varia‐ tions over time and the discontinuities among the identifications forced upon us by rapid change" [13]. In such a kind of changing world, the differences regarding the identifications of the ex‐colonizer and the ex‐colonized dominated the multicultural societies in the postco‐ lonial era as seen in Naipaul's work as well.

Together with his identity crisis in England, the protagonist also refers to his identity problem in New York when he first arrives in the city. While he is writing his work in England, he re‐examines his immigration to New York and emphasizes how he feels as a stranger not only in London but also in New York, as a consequence he stresses: "Was there some fear of travel, in spite of my longing for the day, and in spite of my genuine excitement? Was this reaching out to people a response to solitude–since for the first time in my life I was solitary? Was it the fear of New York? Certainly" [6]. The fear of adaptation and the anxiety of being rejected by the American come to the fore, and therefore, he indicates that although it is the first time he is solitary in New York, the reason for his discomfort is not his state of solitariness but his fear of the foreign city, which proves that leaving one's homeland and immigrating to a new envi‐ ronment result in cultural shock. Moreover, his plane's late arrival at the airport in New York and the British Consulate officer's leaving the airport before meeting him cause him to feel distressed. In this regard, Bhabha's theory asserting the otherness of the colonized is also dom‐ inant in the novel. The otherness of the protagonist makes him more vulnerable. Since he is so sensitive because of his loneliness and isolation in the big city, he begins to blame the man from the consulate as he leaves him alone in the big city, so he is deceived by the taxi driver [6].

His being subjected to alienation on the first day of his arrival and the taxi driver cheating him make him feel despised, oppressed and othered. In this regard, he begins to blame the Westerners who do not help him or protect him, and consequently, he cannot get rid of this feeling of humiliation for many years. Under the negative impact of his being an immigrant and a foreigner in a foreign country, he cannot escape from the "panic" dominating himself and he indicates that he is "lost" in New York [6].

Feeling lost in his hotel room in New York, he regards himself as "suppressed, half true," which justifies that he is culturally depressed. Even if there were multiculturalist policies in Britain for the immigrants from the ex‐colonial countries, it did not mean that the sufferings of immigrants because of their hybridity came to an end [14]. Since Bhabha's concept of ambiva‐ lence is also prevailing in the novel, due to this contradiction the protagonist cannot overcome his cultural trauma and feel comfortable.

Furthermore, as an immigrant from Trinidad, he has also suffered from lack of social and edu‐ cational opportunities. So in New York, when he sees the newspaper, *The New York Times*, for the first time in his life, he feels that he does not belong to the city and he thinks that it is too late for him to improve himself completely due to the chances he has missed till that moment:

*But to read a newspaper for the first time is like coming into a film that has been on for an hour. To understand them [newspapers] you have to take knowledge to them; the knowledge that serves best is the knowledge provided by the newspaper itself. It made me feel a stranger, that paper [6].*

The extract above shows that the former colonized did not have the opportunity even to read a newspaper in his homeland due to insufficiencies. Moreover, he thinks that even if he has the chance to read the newspaper after the colonial period, he does not have the knowledge to grasp the issues indicated in the newspaper, so he feels like a stranger once more when he realizes his inability to respond to them, as a result as Bauman suggests, "[a]ll societies produce strangers, but each kind of society produces its own kind of strangers, and produces them in its own inimitable way" [15]. The state of being strange can also be associated with Bhabha's concepts of hybridity and otherness, which caused the colonized to feel incomplete. In particular, when they encountered, after immigrating to the postcolonial Western societies, the opportunities the colonizer benefited from, they felt more and more othered. Thus, in the novel, considering lack of opportunities for the colonized people during the colonial era, one can refer to the protagonist not having seen a French film before despite his readings about French films [6]; therefore, what makes him desperate is the insufficiency of social and educa‐ tional facilities as he says along these lines:

*So much of my education had been like that, abstract, a test of memory: like a man, denied the chance of visiting famous cities, learning their street maps instead. So much of my education had been like that: monkish, medieval, learning quite separate from everyday things [6].*

Although he received education before, it does not mean that he feels qualified enough to stand on his own feet; as an ex‐colonized, he feels that he could not make the maximum use of educational chances due to his status. On the other hand, despite the fact that he has all the chances in the post‐war West, it does not enable him to feel fortunate due to his frag‐ mented identity. How he describes his position in a bookshop in New York shows that he is unfamiliar with the names and titles belonging to the West and he wants to see the familiar so as to escape his cultural trauma [6]. Even being surrounded by innumerable books in the New York bookshop does not make him feel joyful and satisfied as he is not familiar with all of the authors, as a result he feels humiliated, incomplete and hybrid due to his background. Therefore, he points out: "Yet, with the humiliations of my first twenty‐four hours of travel, my first twenty‐four hours in the great world, with my increasing sense of my solitude in this world, I was aware [...] that I felt no joy" [6]. Feeling despised and inferior, it is impossible for him to overcome his anxiety and cultural shock, so he cannot escape from feelings of loneli‐ ness, isolation and inferiority complex. Therefore, "[w]henever the process of identity forma‐ tion is premised on an exclusive boundary between 'us' and 'them', the hybrid, born out of the transgression of this boundary, figures as a form of danger, loss and degeneration" [16], so the protagonist regards himself as the other, as "them" due to his hybridity, as a consequence he believes he will be considered to be a "danger, loss and degeneration." Bhabha's emphasis on the cultural otherness is obvious through the expressions of the character, who regards himself as the outsider because of his hybrid state.

In the light of the issues discussed, it is obvious that the protagonist struggles not only with his writing process, but also adaptation problems in London and in New York. Trying to cope with his hybridity and cultural difference, the protagonist reveals his colonial background and his dilemma due to his Indian, Trinidadian background and Western experience. In this respect, Bhabha's postcolonial concepts can also be recognized in *The Enigma of Arrival*, which demon‐ strates the inner conflict of an author because of his former colonial and postcolonial identities.

## **4. Zadie Smith's** *White Teeth*

re‐examines his immigration to New York and emphasizes how he feels as a stranger not only in London but also in New York, as a consequence he stresses: "Was there some fear of travel, in spite of my longing for the day, and in spite of my genuine excitement? Was this reaching out to people a response to solitude–since for the first time in my life I was solitary? Was it the fear of New York? Certainly" [6]. The fear of adaptation and the anxiety of being rejected by the American come to the fore, and therefore, he indicates that although it is the first time he is solitary in New York, the reason for his discomfort is not his state of solitariness but his fear of the foreign city, which proves that leaving one's homeland and immigrating to a new envi‐ ronment result in cultural shock. Moreover, his plane's late arrival at the airport in New York and the British Consulate officer's leaving the airport before meeting him cause him to feel distressed. In this regard, Bhabha's theory asserting the otherness of the colonized is also dom‐ inant in the novel. The otherness of the protagonist makes him more vulnerable. Since he is so sensitive because of his loneliness and isolation in the big city, he begins to blame the man from the consulate as he leaves him alone in the big city, so he is deceived by the taxi driver [6]. His being subjected to alienation on the first day of his arrival and the taxi driver cheating him make him feel despised, oppressed and othered. In this regard, he begins to blame the Westerners who do not help him or protect him, and consequently, he cannot get rid of this feeling of humiliation for many years. Under the negative impact of his being an immigrant and a foreigner in a foreign country, he cannot escape from the "panic" dominating himself

Feeling lost in his hotel room in New York, he regards himself as "suppressed, half true," which justifies that he is culturally depressed. Even if there were multiculturalist policies in Britain for the immigrants from the ex‐colonial countries, it did not mean that the sufferings of immigrants because of their hybridity came to an end [14]. Since Bhabha's concept of ambiva‐ lence is also prevailing in the novel, due to this contradiction the protagonist cannot overcome

Furthermore, as an immigrant from Trinidad, he has also suffered from lack of social and edu‐ cational opportunities. So in New York, when he sees the newspaper, *The New York Times*, for the first time in his life, he feels that he does not belong to the city and he thinks that it is too late for him to improve himself completely due to the chances he has missed till that moment: *But to read a newspaper for the first time is like coming into a film that has been on for an hour. To understand them [newspapers] you have to take knowledge to them; the knowledge that serves best is the* 

The extract above shows that the former colonized did not have the opportunity even to read a newspaper in his homeland due to insufficiencies. Moreover, he thinks that even if he has the chance to read the newspaper after the colonial period, he does not have the knowledge to grasp the issues indicated in the newspaper, so he feels like a stranger once more when he realizes his inability to respond to them, as a result as Bauman suggests, "[a]ll societies produce strangers, but each kind of society produces its own kind of strangers, and produces them in its own inimitable way" [15]. The state of being strange can also be associated with Bhabha's concepts of hybridity and otherness, which caused the colonized to feel incomplete. In particular, when they encountered, after immigrating to the postcolonial Western societies,

*knowledge provided by the newspaper itself. It made me feel a stranger, that paper [6].*

and he indicates that he is "lost" in New York [6].

22 People's Movements in the 21st Century - Risks, Challenges and Benefits

his cultural trauma and feel comfortable.

Britain is a multicultural country, which consists of various nations within itself. In par‐ ticular, the immigrants, who came to Britain from different countries after World War II, constituted a significant part of Britain. Most of the immigrants migrated to Britain with great expectations in order to improve their living conditions with better job opportunities; however, they were faced with insufficient conditions, humiliation, poverty and misery, so particularly after World War II, they suffered too much as a consequence of cultural trauma, racism and problems of otherness in Britain.

In this sense, Z. Smith's novel entitled *White Teeth* reflects the situation of the immigrants in Britain by portraying the oppression imposed on them due to their race. When Smith's cultural origin is taken into account, it can be deduced that her biography is compatible with the background of her characters in her novel. She was born in the north London suburb of Willesden to a Jamaican mother and an English father [17]. Therefore, coming from a multi‐ cultural family, Smith experienced the cultural values of these two countries and found the opportunity to observe the differences between the Jamaican and the English cultures. As a result in her novel, *White Teeth*, she effectively highlighted the conflicts between the cultural notions of immigrants and those of belonging to the English.

After World War II, Britain suffered from a severe labour shortage, especially in unskilled jobs and in service industries; therefore, the more there appeared people who decided to move from the rural areas of England to the growing urban areas of the country to work in the industrial centres, the more the ethnic profile of Britain changed [18]. As a result, cultural contradictions and inequalities became obvious because of different cultural norms, religious doctrines and traditions in British society.

In *White Teeth*, Smith sheds light on the isolation and alienation of the immigrants in England by showing the psychological trauma and cultural conflict these immigrants experience in the foreign country. In the novel, the difficult conditions people from different countries in England had to cope with in the postcolonial English society can be observed. In the work, the couple, Samad Iqbal and Alsana, who came to England from Bangladesh, represent those who are faced with suffering, degradation and racism due to their cultural, social and reli‐ gious differences. In the novel, Samad is humiliated in English society because of his origin and culture. While he is looking for a more appropriate job, he starts to work as a waiter; however, he experiences nothing, but humiliation [19].

In this sense, it is obvious that the *other* is doomed to be isolated and humiliated at work in England. As a consequence, cultural distinction appears between the British citizens and the *others*, which places a significant priority on differences of skin colour. So although the post‐war immigrants came to Britain from the Commonwealth to fill vacancies and labour shortage, they suffered from unemployment or from the harsh manners of the British employers [18]. Here Bhabha's concept suggesting the "in‐between" position of the colo‐ nized can easily be realized as seen along these lines:

*[…] the borders that are conventionally assumed to exist between colonizer and colonized, East and West, self and Other, are refigured in Bhabha's theory of hybridity. Bhabha argues that borders presuppose a no-man's land, an in-between space that simultaneously divides and connects two areas. This space, he suggests, is productive and enabling. Using the biological terms 'hybrid' to denote the liminal position of the migrant, Bhabha celebrates the intermingling of cultures and contests the idea of cultural purity [9].*

What is ironic here is that, according to Bhabha, this re‐figuration and theory of hybrid‐ ity would propose cultural unity and harmony among different cultures, but in the novel, *White Teeth*, the result is not so promising. Therefore, Samad is suffocated owing to the class distinction in the areas of employment, so he wants to challenge cultural discrimination and racism by revealing his identity and social position with a "placard" in society among the Westerners [19]; however, as indicated in the novel, "[b]ut, no such placard existing, he had instead the urge, the need, to speak to every man, and, like the ancient Mariner, explain constantly, constantly wanting to reassert something, anything," this shows that he suffers from cultural and racial discrimination and he wants to prove his identity among the English.

particularly after World War II, they suffered too much as a consequence of cultural trauma,

In this sense, Z. Smith's novel entitled *White Teeth* reflects the situation of the immigrants in Britain by portraying the oppression imposed on them due to their race. When Smith's cultural origin is taken into account, it can be deduced that her biography is compatible with the background of her characters in her novel. She was born in the north London suburb of Willesden to a Jamaican mother and an English father [17]. Therefore, coming from a multi‐ cultural family, Smith experienced the cultural values of these two countries and found the opportunity to observe the differences between the Jamaican and the English cultures. As a result in her novel, *White Teeth*, she effectively highlighted the conflicts between the cultural

After World War II, Britain suffered from a severe labour shortage, especially in unskilled jobs and in service industries; therefore, the more there appeared people who decided to move from the rural areas of England to the growing urban areas of the country to work in the industrial centres, the more the ethnic profile of Britain changed [18]. As a result, cultural contradictions and inequalities became obvious because of different cultural norms, religious

In *White Teeth*, Smith sheds light on the isolation and alienation of the immigrants in England by showing the psychological trauma and cultural conflict these immigrants experience in the foreign country. In the novel, the difficult conditions people from different countries in England had to cope with in the postcolonial English society can be observed. In the work, the couple, Samad Iqbal and Alsana, who came to England from Bangladesh, represent those who are faced with suffering, degradation and racism due to their cultural, social and reli‐ gious differences. In the novel, Samad is humiliated in English society because of his origin and culture. While he is looking for a more appropriate job, he starts to work as a waiter;

In this sense, it is obvious that the *other* is doomed to be isolated and humiliated at work in England. As a consequence, cultural distinction appears between the British citizens and the *others*, which places a significant priority on differences of skin colour. So although the post‐war immigrants came to Britain from the Commonwealth to fill vacancies and labour shortage, they suffered from unemployment or from the harsh manners of the British employers [18]. Here Bhabha's concept suggesting the "in‐between" position of the colo‐

*[…] the borders that are conventionally assumed to exist between colonizer and colonized, East and West, self and Other, are refigured in Bhabha's theory of hybridity. Bhabha argues that borders presuppose a no-man's land, an in-between space that simultaneously divides and connects two areas. This space, he suggests, is productive and enabling. Using the biological terms 'hybrid' to denote the liminal position of the migrant, Bhabha celebrates the intermingling of cultures and contests the idea of cultural purity [9].*

What is ironic here is that, according to Bhabha, this re‐figuration and theory of hybrid‐ ity would propose cultural unity and harmony among different cultures, but in the novel, *White Teeth*, the result is not so promising. Therefore, Samad is suffocated owing to the class

racism and problems of otherness in Britain.

24 People's Movements in the 21st Century - Risks, Challenges and Benefits

doctrines and traditions in British society.

however, he experiences nothing, but humiliation [19].

nized can easily be realized as seen along these lines:

notions of immigrants and those of belonging to the English.

Furthermore, as an immigrant in the West, Samad and his family undergo economic depres‐ sion and find it hard to survive as narrated along these lines: "The matter was … what was the matter? The house was the matter" [19]. Apart from experiencing the cultural trauma, immi‐ grants were also subjected to accommodation problems in that period. Smith also portrays insufficient living conditions of the immigrants, struggling with poverty and inadequacy of their needs being met. In the novel, Alsana quarrels with Samad because of their poverty and their struggle to make a living as immigrants in English society. Her worries about their situ‐ ation in the foreign land can be recognized in her dialogue with Samad:

*What is the point of moving here - nice house, yes, very nice, very nice-but where is the food? You fight in an old, forgotten war with some Englishmen…married to a black! Whose friends are they? These are the people my child will grow up around? Their children-half blacky-white? But tell me, where is our food? […]* [19].

The immigrants clearly hoped to lead a comfortable life in England, but what they experi‐ enced was incompatible with their expectations, because they were exposed to insufficient liv‐ ing conditions and experienced financial problems, class distinction and poverty in England. In this sense, when the rate of income in England is taken into consideration according to the figures released by the Department of Social Security in July 1990, it is clear that "income inequality widened between 1979 and 1988, becoming greater than at any time since the Second World War" [20]. Income inequality and inadequacy of living and working conditions caused the immigrants to suffer, and similarly, Samad Iqbal undergoes the hardship of being a stranger in England, so he is degraded in the restaurant he works.

The reason why Smith creates immigrant characters suffering from cultural differences in the postcolonial West is that she wants to portray the difficulty for the immigrants to adapt into a new environment and to express themselves. Similarly, Bhabha also reflects the problematic and contradictory status of the hybrids in his work *The Location of Culture*, which "[…] is con‐ cerned with these dynamics of cultural difference and with finding ways that the subaltern can have voice, can have representation" [21].

Together with the problems related to the inequality between the English and the minority groups in the post‐WWII Britain, the cultural conflicts also come to the fore in England as a result of migrants coming from different cultures. In *White Teeth*, the conflicts in terms of religion draw attention because of some problems between the two different cultures. For instance, when one of Samad's sons, Magid, wants to participate in the Harvest Festival at school, Samad objects, because as a Muslim he does not approve of Christian festivals, so he does not let Magid participate in the festival and says, *"I told you already. I do not want you participating in that nonsense. It has nothing to do with us, Magid. Why are you always trying to be somebody you are not?"* [19]. Furthermore, Samad decides to send back Magid to their native land, Bangladesh, in order to isolate him from the cultural norms and social habits of the English and to make him stick to his own culture and religion [19]. This proves that Samad fears the fact that if Magid accepts his hybridity, he will be subjected to the risk of losing his original background; so he tries to lead his son to be non‐hybridic. In this way, [f]or Bhabha the non‐hybridic […] is a commitment to "unitary" or "originary" identity, identity as "pres‐ ence […]" [22]. Therefore, Samad aims at protecting the "originary," and "presence" of his son. In this sense, his ideas related to his desire to protect his own culture and religion by sending his son to their homeland [19] can be interpreted as his panic about his son being an atheist in the West.

In the light of Samad's hesitation, it is obvious that he is worried not only about losing his own religion and culture as a consequence of being culturally influenced by the English traditions, but he also fears the fact that his children may negatively be influenced by the English culture. In this respect, it should be noted that the second generation, who has a tendency to adopt the English culture, experiences intergenerational difficulties and cultural conflict in the post‐ WWII England. As they have been brought up in England, they are more flexible in terms of adopting the English culture, but they are torn between their own roots and the English life style, as a result their hybridity leads them to mimicry. In this regard, "[t]hrough the concepts of hybridity and mimicry, Bhabha suggests an effectiveness of cultural difference that both resists enclosures of culture and displaces the exclusive power of colonialist discourse" [23]. Such a kind of "colonialist discourse" is also dominant in Smith's work. When the worries of Samad about his children are taken into account, he is aware of the fact that "it is not easy to escape mentally from a concrete situation, to refuse its ideology while continuing to live with its actual relationships" [24]. Being exposed to these "actual relationships," the second generation is more adaptable to the English life style. In *White Teeth*, striking examples related to the situation of the second generation draw attention; for instance, the son of Samad Iqbal and Alsana, Magid, does his best in order to be accepted by his English friends; therefore, on his ninth birthday, when his friends ask for "Mark Smith" instead of Magid, Alsana says: "Mark? No Mark here. You have the wrong house" [19]. This situation shows the desire of the second generation to be regarded as a part of the English society by eliminating their original characteristics. On the other side, the first generation does not want to lose their cul‐ tural heritage; therefore, Samad says: *"I give you a glorious name like Magid Mahfooz Murshed Mubtasim Iqbal! […] and you want to be called Mark Smith"* [19]. As the representative of the first generation, Samad rejects the Western norms and shows his anger towards his son when he wants to get rid of his cultural origin. It is known that Britain had an enormous power and authority over the other nations even in the postcolonial era, "the British Empire was thus viewed as the highest stage of the social organization" [25]. So Magid changes his name in order to find a position among the English. In addition, his desire to reject his origin and to adopt the Western traditions can also be observed in the novel. He is ashamed of belonging to an Eastern family, and the narrator reflects his desire to be from a Western family so that he would have the chance to join in the Harvest Festival [19].

As portrayed in the novel, Magid wants to escape his origins, his family and their traditions in order to be regarded superior and respectable by the Westerners, so he wishes that he had a chance to have a Western family, who practised Western habits and who allowed him to be involved in Western practices like the Harvest Festival. On the other hand, his father Samad is strictly against his children participating in Western social life and their insisting on mimick‐ ing the Western habits; consequently, his discomfort with Magid's insistence on being a part of the Harvest Festival and his asking Magid to come with him to haj can be related to his worries about loss of personal identity. No matter how much Samad tries to change the mind of Magid, he fails and Magid rejects the pilgrimage to Mecca [19].

land, Bangladesh, in order to isolate him from the cultural norms and social habits of the English and to make him stick to his own culture and religion [19]. This proves that Samad fears the fact that if Magid accepts his hybridity, he will be subjected to the risk of losing his original background; so he tries to lead his son to be non‐hybridic. In this way, [f]or Bhabha the non‐hybridic […] is a commitment to "unitary" or "originary" identity, identity as "pres‐ ence […]" [22]. Therefore, Samad aims at protecting the "originary," and "presence" of his son. In this sense, his ideas related to his desire to protect his own culture and religion by sending his son to their homeland [19] can be interpreted as his panic about his son being an

26 People's Movements in the 21st Century - Risks, Challenges and Benefits

In the light of Samad's hesitation, it is obvious that he is worried not only about losing his own religion and culture as a consequence of being culturally influenced by the English traditions, but he also fears the fact that his children may negatively be influenced by the English culture. In this respect, it should be noted that the second generation, who has a tendency to adopt the English culture, experiences intergenerational difficulties and cultural conflict in the post‐ WWII England. As they have been brought up in England, they are more flexible in terms of adopting the English culture, but they are torn between their own roots and the English life style, as a result their hybridity leads them to mimicry. In this regard, "[t]hrough the concepts of hybridity and mimicry, Bhabha suggests an effectiveness of cultural difference that both resists enclosures of culture and displaces the exclusive power of colonialist discourse" [23]. Such a kind of "colonialist discourse" is also dominant in Smith's work. When the worries of Samad about his children are taken into account, he is aware of the fact that "it is not easy to escape mentally from a concrete situation, to refuse its ideology while continuing to live with its actual relationships" [24]. Being exposed to these "actual relationships," the second generation is more adaptable to the English life style. In *White Teeth*, striking examples related to the situation of the second generation draw attention; for instance, the son of Samad Iqbal and Alsana, Magid, does his best in order to be accepted by his English friends; therefore, on his ninth birthday, when his friends ask for "Mark Smith" instead of Magid, Alsana says: "Mark? No Mark here. You have the wrong house" [19]. This situation shows the desire of the second generation to be regarded as a part of the English society by eliminating their original characteristics. On the other side, the first generation does not want to lose their cul‐ tural heritage; therefore, Samad says: *"I give you a glorious name like Magid Mahfooz Murshed Mubtasim Iqbal! […] and you want to be called Mark Smith"* [19]. As the representative of the first generation, Samad rejects the Western norms and shows his anger towards his son when he wants to get rid of his cultural origin. It is known that Britain had an enormous power and authority over the other nations even in the postcolonial era, "the British Empire was thus viewed as the highest stage of the social organization" [25]. So Magid changes his name in order to find a position among the English. In addition, his desire to reject his origin and to adopt the Western traditions can also be observed in the novel. He is ashamed of belonging to an Eastern family, and the narrator reflects his desire to be from a Western family so that he

would have the chance to join in the Harvest Festival [19].

As portrayed in the novel, Magid wants to escape his origins, his family and their traditions in order to be regarded superior and respectable by the Westerners, so he wishes that he had a chance to have a Western family, who practised Western habits and who allowed him to be

atheist in the West.

Magid rejecting his father's proposal about going to Mecca and his challenge against his father's hatred to Western values show that the first and the second generations from the East struggle with each other in the West because of the former's fear of losing their cultural prin‐ ciples and the latter's desire to devote themselves to the Western values. There is no doubt that immigrants whether belonging to the first or second generations experience cultural trauma when exposed to the postcolonial West. While the former tries to resist the Western way of life due to fear of losing their own values, the latter tries to mimic the Western habits in order not to be rejected and be despised by the Westerners. In this manner, the vulnerable position of the immigrants in the post‐war West is also explained in the novel. It is stated that immigrants in the West have a tendency to repeat the manners of the Westerners, as a result they cannot escape the cultural trauma [19].

Like Iqbals in the novel, many immigrants from the East experienced similar problems lead‐ ing them to a cultural trauma. It is inevitable for these immigrants to suffer from the term "original trauma," which is defined in the extract above. As they cannot escape from this trauma, they are familiar with it, but find it hard to overcome it. Highlighting the cultural trauma undergone by the immigrants in the postcolonial West, Smith portrays not only the problems of the Iqbal family, but also the desperate condition of the Jones family with whom the Iqbal family has a close relationship. In this respect, when Samad Iqbal's friend, Archie's daughter Irie is taken into consideration, she can also be regarded as the representative of the suffering second generation. Irie's father, Archie Jones, is a working class English man, whereas her mother, Clara, is a black Jamaican immigrant. Consequently, as the daughter of a multicultural family, she has been brought up in England in accordance with her origins; nev‐ ertheless, she is surrounded by the English environment in which she desires to be involved. As a result, like Magid, she also tries to resemble the English by trying to change her original characteristics. In particular, one of the experiences she is exposed to in class leads her to be ashamed of her race and culture. After the sonnet entitled *The Dark Lady* is read in a course at school, Irie asks whether she is really black or not. Her teacher, Mrs Roddy, indicates that The Dark Lady cannot be defined as black, because there was no possibility to see slaves in England in that period and only slaves can be titled as black [19].

The reply of the teacher makes Irie uncomfortable and she feels inferior due to the colour of her skin. Considering the position of the black immigrants in England, it is doubtless that "[t] he history of Blacks in Britain and in the entire Black Atlantic expresses the kinds of themes indicative of the general fragmentation process of the world system as well as the intellectual cosmopolitan reaction to that process […]" [26]. Because of her fragmented identity, Irie finds it hard to overcome her cultural adaptation problems. Dwelling on the reference to slavery in the extract, it can also be defined as disturbing for Irie as the teacher implies that only the black can be slaves. Furthermore, she also feels uneasy when she has the idea that the prefer‐ ence for women was to be excessively pale in 1660s, and she believes that the situation has not changed since those days. This shows the isolation and alienation of the black immigrants in postcolonial English society. Although Irie is born in England, she is treated as if she were a foreigner due to the colour of her skin; in this sense, racism appeared in English society in the post‐war era. As racism is a reactionary conception and suggests that there are physical and psychological inequalities between human races, this reduces black and Asian people's chances of success in postcolonial Britain and forces them to survive with low incomes [27]. When the racial issue in Britain is taken into consideration, the 1976 Race Relations Act draws attention. Even though it was put into practice in order to create a more peaceful environment in which all the races were equal and independent, discrimination and inequality in the post‐ war British society still continued to some extent [28]. In this respect, it is not surprising to see that Irie wants to change her curly, black hair into straight, reddish black hair for the sake of acquiring the appearance of the English women [19]. Nevertheless, the result is a disaster and Neena makes fun of Irie, so "Irie couldn't say anything for a moment. She had not considered the possibility that she looked anything less than terrific" [19].

It is obvious that even if Irie aims at resembling the English, the Western women, the result is nothing but a disaster for her as another character in the novel, Neena indicates. Since Irie does her best to look like an English by changing the originality of her hair, she hopes that she will be respected and admired by the others; however, she merely becomes an interesting topic for the people around herself who would like to make fun of her. The situ‐ ation shows that Irie feels uncomfortable due to her hybridity and wants to be recognized and accepted by English society, which is the source of superiority and power as stressed in the novel: "There was England, a gigantic mirror, and there was Irie, without reflection. A stranger in a stranger land" [19]. Her feeling like a "stranger in a stranger land" proves that she is under the pressure of cultural trauma, which causes her to regard herself inferior and powerless in the "gigantic mirror." The situation of the second generation can be related to Homi Bhabha's ideas about the efforts of the "hybrid others" to mimic the "Westerners." In this sense, "[h]ybridity is a term that Bhabha uses to describe the notion of mixed or hybrid identities which encompass the contradictory history of colonization, in contradis‐ tinction to the concept of a pure identity" [29]. Therefore, the attempts of the second genera‐ tion to mimic the English in *White Teeth* show that the young generation lose their "pure identities" and are involved with the English identities. For example, Magid wants to study English law, which makes his father Samad worried about the loss of their own origins and religious views, so he emphasizes as follows:

*"Allah knows how I pinned all my hopes on Magid. And now he says he is coming back to study the English law. […]. He wants to enforce the laws of man rather than the laws of God. He has learnt none of the lessons of Muhammad […]"* [19].

Samad's fear for the future of his sons proves that he does not want to be lost in English society, which has altered the attitudes of his sons, their tendencies and habits. However, the more his sons interact with the English, the more they are accustomed to the living style and customs of the English, which makes not only Samad but also Alsana uncomfortable as she indicates*: "The English are the only people … who want to teach you and steal from you at the same*  *time"* [19]. In this manner, the second generations being under the undeniable influence of the Western culture and turning into Western traditions can be explained by the perspectives of Richard Hoggart and Raymond Williams, who define culture as a transformation, an active construction and experience [30]. In this sense, it can be deduced that one gains the cultural knowledge through a conscious learning process, so there is much to be gained by observation or participation. As a consequence, observing the customs of the English and participating in English social life, according to their parents, Magid and Irie turn out to be more English than the English. In fact, why they tend to adopt the English values and try to escape their own values is that they do not want to be excluded from the English society, even if in Bhabha's theory the issue emphasized is that "[…] members of postcolonial societies and minorities should not regard their ethnic or cultural traits as a limitation but as a potential wealth" [31].

black can be slaves. Furthermore, she also feels uneasy when she has the idea that the prefer‐ ence for women was to be excessively pale in 1660s, and she believes that the situation has not changed since those days. This shows the isolation and alienation of the black immigrants in postcolonial English society. Although Irie is born in England, she is treated as if she were a foreigner due to the colour of her skin; in this sense, racism appeared in English society in the post‐war era. As racism is a reactionary conception and suggests that there are physical and psychological inequalities between human races, this reduces black and Asian people's chances of success in postcolonial Britain and forces them to survive with low incomes [27]. When the racial issue in Britain is taken into consideration, the 1976 Race Relations Act draws attention. Even though it was put into practice in order to create a more peaceful environment in which all the races were equal and independent, discrimination and inequality in the post‐ war British society still continued to some extent [28]. In this respect, it is not surprising to see that Irie wants to change her curly, black hair into straight, reddish black hair for the sake of acquiring the appearance of the English women [19]. Nevertheless, the result is a disaster and Neena makes fun of Irie, so "Irie couldn't say anything for a moment. She had not considered

It is obvious that even if Irie aims at resembling the English, the Western women, the result is nothing but a disaster for her as another character in the novel, Neena indicates. Since Irie does her best to look like an English by changing the originality of her hair, she hopes that she will be respected and admired by the others; however, she merely becomes an interesting topic for the people around herself who would like to make fun of her. The situ‐ ation shows that Irie feels uncomfortable due to her hybridity and wants to be recognized and accepted by English society, which is the source of superiority and power as stressed in the novel: "There was England, a gigantic mirror, and there was Irie, without reflection. A stranger in a stranger land" [19]. Her feeling like a "stranger in a stranger land" proves that she is under the pressure of cultural trauma, which causes her to regard herself inferior and powerless in the "gigantic mirror." The situation of the second generation can be related to Homi Bhabha's ideas about the efforts of the "hybrid others" to mimic the "Westerners." In this sense, "[h]ybridity is a term that Bhabha uses to describe the notion of mixed or hybrid identities which encompass the contradictory history of colonization, in contradis‐ tinction to the concept of a pure identity" [29]. Therefore, the attempts of the second genera‐ tion to mimic the English in *White Teeth* show that the young generation lose their "pure identities" and are involved with the English identities. For example, Magid wants to study English law, which makes his father Samad worried about the loss of their own origins and

*"Allah knows how I pinned all my hopes on Magid. And now he says he is coming back to study the English law. […]. He wants to enforce the laws of man rather than the laws of God. He has learnt none* 

Samad's fear for the future of his sons proves that he does not want to be lost in English society, which has altered the attitudes of his sons, their tendencies and habits. However, the more his sons interact with the English, the more they are accustomed to the living style and customs of the English, which makes not only Samad but also Alsana uncomfortable as she indicates*: "The English are the only people … who want to teach you and steal from you at the same* 

the possibility that she looked anything less than terrific" [19].

28 People's Movements in the 21st Century - Risks, Challenges and Benefits

religious views, so he emphasizes as follows:

*of the lessons of Muhammad […]"* [19].

Thus, immigrants undergo a process of cultural conflict and psychological trauma in the for‐ eign country. In the novel, one of the events regarding the cultural clash between the immi‐ grants and the English can be recognized, for instance, while Alsana, Clara and Neena, before Irie's birth, are talking about the name of the baby. Alsana advises Clara to give the name, Sarah, which her husband Archie likes. So she recommends her to please her husband and to be an obedient woman. In this sense, Alsana's niece Neena protests against the submissive and passive role attributed to women as follows: "There's got to be communication between men and women in the West […]" [19]. In this respect, the difference between Eastern and Western women is stressed in *White Teeth*; as an Eastern woman, Alsana has difficulty to express her ideas and to stand on her own feet, so she submits to the wishes of men, in this case to the wishes of her husband. As a consequence, Neena reminds her of the environment where she is leading her life and underlines the incompatibility of her obedient nature with the indepen‐ dent nature of the Western women in England. Although Alsana begins to become a part of the English way of life, she cannot break her ties with her own culture. When the gender issue in the nineteenth and twentieth century Eastern societies is taken into account, it is clear that women suffered from lack of independence. In this sense, Alsana's obedient aspect reflects her own cultural origin. The English culture and the culture of the East are contradictory. Although "[…] for Bhabha hybridity is a site of subaltern cultural and epistemological resis‐ tance to colonialism" [32], as observed in the novel, in some respects hybridity brings about serious clashes between the Easterners and the Westerners.

Considering the reaction of Samad, one of the immigrants belonging to the first generation, being against the Western norms, it is clear that he does not want to lose his personal identity, so he is against adopting all of the western notions for the sake of overcoming the adaptation problems, as a consequence when Archie calls him Sam instead of Samad, he turns out to be angry and says: "*'Don't call me Sam,' […], 'I'm not one of your English matey-boys. My name is Samad Miah Iqbal. Not Sam. Not Sammy. And not – God forbid – Samuel. It is Samad'"* [19]. Samad's anger after hearing that Archie calls him Sam is a signal of his fear of losing his identity, which is one of the most significant characteristics of the immigrants in the post‐war West.

Coping with all these conflicts in England, the representatives of the second generation were oppressed due to the pressure imposed on them by their families and by the norms of English society. As a result, while one of the twin sons of Samad and Alsana, Magid turns out to be an atheist, Millat becomes a militant [19]. So the pressure of being a part of two differ‐ ent cultures makes them suffer as the character, Joyce indicates in the novel: *"The fact is both these boys have serious emotional problems. They've been split up by their religions, by their cultures. Can you imagine the trauma?"* [19]. The cultural conflict leads Magid and Millat to emotional suffering, which brings about the feeling of uncertainty about their origins. The increasing number of British‐born children of immigrant families suffered from cultural alienation and isolation in the post‐WWII Britain [27]. In order not to be alienated and isolated, they mimic the English, and thus, "[b]y differently repeating the 'original culture', the 'self' of colonial culture splits, revealing its requirement for difference and otherness in order to be estab‐ lished as superior" [33].

In this manner, Samad Iqbal believes that it is the corruption in England which has destroyed his family and their cultural roots. He says: *"I have been corrupted by England, I see that now-my children, my wife, they too have been corrupted"* [19]. Since the customs and lifestyle in England are not in accordance with his Eastern culture, he regards the English culture as corrupted. In this sense, multiculturalism in England resulted in some cultural problems among those who made an effort to survive there despite all cultural, traditional and religious discrepancies. As mentioned in *Resistance Through Rituals*, culture is made up of many competing and conflict‐ ing groups and each of them defines itself through its distinctive way of life [34]. Therefore, in *White Teeth*, as a Muslim immigrant from Bangladesh, Samad Iqbal cannot reconcile with the English owing to his Eastern perspective and traditions, so he says: "I am corrupt, my sons are becoming corrupt, we are all soon to burn in the fires of hell" [19]. Similarly, Alsana objects the pressure of English culture upon her family: *"I am saying these people are taking my son away from me! They're Englishifying him completely! They're deliberately leading him away from his culture and his family and his religion"* [19]. Considering Bhabha's views about the conflicting relationship between the colonized and the colonizer, it is undeniable that the colonized people leaving their cultural values behind in the postcolonial Western societies and their adopting the culture of the West, the practice of mimicry, disturb the colonizer in a sense, because "[i]n mimicry the colonizer sees himself in a mirror that slightly but effectively distorts his image – that subtly and unsettingly 'others' his own identity" [35]. The cultural contradictions in the postcolonial period between the two parts resulted in the "in‐between" position of the ex‐colonized in the dominance of the Western norms. In this respect, the domi‐ nance of English culture, customs and lifestyle oppressed the immigrants who came to Britain in the post‐war epoch; therefore, Smith aims at bringing various people together in order to display their efforts to live together despite their sufferings. In an interview by O'Grady, Smith highlights her interest in combining various cultures with one another and analysing the position of the hybrid [36].

Consequently, since Smith comes from a culturally mixed family as well, she is interested in people's origins and ethnic identities and focuses on this in *White Teeth* by shedding light on different understandings of different nations, which turned out to be a problematic issue in England after WWII. Applying Bhabha's concepts to the novel, the characters immigrating to London from the East reflect his ideas. Thus, the reflection of the multicultural English society in the novel shows that "[…] the postcolonial subject comes to proclaim the death of national literature" [37]; consequently, with the rise of postcolonialism, the condition of the "postcolo‐ nial subject" in cultural plurality was the issue analysed by many novelists, including Smith.

As observed throughout the analysis, in *White Teeth*, Smith portrays the interaction between the English and the immigrants in England in order to emphasize the cultural, religious and social differences between these people. Furthermore, she concentrates on the inner conflicts and sufferings of the immigrants due to their adaptation problems and reflects on the con‐ tradiction between the English and the Eastern cultures by creating characters with differ‐ ent social and cultural backgrounds. Thus, Smith deals with the immigrants' problems of acculturation and integration in England by dwelling on the emotional and psychological problems of both the first and the second generations. In this sense, while the first generation fears that they will lose their cultural roots as a result of their interaction with the English, the second generation is obsessed with adopting the English culture in order to be accepted by the English. As a consequence, the struggle between the first and the second generation of immigrants can be observed. In other words, not only the conflict between the English and the immigrants but also the difficulties between two generations of immigrant families draw attention in the novel. In this regard, Bhabha's postcolonial terms and concepts can be applied to the work. Smith demonstrates the conditions of a culturally mixed society in post‐WWII England by stressing the cultural conflict between the English and the immigrants in the postcolonial English society.

## **5. Conclusion**

to be an atheist, Millat becomes a militant [19]. So the pressure of being a part of two differ‐ ent cultures makes them suffer as the character, Joyce indicates in the novel: *"The fact is both these boys have serious emotional problems. They've been split up by their religions, by their cultures. Can you imagine the trauma?"* [19]. The cultural conflict leads Magid and Millat to emotional suffering, which brings about the feeling of uncertainty about their origins. The increasing number of British‐born children of immigrant families suffered from cultural alienation and isolation in the post‐WWII Britain [27]. In order not to be alienated and isolated, they mimic the English, and thus, "[b]y differently repeating the 'original culture', the 'self' of colonial culture splits, revealing its requirement for difference and otherness in order to be estab‐

In this manner, Samad Iqbal believes that it is the corruption in England which has destroyed his family and their cultural roots. He says: *"I have been corrupted by England, I see that now-my children, my wife, they too have been corrupted"* [19]. Since the customs and lifestyle in England are not in accordance with his Eastern culture, he regards the English culture as corrupted. In this sense, multiculturalism in England resulted in some cultural problems among those who made an effort to survive there despite all cultural, traditional and religious discrepancies. As mentioned in *Resistance Through Rituals*, culture is made up of many competing and conflict‐ ing groups and each of them defines itself through its distinctive way of life [34]. Therefore, in *White Teeth*, as a Muslim immigrant from Bangladesh, Samad Iqbal cannot reconcile with the English owing to his Eastern perspective and traditions, so he says: "I am corrupt, my sons are becoming corrupt, we are all soon to burn in the fires of hell" [19]. Similarly, Alsana objects the pressure of English culture upon her family: *"I am saying these people are taking my son away from me! They're Englishifying him completely! They're deliberately leading him away from his culture and his family and his religion"* [19]. Considering Bhabha's views about the conflicting relationship between the colonized and the colonizer, it is undeniable that the colonized people leaving their cultural values behind in the postcolonial Western societies and their adopting the culture of the West, the practice of mimicry, disturb the colonizer in a sense, because "[i]n mimicry the colonizer sees himself in a mirror that slightly but effectively distorts his image – that subtly and unsettingly 'others' his own identity" [35]. The cultural contradictions in the postcolonial period between the two parts resulted in the "in‐between" position of the ex‐colonized in the dominance of the Western norms. In this respect, the domi‐ nance of English culture, customs and lifestyle oppressed the immigrants who came to Britain in the post‐war epoch; therefore, Smith aims at bringing various people together in order to display their efforts to live together despite their sufferings. In an interview by O'Grady, Smith highlights her interest in combining various cultures with one another and analysing

Consequently, since Smith comes from a culturally mixed family as well, she is interested in people's origins and ethnic identities and focuses on this in *White Teeth* by shedding light on different understandings of different nations, which turned out to be a problematic issue in England after WWII. Applying Bhabha's concepts to the novel, the characters immigrating to London from the East reflect his ideas. Thus, the reflection of the multicultural English society in the novel shows that "[…] the postcolonial subject comes to proclaim the death of national

lished as superior" [33].

30 People's Movements in the 21st Century - Risks, Challenges and Benefits

the position of the hybrid [36].

In the light of the issues discussed in this chapter, it is clear that in postcolonial Western societ‐ ies, in this case in England, one could recognize the cultural and social contradictions between the ex‐colonized and the ex‐colonizer. The conflict between the two parts caused divisions and disorder in these societies, as a result of which, particularly, the former colonized suf‐ fered due to their "in‐between" status. In this regard, the novels analysed in this chapter, *The Enigma of Arrival* and *White Teeth,* can be regarded as prominent examples portraying the cultural trauma undergone by the ex‐colonized in the postcolonial Western areas. The analy‐ sis shows that under the influence of E. Said's concepts of "Orientalism" and "otherness," H. Bhabha put forward his postcolonial theory with new terms and his postcolonial concepts can also be recognized in these novels.

*The Enigma of Arrival*, shedding light on the hybridity of an author trying to adapt into the Western culture in London and New York, illustrates the cultural contradictions of this iso‐ lated and alienated Trinidadian man with Indian heritage, like V.S. Naipaul himself. The story proves that it was cruel and challenging to be a hybrid in the postcolonial era. In *White Teeth*, the cultural distress of immigrants from Bangladesh in postcolonial London reflects the hardships experienced by the Easterners in the West and demonstrates the difficulty for immigrants to overcome their adaptation problems and the intergenerational difficulties. Similarly, Z. Smith's hybrid position can also be identified in the novel through the sufferings of the culturally excluded characters, who feel that they are the "other."

To conclude, both of the novels effectively highlight Bhabha's postcolonial concepts such as hybridity, otherness, cultural differentiation and ambivalence by putting emphasis on the cul‐ tural problems of immigrants torn between their own cultural values and the Western norms. "The cultural hybrid is therefore a complex building that both resembles and differs from the colonising agent" [38]. In *The Enigma of Arrival*, the hybrid character's feelings of isolation and otherness in the West come to the fore as a result of his inability to reconcile his own culture with the cultural norms of the West. In *White Teeth*, on the one side, the first‐generation immi‐ grants want to maintain their traditions but experience cultural adaptation problems, feel lost, isolated and alienated due to their desire not to leave their own culture behind in the West. On the other side, the second‐generation immigrants suffer because of their conflicts with their parents—the first‐generation immigrants—who complain about their children's devo‐ tion to the cultural notions of the West. Since the second‐generation immigrants do not try to maintain their cultural heritage, they do their best to resemble the ex‐colonizer, but because of their different backgrounds when they imitate the Westerners, they experience many difficul‐ ties and also suffer. It is obvious that the two novels describe similar difficulties experienced by immigrants and the authors of these works voice the identity problems of culturally split people in the postcolonial era.

## **Author details**

Berna Köseoğlu

Address all correspondence to: berna.koseoglu@kocaeli.edu.tr

Kocaeli University, Faculty of Arts and Sciences, Western Languages and Literatures, Department of English Language and Literature, Kocaeli, Turkey

## **References**


[9] Malpas S, Wake P, editors. The Routledge Companion to Critical Theory. New York: Routledge; 2006.

To conclude, both of the novels effectively highlight Bhabha's postcolonial concepts such as hybridity, otherness, cultural differentiation and ambivalence by putting emphasis on the cul‐ tural problems of immigrants torn between their own cultural values and the Western norms. "The cultural hybrid is therefore a complex building that both resembles and differs from the colonising agent" [38]. In *The Enigma of Arrival*, the hybrid character's feelings of isolation and otherness in the West come to the fore as a result of his inability to reconcile his own culture with the cultural norms of the West. In *White Teeth*, on the one side, the first‐generation immi‐ grants want to maintain their traditions but experience cultural adaptation problems, feel lost, isolated and alienated due to their desire not to leave their own culture behind in the West. On the other side, the second‐generation immigrants suffer because of their conflicts with their parents—the first‐generation immigrants—who complain about their children's devo‐ tion to the cultural notions of the West. Since the second‐generation immigrants do not try to maintain their cultural heritage, they do their best to resemble the ex‐colonizer, but because of their different backgrounds when they imitate the Westerners, they experience many difficul‐ ties and also suffer. It is obvious that the two novels describe similar difficulties experienced by immigrants and the authors of these works voice the identity problems of culturally split

Kocaeli University, Faculty of Arts and Sciences, Western Languages and Literatures,

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Address all correspondence to: berna.koseoglu@kocaeli.edu.tr

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Department of English Language and Literature, Kocaeli, Turkey

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**Author details**

Berna Köseoğlu

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[37] Amoko A. Race and postcoloniality. The Routledge Companion to Critical Theory.

[38] Swiatloch M. The construction of identity in Northern Ireland: Hybrid states, national‐ ism, and images of violence in contemporary Northern Irish novels. In Reitemeier F, editor. Strangers, Migrants, Exiles: Negotiating Identity in Literature. Göttingen:

Colonial in Thailand. Hong Kong: Hong Kong UP; 2010. p. 187–206.

New York: Routledge and Taylor & Francis Group; 2006. p. 3–59.

[35] Bertens H. Literary Theory. The Basics. New York: Routledge; 2008.

**Provisional chapter**

## **Immigration and Food Insecurity: The Canadian Experience—A Literature Review Immigration and Food Insecurity: The Canadian Experience—A Literature Review**

Diana Tarraf, Dia Sanou and Isabelle Giroux Diana Tarraf, Dia Sanou and Isabelle Giroux Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/66824

#### **Abstract**

Canada is a popular destination for immigrants and integration of newcomers is an important strategy for its demographic growth and economic development. Food inse‐ curity disproportionately affects newcomers in Canada; unfortunately, they occupy the lower end of the socio‐economic spectrum and thus adding to the burden of socio‐cul‐ tural challenges they are already facing. The high level of food insecurity contributes to poor diet quality and the rise in overweight and other chronic health conditions and therefore to the loss of healthy immigrant status. Indeed, statistical evidence, mainly of the overall Canadian population, demonstrates that individuals living in food‐insecure households have higher rates of self‐reported poor health and chronic health conditions. Therefore, understanding and properly addressing the factors associated with food inse‐ curity among Canadian immigrants is crucial for an adequate integration of immigrants. This chapter suggests that an adequate and appropriate understanding of food security for Canadian immigrant populations requires consideration of a cultural perspective in addition to the traditional individual, household and community levels and the develop‐ ment of measurement tools to capture this cultural dimension. It is proposed the concept of cultural food insecurity encompasses the four usual dimensions (availability, acces‐ sibility, utilization, and stability) and a newly proposed fifth cultural dimension. Future research should aim at validating the relevance of this cultural perspective as a fifth pillar for food security and developing measurement tools to assess it.

**Keywords:** Canada, Acculturation, food insecurity, availability, accessibility, utilization, stability, cultural appropriateness, immigration, nutritional health

## **1. Introduction**

Upon arrival to Canada, immigrants present fewer health risk, lower levels of disability as well as fewer chronic conditions compared to Canadian‐born individuals [1, 2]. However,

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

their health status deteriorates with the number of years spent in Canada and converges to that on the native‐born populations. For instance, it was noted that recent immigrants had fewer chronic conditions than Canadian‐born individuals, but that there is a gradual decline in health status over time in Canada [2]. Also, the rate of obesity among immigrants was found to be substantially lower than their Canadian‐born counterparts but increase with their duration of stay in Canada [3]. This trend among immigrants has been noted in several other western countries and has been called the "*healthy immigrant effect*" [4].

An extensive body of research has focused on exploring the "*healthy immigrant effect"* in Canada as well as in other western countries. A number of mechanisms contribute to this decline in health status, including diet and lifestyle changes, reduction of socioeconomic sta‐ tus, social exclusion, and a medical system that is suboptimal in culturally competent care. In terms of the impact of immigrants' diet on their health, food insecurity, if overlooked or not addressed enough, can compromise the nutritional and mental health of immigrants. Furthermore, food insecurity can have an effect on immigrants' diet and lifestyle changes, as they tend to converge to that of Canadian‐born individuals.

The purpose of this chapter is to shed light on a number of issues that affect the food secu‐ rity situation of Canadian immigrants. As part of our research investigating the health of Canadian immigrants, we gathered data from peer‐reviewed research and other reliable gov‐ ernment publications in order to provide easy access to current evidence on these issues and to inform the development of policies and programs that address food insecurity issues expe‐ rienced by Canadian immigrants.

## **2. Immigration to Canada in perspective**

Canada is a popular destination for immigrants and their integration is a central strategy for the country's demographic growth and economic development. Since 1988, Canada has welcomed an average of 230,000 immigrants per year. In 2011, the immigrant population in Canada was approximately 20.6% of the total population, or roughly 6.8 million people. By 2031, it is expected that the foreign‐born population in Canada will be over 25% of the popu‐ lation [5]. Immigrants to Canada come from over 200 countries, and are thus a tremendously culturally diverse group. This presents a number of challenges for culturally sensitive integra‐ tion strategies, such as in the workplace, in the community, or in the healthcare context.

The majority of newcomers to Canada settle in urban areas. Predominantly, Canada's three largest metropolitan areas (Toronto, Vancouver, and Montreal) accounted for about two thirds (62.5%) of new arrivals. Combined, the three largest visible minority groups (South Asians, Chinese, and Blacks) accounted for 61.3% of the visible minority population in 2011 [6]. In Vancouver, Chinese were by far the largest visible minority group. On the other hand, Ontario was the province that received the highest number of immigrants each year and the majority of francophone immigrants settling outside Quebec (69%) [7].

Newcomers choose to immigrate to Canada for a variety of reasons, including world‐class education, clean environment, safety and security, and better financial prospects. In fact, Canada performs very well in various measures of well‐being compared to most other coun‐ tries as given in the Organization for Economic Cooperation and Development's (OECD) *Better Life Index*, which allows the comparison of well‐being across countries based on various essential topics [8]. Canada ranks above the average in housing, subjective well‐being, per‐ sonal security, health status, income and wealth, social connections, environmental quality, jobs and earnings, education and skills, work‐life balance, and civic engagement.

With about 6.8 million immigrants living in Canada, there is no doubt that immigrants have an important economic effect and create cultural changes. A large and growing body of evi‐ dence into the economic impact of immigrants on their host countries has been conducted in developed countries. The evidence largely points to positive effects, including the growth and expansion of the skilled labor pool, significant contributions to research and innovation, as well as entrepreneurial activity and trade [9]. In fact, Canada's work force is aging and this demographic change points to impending labor shortages in the near future. Undeniably, labor shortages could become severe in every part of the country regardless of economic situ‐ ations. Policy‐makers across Canada have called for growing levels of immigration to help counteract the aging baby boomer generation.

Research on the economic impact of immigration supports the idea that immigration has rein‐ forced the Canadian economy and local communities in numerous ways, especially by diver‐ sifying and enriching the labor pool. As of 2011, immigrant workers constituted 22% of the Canadian labor force and had accounted for 41% of growth in the Canadian labor force since 2006 [10]. Additionally, immigrants contribute to the tax base, invest in local business, create new businesses and jobs, innovate, and offer valuable trade and cultural ties with their home countries [11]. Furthermore, newcomers' cultures, including what they eat and the social activi‐ ties in which they take part, tend to change over time to and gets closer to the Canadian culture.

## **3. Current situation of food insecurity among Canadian immigrants**

#### **3.1. Concept of food insecurity**

their health status deteriorates with the number of years spent in Canada and converges to that on the native‐born populations. For instance, it was noted that recent immigrants had fewer chronic conditions than Canadian‐born individuals, but that there is a gradual decline in health status over time in Canada [2]. Also, the rate of obesity among immigrants was found to be substantially lower than their Canadian‐born counterparts but increase with their duration of stay in Canada [3]. This trend among immigrants has been noted in several other

An extensive body of research has focused on exploring the "*healthy immigrant effect"* in Canada as well as in other western countries. A number of mechanisms contribute to this decline in health status, including diet and lifestyle changes, reduction of socioeconomic sta‐ tus, social exclusion, and a medical system that is suboptimal in culturally competent care. In terms of the impact of immigrants' diet on their health, food insecurity, if overlooked or not addressed enough, can compromise the nutritional and mental health of immigrants. Furthermore, food insecurity can have an effect on immigrants' diet and lifestyle changes, as

The purpose of this chapter is to shed light on a number of issues that affect the food secu‐ rity situation of Canadian immigrants. As part of our research investigating the health of Canadian immigrants, we gathered data from peer‐reviewed research and other reliable gov‐ ernment publications in order to provide easy access to current evidence on these issues and to inform the development of policies and programs that address food insecurity issues expe‐

Canada is a popular destination for immigrants and their integration is a central strategy for the country's demographic growth and economic development. Since 1988, Canada has welcomed an average of 230,000 immigrants per year. In 2011, the immigrant population in Canada was approximately 20.6% of the total population, or roughly 6.8 million people. By 2031, it is expected that the foreign‐born population in Canada will be over 25% of the popu‐ lation [5]. Immigrants to Canada come from over 200 countries, and are thus a tremendously culturally diverse group. This presents a number of challenges for culturally sensitive integra‐ tion strategies, such as in the workplace, in the community, or in the healthcare context.

The majority of newcomers to Canada settle in urban areas. Predominantly, Canada's three largest metropolitan areas (Toronto, Vancouver, and Montreal) accounted for about two thirds (62.5%) of new arrivals. Combined, the three largest visible minority groups (South Asians, Chinese, and Blacks) accounted for 61.3% of the visible minority population in 2011 [6]. In Vancouver, Chinese were by far the largest visible minority group. On the other hand, Ontario was the province that received the highest number of immigrants each year and the

Newcomers choose to immigrate to Canada for a variety of reasons, including world‐class education, clean environment, safety and security, and better financial prospects. In fact,

majority of francophone immigrants settling outside Quebec (69%) [7].

western countries and has been called the "*healthy immigrant effect*" [4].

they tend to converge to that of Canadian‐born individuals.

38 People's Movements in the 21st Century - Risks, Challenges and Benefits

rienced by Canadian immigrants.

**2. Immigration to Canada in perspective**

The concept of food security was introduced in global debates in the mid‐1970s, with a pri‐ mary focus on food supply problems, more specifically, on the availability of enough foods to cover global and national needs [12, 13]. Since then, the definition of food security has consid‐ erably evolved from the global and national hunger and food crisis perspective to encompass food availability, access, and consumption at household level and its consequences on indi‐ vidual well‐being over time.

The initial definition of food security was provided by the 1974 World Food Summit as:

*"availability at all times of adequate world food supplies of basic foodstuffs to sustain a steady expansion of food consumption and to offset fluctuations in production and prices" [14].*

After a series of international consultations, the 1996 World Food Summit adopted a more careful redefinition that goes beyond the global supply and price perspectives to include eco‐ nomic accessibility and health dimensions at household and individual levels:

*"Food security, at the individual, household, national, regional and global levels [is achieved] when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life" [15].*

The most commonly used definition is a slightly modified version proposed by the FAO in the State of Food Insecurity (SOFI) 2001:

*"Food security [is] a situation that exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life" [16].*

Based on this SOFI 2001 definition, food insecurity therefore exists when people do not have adequate physical, social, or economic access to food as defined above. Household *food insecurity* is the application of this *concept* to the family level, with individuals within households as the focus of concern [12]. Households that are food insecure have trouble, or concern about, consistently accessing adequate and nutritionally adequate foods.

The definition of food security encompasses four dimensions: availability, access, utilization, and stability [17]. The availability dimension refers to the production and supply (including food aid) of sufficient quantities of food of appropriate quality to nourish the entire popula‐ tions and is concerned with global, national, household, and individual levels. The access dimension includes both physical access and economic affordability of appropriate foods for a nutritious diet. While in many developing countries, food access mainly lies on productive capacities, accessibility in Canada is concerned with the economic ability of individuals and households to purchase food in the market system and is therefore dependent to the pur‐ chasing power. It is for this reason that, using a standard multiple‐indicator measure of food security, Health Canada linked the issue to income‐related food insecurity in Canada [18]. Utilization refers to the ability of individuals and households to make healthy food choices in their local environments and use the food procured in such a way that it meets their dietary needs. The utilization pillar requires nonfood‐related inputs such as clean water, sanitation, and health care to reach a state of nutritional well‐being where all physiological needs are met [17]. It also takes into account postharvesting management and processing, food safety, consumption patterns, dietary diversification, and intra‐household distribution. The stability dimension refers the ability to ensure the above three dimensions at all times. The stability principle suggests that households and individual access to nutritious foods should not be compromised by any shock (economic crisis, natural and human‐made disasters).

Most food security‐related policies and program research have emphasized the first three dimensions namely access, availability, and utilization. Stability is often considered cross‐cut‐ ting and therefore not well addressed as a stand‐alone issue. Further, despite sociocultural perspective is well considered in the definition of food insecurity through food preferences, none of the four dimensions captures properly the cultural perspective. This cultural aspect is particularly important for some population groups in Canada such as Aboriginal people and immigrants who have some cultural relationship with foods [19]. In such situation, the issue of food insecurity is not only unavailability of or inaccessibility to foods due to lack of financial resources to procure them, but also culturally inappropriateness of available foods. Indeed, even if immigrants are not economically vulnerable, accessing home‐country foods of their choice is challenging, creating individual worries or concerns about feeding their family. This specific feeling of food insecurity uniquely experienced by immigrants and Aboriginal people might account for the comparative high level of food insecurity in these subgroups of Canadian populations. Unfortunately, it is not captured by existing measure‐ ment tools. Therefore, the concept of cultural food security that was proposed for Aboriginal people should be expanded to Canadian immigrants and other population worldwide who are experiencing significant challenges to access food of their cultural preference. For the conceptualization of an adequate and appropriate understanding of this cultural perspective of food insecurity, a fifth dimension namely cultural appropriateness should be considered in addition to availability, accessibility, utilization, and stability. The dimension of cultural appropriateness will focus on the ability of newcomers to reliably access to their preferred home‐country foods in the host country. Appropriate tools and indicators should be devel‐ oped to measure this newly proposed dimension of food security. Examples of indicators could include concern or worries about not having these foods, traditional knowledge of these foods, access to home‐country foods, safety and nutritional values of these foods, and perceived cultural values of these foods.

Plenty has been written about the significance of ensuring food security for everyone, since food is deemed a basic human right and a crucial condition for a population to be well‐ nourished and in good physical and mental health. Yet, this objective has not been entirely achieved for all members of society. In Canada and other developed countries, it is under‐ stood that food insecurity is strongly linked with household income and is a reality for many socio‐economically vulnerable Canadian households. Food insecurity is understood to be a dynamic process, which can range in severity from uncertainty concerning food supplies, to reductions in the quantity and quality of food intake.

#### **3.2. The situation among Canadian immigrants**

*"Food security, at the individual, household, national, regional and global levels [is achieved] when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet* 

The most commonly used definition is a slightly modified version proposed by the FAO in the

*"Food security [is] a situation that exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences* 

Based on this SOFI 2001 definition, food insecurity therefore exists when people do not have adequate physical, social, or economic access to food as defined above. Household *food insecurity* is the application of this *concept* to the family level, with individuals within households as the focus of concern [12]. Households that are food insecure have trouble, or concern about,

The definition of food security encompasses four dimensions: availability, access, utilization, and stability [17]. The availability dimension refers to the production and supply (including food aid) of sufficient quantities of food of appropriate quality to nourish the entire popula‐ tions and is concerned with global, national, household, and individual levels. The access dimension includes both physical access and economic affordability of appropriate foods for a nutritious diet. While in many developing countries, food access mainly lies on productive capacities, accessibility in Canada is concerned with the economic ability of individuals and households to purchase food in the market system and is therefore dependent to the pur‐ chasing power. It is for this reason that, using a standard multiple‐indicator measure of food security, Health Canada linked the issue to income‐related food insecurity in Canada [18]. Utilization refers to the ability of individuals and households to make healthy food choices in their local environments and use the food procured in such a way that it meets their dietary needs. The utilization pillar requires nonfood‐related inputs such as clean water, sanitation, and health care to reach a state of nutritional well‐being where all physiological needs are met [17]. It also takes into account postharvesting management and processing, food safety, consumption patterns, dietary diversification, and intra‐household distribution. The stability dimension refers the ability to ensure the above three dimensions at all times. The stability principle suggests that households and individual access to nutritious foods should not be

compromised by any shock (economic crisis, natural and human‐made disasters).

Most food security‐related policies and program research have emphasized the first three dimensions namely access, availability, and utilization. Stability is often considered cross‐cut‐ ting and therefore not well addressed as a stand‐alone issue. Further, despite sociocultural perspective is well considered in the definition of food insecurity through food preferences, none of the four dimensions captures properly the cultural perspective. This cultural aspect is particularly important for some population groups in Canada such as Aboriginal people and immigrants who have some cultural relationship with foods [19]. In such situation, the issue of food insecurity is not only unavailability of or inaccessibility to foods due to lack of financial resources to procure them, but also culturally inappropriateness of available foods. Indeed, even if immigrants are not economically vulnerable, accessing home‐country

*their dietary needs and food preferences for an active and healthy life" [15].*

40 People's Movements in the 21st Century - Risks, Challenges and Benefits

consistently accessing adequate and nutritionally adequate foods.

State of Food Insecurity (SOFI) 2001:

*for an active and healthy life" [16].*

In many developed countries, there are very high rates of stress, financial hardship, and food insecurity among refugees and other forced migrants. Unemployment, low income, and recent arrival are often associated with food insecurity among newcomers [20, 21]. Lack of savings or income places recent immigrant families at a higher risk of food insecurity in the first year following immigration, as many struggle to find a job and may face discrimina‐ tion due to their race or/and their lack of permanent status [22]. In fact, more than half of all refugee families with children under 5 years reported food insecurity in some UK and US studies. In Toronto, Latin American immigrants were found to have a similar prevalence of food insecurity [23].

In 2011–2012, almost 1.1 million Canadian households experienced food insecurity and the prevalence of food insecurity was higher among recent immigrants (19.6%), compared with nonrecent immigrants (11.8%) and the Canadian‐born population (12.4%). Many factors have been found to be linked to food insecurity among immigrants in Canadian cities. For instance, in Latin American immigrants in Toronto, three main correlates of food insecurity were found: social assistance as a main income, use of food banks, and limited literacy in English. More specifically, the prevalence of food insecurity increased as household income decreased [24]. Households receiving provincial or municipal assistance as their main source of income are more vulnerable to food insecurity [23]. Furthermore, more recent immigrants (less than 1 year in Canada) experience higher levels of food insecurity compared with less recent immigrants (1–5 years in Canada; 84% vs. 33%). In addition, immigrants who are not fluent in English are more likely to experience food security [23].

All of these data suggests that if Canada wants a healthy and productive population, the issue of food insecurity needs to be addressed.

## **4. Food insecurity and health**

Food is a fundamental determinant of health. The quantity and quality of the food we eat affects our health status, and our health is critical to productivity and prosperity.

Food insecurity in Canada is linked with higher rates of self‐reported poor health and chronic health conditions, including depression, type 2 diabetes, heart disease, and greater stress [25]. Several studies have reported that food‐insecure households are at risk of having monoto‐ nous and low‐quality diets, reduced micronutrient intake, iron‐deficiency anemia, and low intake of fruits, vegetables, and dairy products, particularly among women and youth [26]. A restricted budget, leading to the procurement of cheaper and more energy‐dense foods is also a contributing factor to excessive energy intake and excessive weight gain [26]. Likewise, food insecurity is linked with poor diet and health among Canadian immigrants [27].

The following sections examine the relationships between food insecurity and nutritional intakes, health and well‐being in Canada.

#### **4.1. Food insecurity and nutritional intake**

The first Canadian national study to assess the association between food insecurity and nutri‐ tional intakes was the 2004 Canadian Community Health Survey (CCHS) [28]. In this study, food‐insecure women in the 19–30 and 31–50 age groups had lower intakes of dietary fiber. Moreover, food insecurity was linked with lower protein intakes across adult age and sex groups. Also, among males and females in the 19–30 age groups and among women in the 31–50 age groups, food insecurity was associated with lower consumption of fruit and veg‐ etables. It was also found that food‐insecure males and females over the age of 50 had lower intakes of milk than those who were food secure in the same age group. In all age groups, food insecurity was associated with inadequate intakes of magnesium and protein, and with folate, vitamin A, zinc, and vitamin C for certain groups [28]. Some groups of food‐insecure children and teenagers in the 9–13 and 14–18 age groups had a high prevalence of inadequate intakes of protein, vitamin A, vitamin C, magnesium, and zinc, although results were not consistent across groups. Adolescents who were food insecure also had significantly lower intakes of fruit and vegetables than those who were food secure [28].

Furthermore, an analysis of the diets of 8938 youth aged 9–18 years from the 2004 CCHS sug‐ gested that low‐income food‐insecure girls had both lower milk consumption and vitamin D intake and a higher intake of sweetened beverages (such as pop and juice drinks) than low‐income food secure girls [26]. Additionally, a recent study assessed the relationship of food insecurity to iron deficiency and stature in a sample of 292 school‐aged Inuit children from Nunavik (Northern Quebec), who were followed for 10 years [29]. Food‐insecure chil‐ dren were slightly more likely to have iron‐deficiency anemia (a condition in which blood lacks adequate healthy red blood cells due to insufficient iron) and had significantly lower mean hemoglobin levels (a blood indicator of anemia) than those who were food secure [29], again pointing to the negative impact of food insecurity on the quality of diet and health of individuals.

#### **4.2. Food insecurity and chronic health conditions**

decreased [24]. Households receiving provincial or municipal assistance as their main source of income are more vulnerable to food insecurity [23]. Furthermore, more recent immigrants (less than 1 year in Canada) experience higher levels of food insecurity compared with less recent immigrants (1–5 years in Canada; 84% vs. 33%). In addition, immigrants who are not

All of these data suggests that if Canada wants a healthy and productive population, the issue

Food is a fundamental determinant of health. The quantity and quality of the food we eat

Food insecurity in Canada is linked with higher rates of self‐reported poor health and chronic health conditions, including depression, type 2 diabetes, heart disease, and greater stress [25]. Several studies have reported that food‐insecure households are at risk of having monoto‐ nous and low‐quality diets, reduced micronutrient intake, iron‐deficiency anemia, and low intake of fruits, vegetables, and dairy products, particularly among women and youth [26]. A restricted budget, leading to the procurement of cheaper and more energy‐dense foods is also a contributing factor to excessive energy intake and excessive weight gain [26]. Likewise, food

The following sections examine the relationships between food insecurity and nutritional

The first Canadian national study to assess the association between food insecurity and nutri‐ tional intakes was the 2004 Canadian Community Health Survey (CCHS) [28]. In this study, food‐insecure women in the 19–30 and 31–50 age groups had lower intakes of dietary fiber. Moreover, food insecurity was linked with lower protein intakes across adult age and sex groups. Also, among males and females in the 19–30 age groups and among women in the 31–50 age groups, food insecurity was associated with lower consumption of fruit and veg‐ etables. It was also found that food‐insecure males and females over the age of 50 had lower intakes of milk than those who were food secure in the same age group. In all age groups, food insecurity was associated with inadequate intakes of magnesium and protein, and with folate, vitamin A, zinc, and vitamin C for certain groups [28]. Some groups of food‐insecure children and teenagers in the 9–13 and 14–18 age groups had a high prevalence of inadequate intakes of protein, vitamin A, vitamin C, magnesium, and zinc, although results were not consistent across groups. Adolescents who were food insecure also had significantly lower

Furthermore, an analysis of the diets of 8938 youth aged 9–18 years from the 2004 CCHS sug‐ gested that low‐income food‐insecure girls had both lower milk consumption and vitamin

affects our health status, and our health is critical to productivity and prosperity.

insecurity is linked with poor diet and health among Canadian immigrants [27].

intakes of fruit and vegetables than those who were food secure [28].

fluent in English are more likely to experience food security [23].

42 People's Movements in the 21st Century - Risks, Challenges and Benefits

of food insecurity needs to be addressed.

intakes, health and well‐being in Canada.

**4.1. Food insecurity and nutritional intake**

**4. Food insecurity and health**

Food insecurity has been linked with higher rates of self‐reported poor health and chronic health conditions, including depression, hypertension, type 2 diabetes, and heart disease [25, 30–34]. For instance, findings from a recent study which explored the associations between food security status (high food security; marginal, moderate, or severe food insecurity), dietary behaviors and intake, and health‐related outcomes (body weight, quality of life, mood, peer relationships, and externalizing problems) in 5853 Nova Scotian grade 5 students [25] sug‐ gested that students living in households experiencing moderate or severe food insecurity had poorer diet quality, higher body mass index, and poorer psychosocial outcomes than students living in households classified as high food secure or marginal food insecure [25].

Another study that assesses the association between household food insecurity and over‐ weight among 10‐ to 11‐year‐old children living in Quebec [35] found that girls who lived in food‐insecure households were almost five times more likely to be overweight in compari‐ son to girls who lived in food secure households. This may seem surprising, as one would think that individuals who are experiencing food insecurity would have less to eat and would consequently have less chance of being overweight. However, the quality of food is affected before the quantity, meaning those affected by food insecurity tend to consume more high‐ energy foods containing less nutrients [28]. It is well known that obesity increases the risk of serious health conditions such as type 2 diabetes [36], hypertension and cardiovascular dis‐ ease [37], fatty liver disease [38], and some types of cancers [39]. Among the many factors that contribute to the increase in rate of obesity among Canadian immigrants is lifestyle nutrition transition, which is thought to be mediated by *acculturation* [40–42]*.* Since some immigrant groups who are already struggling with high unemployment, poverty, and mental distress are more likely to develop onset of these conditions at a younger age and has a lower BMI [43–46], it is important to understand the dynamics between immigration, food insecurity, and the food/diet changes upon settlement in Canada in order to develop tailored actions that will limit the onset of these poor health conditions in food‐insecure immigrant households.

## **5. Immigration, acculturation, and food insecurity**

Changes in dietary habits related to immigration are often referred as *dietary acculturation,* which is the process by which immigrants adopt the dietary practices of the host country. There are various scales to measure acculturation, but the most commonly used by research‐ ers in Canadian context is duration of stay in the host country [47]. Other measures, such as place of birth, country of origin, age at arrival in Canada, and language use or language pro‐ ficiency are also commonly used [47]. These proxy measures consider acculturation as linear and unidirectional process, which excludes the possibility of multiculturalism and interaction between the host country and native country cultures. However, acculturation is a multidi‐ mensional and multidirectional phenomenon that takes different paths [48, 49]. Investigating francophone immigrants' experiences with food insecurity in Montreal [48], identified four models in the dietary acculturation process: assimilation followed by an adaptation phase, ethnocentrism, and integration.

The accommodation phase is a temporary situation experienced by an immigrant in the first 1–3 months upon arrival and is characterized by a full adoption of the host‐country dietary habits and a temporary abandonment of home‐country dietary habits [48]. Since s/he has limited knowledge of the host country context, lacks cooking skills, and does not have access to the native country foods and cooking equipment, the newcomer contents her/himself with whatever foods s/he finds. Therefore, the situation is more or less a temporary reasonable accommodation to a survival situation rather than a voluntary adoption (assimilation) of new habits. As the newcomer identifies the market places and groceries and starts interacting with other immigrants, s/he gradually accesses home‐country foods which give him or her some time to adjust to the new context (adaptation). The dual access to both local and home‐coun‐ try foods offers an opportunity to create unique dietary patterns and to transition to the final dietary patterns of the newcomer.

When given the opportunity, immigrants attempt at first to reproduce home‐country diet which is believed to be healthier [48]. In the long term, the home‐country foods are gradu‐ ally mainstreamed in the host‐country diet, resulting in dietary patterns that balance foods from both home‐ and host‐country culture. At this stage called integration, while enjoying the taste and social meanings of their home‐country foods, immigrants become more familiar with and adopt host‐country foods, creating a dietary mix which increases the diversity of the household diet. The attempt to maintain home‐country diet is challenged by many fac‐ tors including unavailability and affordability of home‐country foods; lack of home‐country ingredients and cooking equipment; time constraints for home‐country food preparation; unavailability of nutrition value of traditional foods; the influence of neighborhood; etc. [47]. In some situations, where the newcomer has plenty of access to home‐country foods, he can overvalue these foods while rejecting and/or despising the host‐country foods, resulting in an ethnocentrism which can be temporary or permanent. This situation, also referred to as dietary enculturation, is more common in immigrants who arrive in Canada at older age and is less frequent in children who do not have enough dietary ties with home country and have little decision power on household diet.

Finally, there are situations where for different reasons, the immigrant decides to abandon home‐country diet and fully adopts Canadian dietary patterns. This process is referred as dietary acculturation [47, 48] as the newcomer renounces his cultural dietary identity. Drivers of dietary acculturation include factors impeding home food consumption as discussed above, pre‐immigration history, unfamiliarity with Canadian foods, grocery procurement patterns and cooking techniques, unawareness of Canadian nutrition discourse, communi‐ cation barriers, social isolation, and financial insecurity. **Figure 1** summarizes the modified dietary trajectories of Canadian immigrants.

There are various scales to measure acculturation, but the most commonly used by research‐ ers in Canadian context is duration of stay in the host country [47]. Other measures, such as place of birth, country of origin, age at arrival in Canada, and language use or language pro‐ ficiency are also commonly used [47]. These proxy measures consider acculturation as linear and unidirectional process, which excludes the possibility of multiculturalism and interaction between the host country and native country cultures. However, acculturation is a multidi‐ mensional and multidirectional phenomenon that takes different paths [48, 49]. Investigating francophone immigrants' experiences with food insecurity in Montreal [48], identified four models in the dietary acculturation process: assimilation followed by an adaptation phase,

The accommodation phase is a temporary situation experienced by an immigrant in the first 1–3 months upon arrival and is characterized by a full adoption of the host‐country dietary habits and a temporary abandonment of home‐country dietary habits [48]. Since s/he has limited knowledge of the host country context, lacks cooking skills, and does not have access to the native country foods and cooking equipment, the newcomer contents her/himself with whatever foods s/he finds. Therefore, the situation is more or less a temporary reasonable accommodation to a survival situation rather than a voluntary adoption (assimilation) of new habits. As the newcomer identifies the market places and groceries and starts interacting with other immigrants, s/he gradually accesses home‐country foods which give him or her some time to adjust to the new context (adaptation). The dual access to both local and home‐coun‐ try foods offers an opportunity to create unique dietary patterns and to transition to the final

When given the opportunity, immigrants attempt at first to reproduce home‐country diet which is believed to be healthier [48]. In the long term, the home‐country foods are gradu‐ ally mainstreamed in the host‐country diet, resulting in dietary patterns that balance foods from both home‐ and host‐country culture. At this stage called integration, while enjoying the taste and social meanings of their home‐country foods, immigrants become more familiar with and adopt host‐country foods, creating a dietary mix which increases the diversity of the household diet. The attempt to maintain home‐country diet is challenged by many fac‐ tors including unavailability and affordability of home‐country foods; lack of home‐country ingredients and cooking equipment; time constraints for home‐country food preparation; unavailability of nutrition value of traditional foods; the influence of neighborhood; etc. [47]. In some situations, where the newcomer has plenty of access to home‐country foods, he can overvalue these foods while rejecting and/or despising the host‐country foods, resulting in an ethnocentrism which can be temporary or permanent. This situation, also referred to as dietary enculturation, is more common in immigrants who arrive in Canada at older age and is less frequent in children who do not have enough dietary ties with home country and have

Finally, there are situations where for different reasons, the immigrant decides to abandon home‐country diet and fully adopts Canadian dietary patterns. This process is referred as dietary acculturation [47, 48] as the newcomer renounces his cultural dietary identity. Drivers of dietary acculturation include factors impeding home food consumption as discussed

ethnocentrism, and integration.

44 People's Movements in the 21st Century - Risks, Challenges and Benefits

dietary patterns of the newcomer.

little decision power on household diet.

**Figure 1.** Dietary transition trajectories of Canadian immigrants.

Pillarela [48] reported that the dynamics leading to changes in dietary habits after migrat‐ ing to another country are inevitable. However, the impact of these changes depends on the path and the degree to which immigrants maintain their former cultural identity as well as the extent to which they adopt the cultural practices of their new homeland. The potential conflict for immigrants to maintain their cultural diet while simultaneously adapting the dietary norms of their new country creates some stress and pressure to obtain home‐country foods of their choice and thus increases the level of worries about not having enough foods of their cultural preferences [47, 50]. This type of food insecurity uniquely experienced by immigrants that is not caused by unavailability or inaccessibility of foods due to lack of resources to procure foods is often not captured by existing measurement tools. A similar observation was made for Canadian Aboriginal people by Power [19], who argued that there is a cultural consideration for Aboriginal people way of relating to their traditional foods, which impacts the four pillars of food security: access, availability, supply, and utilization. She therefore proposed the concept of cultural food insecurity to emphasize the importance of cultural inappropriateness for Aboriginal people of foods available in the Canadian mar‐ ket system [19].

## **6. Immigration and nutrient intake in Canada**

A few studies have looked at immigrants' intake of nutrients compared to that of the nonim‐ migrant Canadian population. Overall, immigrants were at higher risk of insufficient calcium, iron, and protein intake [51]. This is especially true for those of Asian descent. Also, a long exposure to the Canadian culture was linked with an increased intake of fat and sodium by newcomers [50, 52]. However, some studies suggest the opposite. For example, one study involving older adult immigrants in London, Ontario found that keeping a traditional diet and consuming ethnic foods may be associated with an increased intake of salt, which was found to be two to four times the daily adequate intake for some individuals [53].

Nevertheless, most studies tend to show that immigrants' traditional diet, which is usually low in processed foods, is healthier than that of the typical Canadian diet [47]. This is espe‐ cially true for immigrants of African and Haitian origins [54]. For example, a Canadian study found that French‐speaking Africans living in Montreal had a tendency to maintain their home country's traditional diet, which had a significantly higher nutritional quality than the modern Canadian diet [54]. To determine the nutritional quality of the different dietary pat‐ terns, researchers used a variety of diet quality indexes (such as the "micronutrient adequacy" score [55], the "healthfulness" score [56], and the Healthy Eating Index [57]). A diet quality index is basically a measure, on a numeric scale, of the overall acceptability of food intake of an individual or population compared to dietary guidelines [58]. In the group of Africans in Montreal, participants who consumed a modern (or Western) diet had more than twice the risk of being resistant to insulin, which is a risk factor of type 2 diabetes, than those who con‐ sumed a traditional diet. Also, in another study, Punjabi women living in Toronto, Canada who kept consuming a traditional diet were described as having a healthier diet compared to a typical Western diet [59].

It is important to note that healthy dietary patterns can only be followed if food is available, acces‐ sible, and desirable [54]. They are peripheral if people are in a state of chronic food insecurity.

## **7. Implications for policies and programs**

Pillarela [48] reported that the dynamics leading to changes in dietary habits after migrat‐ ing to another country are inevitable. However, the impact of these changes depends on the path and the degree to which immigrants maintain their former cultural identity as well as the extent to which they adopt the cultural practices of their new homeland. The potential conflict for immigrants to maintain their cultural diet while simultaneously adapting the dietary norms of their new country creates some stress and pressure to obtain home‐country foods of their choice and thus increases the level of worries about not having enough foods of their cultural preferences [47, 50]. This type of food insecurity uniquely experienced by immigrants that is not caused by unavailability or inaccessibility of foods due to lack of resources to procure foods is often not captured by existing measurement tools. A similar observation was made for Canadian Aboriginal people by Power [19], who argued that there is a cultural consideration for Aboriginal people way of relating to their traditional foods, which impacts the four pillars of food security: access, availability, supply, and utilization. She therefore proposed the concept of cultural food insecurity to emphasize the importance of cultural inappropriateness for Aboriginal people of foods available in the Canadian mar‐

A few studies have looked at immigrants' intake of nutrients compared to that of the nonim‐ migrant Canadian population. Overall, immigrants were at higher risk of insufficient calcium, iron, and protein intake [51]. This is especially true for those of Asian descent. Also, a long exposure to the Canadian culture was linked with an increased intake of fat and sodium by newcomers [50, 52]. However, some studies suggest the opposite. For example, one study involving older adult immigrants in London, Ontario found that keeping a traditional diet and consuming ethnic foods may be associated with an increased intake of salt, which was

Nevertheless, most studies tend to show that immigrants' traditional diet, which is usually low in processed foods, is healthier than that of the typical Canadian diet [47]. This is espe‐ cially true for immigrants of African and Haitian origins [54]. For example, a Canadian study found that French‐speaking Africans living in Montreal had a tendency to maintain their home country's traditional diet, which had a significantly higher nutritional quality than the modern Canadian diet [54]. To determine the nutritional quality of the different dietary pat‐ terns, researchers used a variety of diet quality indexes (such as the "micronutrient adequacy" score [55], the "healthfulness" score [56], and the Healthy Eating Index [57]). A diet quality index is basically a measure, on a numeric scale, of the overall acceptability of food intake of an individual or population compared to dietary guidelines [58]. In the group of Africans in Montreal, participants who consumed a modern (or Western) diet had more than twice the risk of being resistant to insulin, which is a risk factor of type 2 diabetes, than those who con‐ sumed a traditional diet. Also, in another study, Punjabi women living in Toronto, Canada who kept consuming a traditional diet were described as having a healthier diet compared to

found to be two to four times the daily adequate intake for some individuals [53].

ket system [19].

a typical Western diet [59].

**6. Immigration and nutrient intake in Canada**

46 People's Movements in the 21st Century - Risks, Challenges and Benefits

Immigrants are vulnerable to food insecurity and the latter negatively impacts their health, therefore it is important to consider implications for community policies and programs. Data suggest the need to design community programs to raise awareness of the issue of food inse‐ curity among this population. The alarming situation also calls for mainstreaming food secu‐ rity initiatives in development policies as well as strategy and programs aimed at a better integration of newcomers to Canada.

There are numerous policies that influence the financial resources of households, which in turn influence their food security status. In Canada, certain examples of relevant policies include those impacting social assistance rates, minimum wage, employment standards, affordable housing, child benefits, and affordable childcare. Policies and programs that specifically target community‐level food insecurity include community kitchens, food skill development work‐ shops, self‐provisioning activities such as community gardens, and alternative food‐distribu‐ tion systems, as well as farmers' market options. Combating food insecurity through charitable food banks is another popular strategy in Canada. Food banks have seen a 23% rise in use between 2008 and 2013 across the country and a 19.6% rise in the number of people assisted in Ontario during the same period [60]. School‐ and community‐based programs such as school breakfast and lunches have also been implemented in many areas. Unfortunately, school set‐ ting strategies are often short lived, as students will not have access to the programs in the summer and during holidays. Finally, federal policy responses such as increasing income from National Child Benefit payments and social assistance and indexing them to inflation can be greatly beneficial for low‐income families, including many immigrant families [60].

On another note, we also suggest providing access to jobs that do not require speaking the English language but to employment opportunities where French is spoken. This would improve the financial situation of French‐speaking immigrants to Canada and reduce their risk of food insecurity. Further, providing affordable and subsidized childcare, flexible work‐ ing hours, and an adequate number of sick days will likely contribute to reduce employment barriers among low‐income families, especially those receiving social assistance. To illustrate, if parents or caregivers cannot take the day off work to take care of their sick children, these children will have to be placed in daycare, which is often expensive for families on social assistance. Moreover, we highlight the need for food insecurity to be addressed in immigrant integration strategies (including evaluation and recognition of education in other countries) in order to improve the financial power of recent immigrants to acquire adequate, nutritious, and culturally acceptable foods.

Food insecurity is persistent in many Canadian households and disproportionately affects new‐ comers. Food insecurity poses a serious risk to the nutritional health and well‐being of both adults and children. Without government policy involvements, it is likely that food‐based responses such as food banks will continue to try to fill the policy gap, even though evidence shows com‐ munities are unable to successfully respond to problems of household food insecurity.

## **8. Conclusion**

This chapter looked at the food‐security of immigrants from a Canadian perspective. National statistics and additional literature demonstrate that Canadian immigrants are experiencing high levels of food insecurity as compared to Canadian‐born populations. There was evidence of a link between socio‐economic status, food insecurity, diet quality, and health and this relation‐ ship mediates the vulnerability level of newcomers to the negative impact of food insecurity.

As Canada is a popular destination for immigrants and integration of newcomers is an impor‐ tant strategy for the country's demographic growth and economic development, understanding and properly addressing the factors associated with food insecurity among Canadian immi‐ grants is crucial, but requires an adequate understanding of the immediate and root causes of the problem. This chapter outlined some evidence that suggest that for Canadian immigrant populations there is a need to consider a cultural perspective in food insecurity in addition to the traditional individual, household, and community levels and the development of measure‐ ment tools to capture this cultural dimension. From a programmatic perspective, the concept of cultural food insecurity is proposed, which encompasses a fifth pillar related to cultural appro‐ priateness in addition to the four usual dimensions of availability, accessibility, utilization, and stability. Future research should aim at confirming the relevance of this cultural perspective as a fifth dimension of food insecurity, its potential contribution to the high rate of food insecurity in Canadian immigrants and developing measurement tools for its assessment.

Since strategies to improve food security of these populations are essential to improving their overall health and long‐term wellbeing, future government and community‐driven programs and policies targeting immigrants should take into account this cultural perspective of food access and preference. In the meantime, given the high level of food insecurity, food security interventions should be considered as upstream interventions alongside other measures for welcoming and integrating immigrants in order for them to successfully contribute to the Canadian social and economic development.

## **Author details**

Diana Tarraf<sup>1</sup> \*, Dia Sanou<sup>2</sup> and Isabelle Giroux<sup>3</sup>

\*Address all correspondence to: dtarr064@uottawa.ca

1 Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Canada

2 Food and Agriculture Organization (FAO), Rome, Italy

3 School of Nutrition Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada

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This chapter looked at the food‐security of immigrants from a Canadian perspective. National statistics and additional literature demonstrate that Canadian immigrants are experiencing high levels of food insecurity as compared to Canadian‐born populations. There was evidence of a link between socio‐economic status, food insecurity, diet quality, and health and this relation‐ ship mediates the vulnerability level of newcomers to the negative impact of food insecurity. As Canada is a popular destination for immigrants and integration of newcomers is an impor‐ tant strategy for the country's demographic growth and economic development, understanding and properly addressing the factors associated with food insecurity among Canadian immi‐ grants is crucial, but requires an adequate understanding of the immediate and root causes of the problem. This chapter outlined some evidence that suggest that for Canadian immigrant populations there is a need to consider a cultural perspective in food insecurity in addition to the traditional individual, household, and community levels and the development of measure‐ ment tools to capture this cultural dimension. From a programmatic perspective, the concept of cultural food insecurity is proposed, which encompasses a fifth pillar related to cultural appro‐ priateness in addition to the four usual dimensions of availability, accessibility, utilization, and stability. Future research should aim at confirming the relevance of this cultural perspective as a fifth dimension of food insecurity, its potential contribution to the high rate of food insecurity

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48 People's Movements in the 21st Century - Risks, Challenges and Benefits

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\*Address all correspondence to: dtarr064@uottawa.ca

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**8. Conclusion**


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52 People's Movements in the 21st Century - Risks, Challenges and Benefits


**Provisional chapter**

**Health-Related Quality of Life (HRQoL) among Elderly Turkish and Polish Migrants and German Natives: The Role of Age, Gender, Income, Discrimination and Social Support Turkish and Polish Migrants and German Natives: The Role of Age, Gender, Income, Discrimination and Social Support**

**Health-Related Quality of Life (HRQoL) among Elderly** 

Johanna Buchcik, Joachim Westenhöfer, Mick Fleming and Colin R. Martin Mick Fleming and Colin R. Martin Additional information is available at the end of the chapter

Johanna Buchcik, Joachim Westenhöfer,

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/66931

#### **Abstract**

**Background:** Migration can negatively and positively influence health-related quality of life (HRQoL). Yet, little is known about the HRQoL of Turkish and Polish migrants and German natives.

In this study, the following hypotheses were formulated: (1) Elderly Turkish as well as Polish migrants show lower HRQoL than elderly German natives. (2) Age and gender significantly influence HRQoL; low income level and perceived discrimination decrease HRQoL; social support increases HRQoL.

**Methods:** A questionnaire (Short form-36 (Sf-36) and other questions) was distributed among 203 migrants and 101 natives. Univariate analysis was performed for the group analysis of the Sf-36 sum scores. Multiple linear regression was used to analyse the influence of the selected predictors on Sf-36 scores.

**Results:** (1) Scores of the Turkish migrants were significantly lower for Role Emotional (RE) and Mental Health (MH) compared to the natives. Scores of the Polish migrants were significantly higher for Physical Functioning (PF) and Vitality (VT) compared to the natives. (2) Age had an effect in both migrant and native groups, but only on PF and RE. Gender was a predictor of HRQoL among the migrants in PF, VT and MH. Migrants with a low income level reported their General Health (GH) and MH as poor. Discrimination had an influence on MH in the migrant groups. Social support was found to predict MH and GH in the German group.

**Conclusion:** Conclusion: Being a migrant does not necessarily entail poor HRQoL. Future research should investigate the health of migrants as well as focus on their health resources.

**Keywords:** , Turkish migrants, Polish migrants, German natives, health-related quality of life, quality of life, Sf-36

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

## **1. Introduction**

According to figures of the German Federal Statistical Office [1], almost one of every five people in Germany has a migration background. Moreover, 15 million people out of 80.3 million people living in Germany have been granted migrant status. About 3.7 million (25.1%) are aged 50 years or older. In the same age bracket (28.9 million), elderly people of a migration background represent 13.0% of the total elderly population [1]. According to this source, it is expected that the number of elderly migrants will grow as young migrants also grow older.

Turkish migrants make up the largest share of the migrant population in Germany. The second largest group of migrants in Germany is Polish [2]. Hence, both Turkish and Polish migrants, aged 60 and above, form an important research group. Consequently, German social and health services are confronted by challenges in satisfying the needs of these people.

HRQoL is the perceived quality of an individual's health and daily life and therefore an important target of health promotion and disease prevention in older life. As a consequence, information regarding health and HRQoL of elderly migrants can serve to meet their needs in a socially and politically expedient way, develop strategies on health care issues and adapt or change policies.

Recent research regarding health of migrants often uses a problem-oriented perspective. The most important determinants which negatively influence the health of elderly migrants can be summarised as low socio-economic status (SES) due to bad working and living conditions [3] and situations which cause suffering post-migration—e.g. discrimination experiences [4].

Apart from this pathogenic approach, some researchers do not just focus on the disadvantages of migration, but also consider the benefits and opportunities it affords. In this regard, families and ethnic communities (seen as a support system) are often mentioned as being important for success in life [5].

Surprisingly, however, research on health and in more detail on HRQoL of elderly migrants, such as the elderly Turkish and Polish population in Germany, is still scarce and insufficient data have been generated, with only a few studies being published [6–8]. Moreover, findings often do not compare the results of different, especially elderly, migrant groups with each other. In view of the paucity of studies, the aim of this study was to obtain information on the HRQoL of elderly Turkish and Polish migrants as well as on elderly native Germans.

## **2. Migrants in Germany**

The German Federal Statistical Office reported that almost every fifth person in Germany has a migration background, i.e. 18.9% of the total population in Germany of 80.3 million [1]. People with a migration background in Germany come predominantly from Turkey (17.9%), followed by Poland (13.1%). First generation migrants are an ageing population in Germany. In fact, according to the Statistical Office [9], about 1.4 million migrants are aged 65 and above. In addition, there are about 2.4 million migrants aged between 50 and 64. Compared with native people in the same age group (15.1 million aged 65 and above; 13.9 million aged 50–64), this number of people represents a substantial part of the total population. As a whole, the numbers of elderly migrants in both categories will increase further in future since the influx of Turkish and Polish migrants is decreasing.

Most Turkish migrants came to Germany between 1955 and 1973 [10]. In order to regulate this migration, the Federal Republic of Germany and Turkey signed the 'agreement for the recruitment of Turkish workers for the German labour market' in 1961. Most Turkish workers were actively hired by the German Federal Labour Office to work in German factories and in the service sector [11]. These the so-called guest workers served as means to relieve the German economy from the labour shortage during the 'economic miracle' [12]. Contrary to initial plans, most of these guest workers and families decided not to return to their home countries but took advantage of better living conditions in the host country, e.g. advantages of the health or educational system [13].

The second major group of migrants came from Poland and other Eastern European Countries as well as from the former Soviet Union. A major part of them—more than 3.9 million people came to Germany after 1945 as 'resettlers', or after 1992 as 'late repatriates'. Most of these migrated after the fall of the 'Iron Curtain' [14], during a time when these regions were governed by Germany. After the Second World War, many of these ethnic Germans and their children endured forced resettlement and suffered ethnic discrimination in Eastern Europe or in the former Soviet Union [14]. Others faced economic hardship. Having a German background, they were allowed to remigrate to Germany and to receive German citizenship [15]. In consequence, many moved to Germany in order to improve their overall prospects and intended to stay in Germany on a long-term basis. Most of them have since been naturalised or hold 'dual citizenship' [16].

## **3. The health situation of migrants**

**1. Introduction**

56 People's Movements in the 21st Century - Risks, Challenges and Benefits

grow older.

or change policies.

important for success in life [5].

**2. Migrants in Germany**

According to figures of the German Federal Statistical Office [1], almost one of every five people in Germany has a migration background. Moreover, 15 million people out of 80.3 million people living in Germany have been granted migrant status. About 3.7 million (25.1%) are aged 50 years or older. In the same age bracket (28.9 million), elderly people of a migration background represent 13.0% of the total elderly population [1]. According to this source, it is expected that the number of elderly migrants will grow as young migrants also

Turkish migrants make up the largest share of the migrant population in Germany. The second largest group of migrants in Germany is Polish [2]. Hence, both Turkish and Polish migrants, aged 60 and above, form an important research group. Consequently, German social and health services are confronted by challenges in satisfying the needs of these people. HRQoL is the perceived quality of an individual's health and daily life and therefore an important target of health promotion and disease prevention in older life. As a consequence, information regarding health and HRQoL of elderly migrants can serve to meet their needs in a socially and politically expedient way, develop strategies on health care issues and adapt

Recent research regarding health of migrants often uses a problem-oriented perspective. The most important determinants which negatively influence the health of elderly migrants can be summarised as low socio-economic status (SES) due to bad working and living conditions [3] and situations which cause suffering post-migration—e.g. discrimination experiences [4].

Apart from this pathogenic approach, some researchers do not just focus on the disadvantages of migration, but also consider the benefits and opportunities it affords. In this regard, families and ethnic communities (seen as a support system) are often mentioned as being

Surprisingly, however, research on health and in more detail on HRQoL of elderly migrants, such as the elderly Turkish and Polish population in Germany, is still scarce and insufficient data have been generated, with only a few studies being published [6–8]. Moreover, findings often do not compare the results of different, especially elderly, migrant groups with each other. In view of the paucity of studies, the aim of this study was to obtain information on the HRQoL of elderly Turkish and Polish migrants as well as on elderly native Germans.

The German Federal Statistical Office reported that almost every fifth person in Germany has a migration background, i.e. 18.9% of the total population in Germany of 80.3 million [1]. People with a migration background in Germany come predominantly from Turkey (17.9%), followed by Poland (13.1%). First generation migrants are an ageing population in Germany. In fact, according to the Statistical Office [9], about 1.4 million migrants are aged 65 and above. Since migrants' health is often seen from a problem-oriented perspective [5, 17], various determinants are considered, which might have a negative impact on health. It seems inappropriate to see migrants' health only in relation to problems and conflicts. In this regard, Eichler [5] recommends combining a pathogenic approach with a salutogenic approach [18], that is, to relate 'trouble-spot' components with social determinants, which might positively affect the health of migrant populations. Consequently, the benefits of migration should be considered when investigating the health and quality of life of elderly migrants. There are determinants that have a positive influence on migrants' health such as strong family and ethnic networking [19].

The most reported determinants of the health of elderly migrants can be categorised as socioeconomic status (SES; e.g. income), psychological aspects (e.g. discrimination) and social networking (e.g. social support). These are described for Turkish and Polish migrants in the following.

#### **3.1. Socio‐economic status as a determinant of health and HRQoL**

A key socio-economic factor influencing elderly migrants' health negatively is that of low income and the concomitant risk of poverty [20]. The link between a low SES and illness and HRQoL has been found in numerous studies [21].

Compared with native Germans, Turkish migrants rarely have adequate education or access to further education and therefore often work in places that are physically and psychologically detrimental to health. They often experience unemployment [22]. Data from the Statistical Office [20] confirm these findings. It shows that elderly Turkish people generally have a much lower monthly net-income and fewer assets than comparable elderly people without a migrant background. Studies have found that older people with a Turkish background do not have generally poorer health than native Germans, but they often suffer from ill health if they have experienced low SES and poor working conditions during their working life [23].

Wiking et al. [24] showed in a cross-sectional study of migrants from Poland (*n* = 840) that the risk of poor self-reported health could be explained by educational status and economic resources. Compared with Turkish migrants, who were mostly expected to stay in the host country only temporarily but decided to remain, most Polish migrants who come to Germany are regarded as ethnic Germans and are allowed to stay permanently [25]. Often they have received German citizenship and have a higher educational level relative to the low educational level of most Turkish migrants—which incurs a positive effect on their health. Polish migrants can face limited job opportunities because their educational qualifications are often not accepted.

#### **3.2. Discrimination as a determinant of health and HRQoL**

Studies exploring the relationship between discrimination and the health of migrants are rare or they are focused on migrants aged below 60 [26]. Psychological stress and mental health problems were reported for migrants relating to the process of acculturation and experiences of discrimination [23].

Turkish migrants in Germany may be more vulnerable to depression. Mohammadzadeh and Tempel [27] reported stressful situations, like trouble with agencies, intercultural conflicts and generational conflicts of older (aged 60 and above) Turkish migrants in their everyday life. The feeling of emptiness and its relation to poor psychological health was shown among first-generation (born in Turkey and migrated to Germany) and second-generation (born in Germany to migrant parents) Turkish migrants [28].

Psychological problems have been reported to play a major role in the health of Polish migrants. It has been shown, for example, that migrants (Polish as well as Turkish) experience stress as a consequence of the migration process and circumstances faced as part of their residence in Germany. These include deprivations and discrimination [29] during the adaptation process. This can have negative physical and psychological effects [30] and consequently decreases HRQoL. A study by Merbach et al. [31] shows that Polish migrants experience more depression and anxiety symptoms than the German host population. In this regard, the intention to assimilate socially and the perception of discrimination along with this intention have a significant influence on health, while adequate German language skills and success of assimilation in Germany contrast this negative picture. In particular, Polish migrants suffer from discrimination in their workplace and in the media, which report judgemental stereotypes [29].

### **3.3. Social networking as a determinant of health and HRQoL**

**3.1. Socio‐economic status as a determinant of health and HRQoL**

HRQoL has been found in numerous studies [21].

58 People's Movements in the 21st Century - Risks, Challenges and Benefits

working life [23].

of discrimination [23].

A key socio-economic factor influencing elderly migrants' health negatively is that of low income and the concomitant risk of poverty [20]. The link between a low SES and illness and

Compared with native Germans, Turkish migrants rarely have adequate education or access to further education and therefore often work in places that are physically and psychologically detrimental to health. They often experience unemployment [22]. Data from the Statistical Office [20] confirm these findings. It shows that elderly Turkish people generally have a much lower monthly net-income and fewer assets than comparable elderly people without a migrant background. Studies have found that older people with a Turkish background do not have generally poorer health than native Germans, but they often suffer from ill health if they have experienced low SES and poor working conditions during their

Wiking et al. [24] showed in a cross-sectional study of migrants from Poland (*n* = 840) that the risk of poor self-reported health could be explained by educational status and economic resources. Compared with Turkish migrants, who were mostly expected to stay in the host country only temporarily but decided to remain, most Polish migrants who come to Germany are regarded as ethnic Germans and are allowed to stay permanently [25]. Often they have received German citizenship and have a higher educational level relative to the low educational level of most Turkish migrants—which incurs a positive effect on their health. Polish migrants can face lim-

Studies exploring the relationship between discrimination and the health of migrants are rare or they are focused on migrants aged below 60 [26]. Psychological stress and mental health problems were reported for migrants relating to the process of acculturation and experiences

Turkish migrants in Germany may be more vulnerable to depression. Mohammadzadeh and Tempel [27] reported stressful situations, like trouble with agencies, intercultural conflicts and generational conflicts of older (aged 60 and above) Turkish migrants in their everyday life. The feeling of emptiness and its relation to poor psychological health was shown among first-generation (born in Turkey and migrated to Germany) and second-generation (born in

Psychological problems have been reported to play a major role in the health of Polish migrants. It has been shown, for example, that migrants (Polish as well as Turkish) experience stress as a consequence of the migration process and circumstances faced as part of their residence in Germany. These include deprivations and discrimination [29] during the adaptation process. This can have negative physical and psychological effects [30] and consequently decreases HRQoL. A study by Merbach et al. [31] shows that Polish migrants experience more depression and anxiety symptoms than the German host population. In this regard, the intention to assimilate socially and the perception of discrimination along with

ited job opportunities because their educational qualifications are often not accepted.

**3.2. Discrimination as a determinant of health and HRQoL**

Germany to migrant parents) Turkish migrants [28].

Social networks act in health-promoting ways [19, 30], and social participation has a positive effect on the health behaviour of older people as it can improve compensating and coping strategies, help to establish self-esteem and decrease social isolation and depression [30].

The Federal Ministry for Family, Seniors, Women and Youth (Bundesministerium für Familie, Senioren, Frauen und Jugend, 2006) [32] particularly mentioned the potential of social networks of elderly Turkish migrants as a model for the elder generation. Social networking might not only be limited to social areas in the host country but also be extended to social spheres in the home country. Elderly Turkish and Polish migrants live 'transnational' [33, 34], which provides for them social contacts with different people, communities and organisations across national boundaries. In this respect, Krumme [34] differentiated between different categories of resources. These include resources like (grand-) children and friends as well as experiences of familiarity in both countries.

## **4. HRQoL of Turkish and Polish migrants and German natives – the study**

Health is an important domain of quality of life (QoL). QoL consists of health domains such as the social, psychological and physical, in addition to the individual's objective health status [35].

The aim of this study was to examine and analyse comparatively the multidimensional and subjective health-related quality of life (HRQoL) of elderly Turkish and Polish migrants and German natives. This raised the question of whether differences between these groups are observable when it comes to HRQoL, and whether the determinants of age, gender, income, discrimination and social support do influence HRQoL.

The HRQoL model proposed by the Sf-36 [36] was of primary interest in this study. This model includes eight dimensions, i.e. physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE) and mental health (MH)) which are related to a physical (PC) and a mental (MC) health component (see **Figure 1**).

Two research questions and hypotheses were formulated for this study:

**1.** The first research question considered whether there are **differences in the HRQoL** of elderly Turkish migrants, Polish migrants and German natives. This was tested by checking for significant differences between the eight Sf-36 sum scores (calculation of sum scores for each of the eight dimensions, followed by statistical analyses (ANOVA and Bonferroni post hoc test). The hypothesis assumed that elderly Turkish as well as elderly Polish migrants show poorer HRQoL than elderly German natives.

**Figure 1.** The Sf-36 model of health-related quality of life (HRQoL). Source: Ware et al. [36].

**2.** The second question and hypothesis focused on possible **predictors influencing the HRQoL** dimensions. The second research question was whether age, gender, income, discrimination and social support significantly influence the HRQoL (with respect to the Sf-36 dimensions) of elderly Turkish and Polish migrants and German natives and if so, what kind of impact they have (positive or negative). This was tested using multiple regression analysis, where the Sf-36 dimensions were the dependent and the five predictors were the independent variables. The hypotheses were as follows: (1) age and gender significantly influence HRQoL; (2) a low income level decreases HRQoL (the lower the income level, the poorer the HRQoL); (3) perceived discrimination decreases HRQoL (the greater the perceived discrimination, the poorer the HRQoL); and (4) social support increases HRQoL (the more social support received, the better the HRQoL).

## **5. Materials and methods**

Approval for the study was granted by the University of Applied Sciences Hamburg (HAW) and by the ethics committee of the University of the West of Scotland (UWS).

#### **5.1. Study participants**

A cross-sectional study design, which included interviews with 304 persons (100 with Turkish, 103 with Polish and 101 with German participants) was used to answer the research questions. The interviews were conducted in the appropriate native languages (interviewers with German and Polish or Turkish language skills) in the period from February 2011 to August 2011 (Turkish participants) and in the period from October 2011 to June 2012 (Polish and German participants).

The participants in this study had to meet certain criteria for inclusion: two of the three groups (Turkish and Polish) had to have first-hand migration experience. The participants had to be at least 60-year old. The participants had to live in selected districts of Hamburg (named Wilhelmsburg, Billstedt, Altona-Nord, Altona-Altstadt and Harburg), because the proportion of migrants is particularly high in these districts. In the case of German participants, the surveys also took place in these districts to ensure greater comparability. The participants did not live in nursing or senior homes and did not require professional nursing care, because having professional support in daily life may result in a different health status and therefore a different HRQoL.

## **5.2. Recruitment of participants**

**2.** The second question and hypothesis focused on possible **predictors influencing the HRQoL** dimensions. The second research question was whether age, gender, income, discrimination and social support significantly influence the HRQoL (with respect to the Sf-36 dimensions) of elderly Turkish and Polish migrants and German natives and if so, what kind of impact they have (positive or negative). This was tested using multiple regression analysis, where the Sf-36 dimensions were the dependent and the five predictors were the independent variables. The hypotheses were as follows: (1) age and gender significantly influence HRQoL; (2) a low income level decreases HRQoL (the lower the income level, the poorer the HRQoL); (3) perceived discrimination decreases HRQoL (the greater the perceived discrimination, the poorer the HRQoL); and (4) social support increases HRQoL

Approval for the study was granted by the University of Applied Sciences Hamburg (HAW)

A cross-sectional study design, which included interviews with 304 persons (100 with Turkish, 103 with Polish and 101 with German participants) was used to answer the research questions. The interviews were conducted in the appropriate native languages (interviewers with German and Polish or Turkish language skills) in the period from February 2011 to August 2011 (Turkish participants) and in the period from October 2011 to June 2012 (Polish

The participants in this study had to meet certain criteria for inclusion: two of the three groups (Turkish and Polish) had to have first-hand migration experience. The participants had to be

and by the ethics committee of the University of the West of Scotland (UWS).

(the more social support received, the better the HRQoL).

**Figure 1.** The Sf-36 model of health-related quality of life (HRQoL). Source: Ware et al. [36].

60 People's Movements in the 21st Century - Risks, Challenges and Benefits

**5. Materials and methods**

**5.1. Study participants**

and German participants).

The recruitment of participants included promotion in a brochure and on a website, but these proved ineffective. The most effective recruitment method was to request participation directly, face-to-face. Turkish participants were located in Turkish facilities, in mosques, in Turkish cafés and on the street, where they spend their leisure time. Polish migrants were recruited in two Catholic churches, in cultural facilities, in cafés, in Polish grocery stores and on the street. German participants were found in cafés, in grocery stores and on the street. In addition, participants were recruited using the snowball method (family members or friends of the interviewers and family members or friends of the participants). **Table 1** gives an overview of the recruitment process for Turkish migrants, Polish migrants and German natives.


**Table 1.** Overview of recruitment process for each group.

#### **5.3. Data collection**

The Turkish study interviews were undertaken in different locations, at a friend's house or in the participants' homes. The Polish interviews mostly took place in the parish hall, in cultural facilities or at the participants' houses. The German participants were mostly interviewed on the street or in various public locations (e.g. bakery, café). To ensure that migrants with poor


**Table 2.** Overview of interview venues for each group.

German language skills could adequately reply to the questions, all participants were given the opportunity to answer in their native language (Turkish, Polish or German). **Table 2** gives an overview of the locations where the interviews were carried out.

#### **5.4. Study instruments**

This study was carried out with a questionnaire composed of the Sf-36 [37], which measures the HRQoL, and questions concerning the interviewee's income, experience of discrimination and social support. In addition, sociodemographic and socio-economic data were reported.

The Sf-36 is a generic instrument with 36 items and eight dimensions, which are converted to values between 0 and 100 (sum scores), with 100 representing the highest and 0 the lowest level of HRQoL. The Sf-36 v.2 instrument, its components, dimensions and items are shown in **Table 3**.

Personal income was determined according to the self-reported income per capita. The following question was asked: 'What is your monthly net income (after taxes and health and social contributions)?' Income was reduced from an original eleven categories to five categories for better clarity (not specified/unknown, income <500, income 500–1500, income 1501–2500 and income 2501–4500).

Discrimination experiences were assessed by asking the question: 'Did you feel treated differently because of your origin in your neighbourhood or at work or when looking for employment?' and could answer with: <yes, several times>, <yes, once>, <never>, <not at all>.

The questionnaire on social support—short form (German: 'Fragebogen zur sozialen Unterstützung—Kurzform' (F-SozU K-14) is an instrument for measuring general, perceived

Health-Related Quality of Life (HRQoL) among Elderly Turkish and Polish Migrants and German Natives: The Role of Age, Gender, Income, Discrimination and Social Support http://dx.doi.org/10.5772/66931 63


**Table 3.** The Sf-36 instrument.

German language skills could adequately reply to the questions, all participants were given the opportunity to answer in their native language (Turkish, Polish or German). **Table 2** gives

This study was carried out with a questionnaire composed of the Sf-36 [37], which measures the HRQoL, and questions concerning the interviewee's income, experience of discrimination and social support. In addition, sociodemographic and socio-economic data were reported. The Sf-36 is a generic instrument with 36 items and eight dimensions, which are converted to values between 0 and 100 (sum scores), with 100 representing the highest and 0 the lowest level of HRQoL. The Sf-36 v.2 instrument, its components, dimensions and items are shown in **Table 3**. Personal income was determined according to the self-reported income per capita. The following question was asked: 'What is your monthly net income (after taxes and health and social contributions)?' Income was reduced from an original eleven categories to five categories for better clarity (not specified/unknown, income <500, income 500–1500, income 1501–2500 and

Discrimination experiences were assessed by asking the question: 'Did you feel treated differently because of your origin in your neighbourhood or at work or when looking for employ-

The questionnaire on social support—short form (German: 'Fragebogen zur sozialen Unterstützung—Kurzform' (F-SozU K-14) is an instrument for measuring general, perceived

ment?' and could answer with: <yes, several times>, <yes, once>, <never>, <not at all>.

an overview of the locations where the interviews were carried out.

**Group**

62 People's Movements in the 21st Century - Risks, Challenges and Benefits

**Interview venue Turkish migrants Polish migrants German natives**

Home 52 78 13

On the street 5 0 15 Facilities: 0 0 0

Store, bakery, Café, market 26 5 62 Mosque 12 0 0 Religious community 0 0 0 Church 0 11 0

**n = 100 n = 103 n = 101**

5 9 11

**5.4. Study instruments**

Absolute numbers of participants.

**Table 2.** Overview of interview venues for each group.

Intercultural institution,

meeting place

income 2501–4500).

social support [38]. It includes 14 items asking about the social support experienced by the respondents. The content addresses emotional support (e.g. being liked by someone, to share feelings with others), practical support (e.g. having someone who takes care of the apartment, to borrow things from) and social integration (e.g. having friends, having similar interests to others). The results of the F-SozU K-14 are represented by scale values (total of items divided by the numbers of items). The higher these values are, the higher the interviewees perceive their level of social support.

#### **5.5. Statistical analysis**

All data were entered and analysed using SPSS version 21. Descriptive statistics were reported as means and standard deviations (means + SD), absolute frequencies and percentages. Statistical significance was set at an alpha level of *p* < 0.05.

The analysis of the Sf-36 data was based on sum scores for each of the eight dimensions. All dimensions were converted to values between 0 and 100 to permit easier comparisons. The scale scores can range from 0 to 100, with 100 representing the highest and 0 the lowest level of HRQoL. All eight dimensions were checked with quantile-quantile plots for normal distribution. As the assumption of normal distribution was confirmed, ANOVA was used to examine whether there were differences between the groups. The Bonferroni post hoc test was used to determine differences between Turkish migrants, Polish migrants and German natives.

The impact of age, gender, discrimination and social support on selected dimensions of the Sf-36 was calculated using multiple regression analysis.

## **6. Results**

#### **6.1. Participants' characteristics**

The demographic characteristics of the sample are shown in **Table 4**. A total of 304 participants responded to the questionnaire (100 Turkish migrants, 103 Polish migrants, 101 German natives). The mean age of the study group was 68.3 + 6.9 (range 60–89). Thirteen Turkish participants did not provide their age. More than half (58.2%) of the sample was female and 41.8% was male. All Turkish participants stated Turkish as their native language. Polish participants named two options: first, language Polish and German, which means that they indicated Polish as their first native language and German as their second native language. Second, language German and Polish, which means that they indicated German as their first and Polish as their second native language.


**Table 4.** Background demographics of study sample.

**Table 5** shows socio-economic data of participants. 11.0% of the Turkish women and men stated that they never went to school. In contrast, all other participants had at least some school education. Polish participants attended school for more than 12 years (45.6%). More Turkish than Polish or German participants reported not having a formal professional education. Only Polish and German groups stated having a monthly personal income >2.501€, however, only 2 and 3 men reported this income.

Health-Related Quality of Life (HRQoL) among Elderly Turkish and Polish Migrants and German Natives: The Role of Age, Gender, Income, Discrimination and Social Support http://dx.doi.org/10.5772/66931 65


**Table 5.** Socio-economic data of study sample.

**6. Results**

**6.1. Participants' characteristics**

64 People's Movements in the 21st Century - Risks, Challenges and Benefits

and Polish as their second native language.

**Age** (years) *n* = 87

**Citizenship** (% (abs.))

**Native language** (% (abs.))

*Notes*: M, mean; SD, standard deviation.

**Table 4.** Background demographics of study sample.

however, only 2 and 3 men reported this income.

The demographic characteristics of the sample are shown in **Table 4**. A total of 304 participants responded to the questionnaire (100 Turkish migrants, 103 Polish migrants, 101 German natives). The mean age of the study group was 68.3 + 6.9 (range 60–89). Thirteen Turkish participants did not provide their age. More than half (58.2%) of the sample was female and 41.8% was male. All Turkish participants stated Turkish as their native language. Polish participants named two options: first, language Polish and German, which means that they indicated Polish as their first native language and German as their second native language. Second, language German and Polish, which means that they indicated German as their first

**Turkish Polish German** *<sup>n</sup>* **= 100** *<sup>n</sup>* **= 103** *<sup>n</sup>* **= 101**

M<sup>1</sup> 65.6 68.9 69.9 SD 4.7 7.3 7.4 Max 79 83 89

Yes 31.0% (31) 83.5% (86) 100% (101)

5. German – 16.5% (17) 100% (101)

No 68.0% (68) 16.5% (17) – Not specified 1.0% (1) – –

1. Turkish 100 % (100) – – 2. Polish – 67.0% (69) – 3. Polish and German 13.6% (14) – 4. German and Polish – 2.9% (3) –

**Table 5** shows socio-economic data of participants. 11.0% of the Turkish women and men stated that they never went to school. In contrast, all other participants had at least some school education. Polish participants attended school for more than 12 years (45.6%). More Turkish than Polish or German participants reported not having a formal professional education. Only Polish and German groups stated having a monthly personal income >2.501€,

#### **6.2. Assessment of the Sf‐36 sum scores**

The values were calculated for each national group and each health dimension [physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE) and mental health (MH)]. ANOVA results indicate significant differences in five of the eight dimensions. The mean scores of the Sf-36 dimensions for participants are presented in **Table 6**.

For PF Polish migrants scored significantly higher than German natives, for GH Polish migrants had higher scores than Turkish migrants, and vitality of the Polish group was higher than that of both other groups. In addition, RE as well as MH were higher in the German group than in the Turkish group but did not differ significantly from the Polish group.

#### **6.3. Predictors of the Sf‐36 dimensions**

When the above-mentioned five predictors were included in the regression analysis for the migrant and native groups, the results for the dimensions were as follows:


**Table6.**Comparison of Sf-36 scores of (a) Turkish elderly, (b) Polish elderly, and (c) German elderly, including mean with SD and possible significant differences.

national groups; groups that do not share the same superscript are significantly different (Bonferroni, *p* < 0.05.

Health-Related Quality of Life (HRQoL) among Elderly Turkish and Polish Migrants and German Natives: The Role of Age, Gender, Income, Discrimination and Social Support http://dx.doi.org/10.5772/66931 67


**Table 7.** Multiple linear regression: significant variables predicting Sf-36 dimensions in migrants and German natives.

Age and gender were found to be significant predictors of physical functioning (PF) in elderly Turkish and Polish migrants: PF decreased with increasing age (the higher the age, the lower the PF scores). In addition, males showed better HRQoL compared to females. Income, perceived discrimination and social support did not significantly predict PF. In the German group, only age turned out to be a significant predictor of decreased HRQoL: PF decreased with an increase in age (the older the participants, the more their PF decreased).

Significant differences in general health (GH) were revealed between migrants and natives. This could be due to the fact that the significant (influencing) variables were different for the two groups. The analysis revealed a significant relationship between income and GH (the lower the income level, the poorer the GH status). In addition, the analysis only showed a significant relationship between social support and GH for the German natives only. In this case, GH increased in relation to an increase in social support in daily life.

With the elderly migrants gender played a role in vitality (VT): VT was found to be poorer in females than in males. Within the group of German natives, VT was found to be poorer in participants who reported having a low income level, which was in contrast to the migrant groups.

When the predictors were included in the regression analysis, a reduction in the emotional aspect (role emotional—RE) of HRQoL was associated with age (the higher the age, the lower the RE scores) in the migrant group. The responses related to age (age significantly influences

**Values** Valid (*n*)/

Turkish

99/1

100/0

99/1

99/1

99/1

100/0

100/0

99/1

missing (*n*)

Polish German

> Mean (SD)

Turkish

Polish German

> ANOVA

F-value

(Sign.1

) Summary of contents of SF-36 health scales.

\*

n.s.

n.s.

\* Physical dimension: PF = ability to perform daily physical activities, e. g. walking, running, lifting, and other moderate physical efforts; RP = extent to which physical

health limits work or daily activities. The higher the sum scores, the lower the extent to which physical health limits work/daily activities; BP = intensity of pain and

its interference with normal activities. The higher the sum score, the lower the intensity of pain and its interference with activities (the absence of pain); GH = personal

Mental dimension: VT = personal evaluation of energy, etc.; SF = extent to which physical health or emotional problems interfere with normal social activities. The higher

the sum score, the lower the extent to which physical health or emotional problems interfere with normal social activities; RE = extent to which emotional problems

limit work or daily activities. The higher the sum score, the lower the extent to which emotional problems limit work or daily activities; MH = personal evaluation of

Significance; *p* < 0.05\*, *p* < 0.01\*\*, *p* < 0.001\*\*\*, n.s. = not significant. a,b : same superscripts indicate that the means are not significantly different between the corresponding

Comparison of Sf-36 scores of (a) Turkish elderly, (b) Polish elderly, and (c) German elderly, including mean with SD and possible significant differences.

national groups; groups that do not share the same superscript are significantly different (Bonferroni, *p* < 0.05.

evaluation of general health status, presently and in the future.

mental health.

**Table 6.**

\*\*\*

n.s.

\*\*

\*

5.131

1.137

1.337

3.135

16.324

1.823

6.503

4.595

63.27 (23.41)b

63.12 (26.32)

32.49 (27.40)

53.22 (20.24)ab

44.06 (20.15)b

47.40 (7.14)

78.49 (22.77)b

67.40 (19.44)b

66 People's Movements in the 21st Century - Risks, Challenges and Benefits

73.64 (20.81)a

67.66 (25.45)

35.63 (28.95)

56.06 (17.11)b

60.19 (21.35)a

48.91 (12.76)

72.65 (25.47)ab

66.02 (19.06)ab

66.44 (26.67)ab

62.15 (31.52)

38.99 (27.99)

49.31 (20.14)a

49.12 (20.26)b

50.13 (9.65)

64.33 (32.91)a

59.56 (19.97)a

101/0

101/0

101/0

101/0

100/1

101/0

93/8

100/1

103/0

103/0

103/0

103/0

103/0

103/0

103/0

103/0

**National group**

**Physical** 

**Role physical** 

**Bodily pain** 

**General health** 

**Vitality (VT)**

**Social** 

**Role emotional** 

**Mental health** 

**functioning (SF)**

**(RE)**

**(MH)**

**functioning (PF)**

**(RP)**

**(BP)**

**(GH)**

RE) was different in all groups, this is because age was positively associated with their RE (the older the person, the better the RE) in the German natives group.

Differences in mental health (MH) were found between German natives and migrants in terms of gender ( **Table 7**). In this dimension, gender played a significant role in the migrant groups, with women showing poorer MH than men. Discrimination was found to predict MH in the group of migrants (the higher the perceived discrimination, the better their MH). Social support was found to improve the MH of German natives (the higher the level of social support, the better their MH). However, income was found to predict MH in both groups (the lower the level of income, the poorer the MH of the individuals).

## **7. Discussion**

To the best of our knowledge, this was the first study assessing HRQoL among elderly Turkish and Polish migrants and German natives [39]. The hypothesis was that being a migrant is associated with disadvantages that lead to a poorer HRQoL, expressed by Sf-36 sum scores, compared to natives. However, the Sf-36 consists of eight dimensions and the hypothesis was confirmed in only two of the eight dimensions (elderly Turkish migrants show lower sum scores in RE and MH compared to German natives).

The findings that some dimensions of HRQoL of migrants are poorer than that of natives confirmed the findings from previous studies showing that the HRQoL of Turkish and Polish migrants was lower than that of native Germans in Physical Functioning [40]. The authors of this study suggested that this was related to limitations in daily activities that corresponded to increasing age. However, the authors also mentioned that elderly migrants face several health disadvantages related to working and housing situations and physical health problems due to their living situation relating to migration. Another study explained the moderate quality of life (QoL) of Turkish migrants compared to a Turkish population living in Turkey as the result of differences in age, marital status and education [6]. Berdes and Zych [8] showed better QoL of Polish American elderly compared with Polish elderly migrants. They explained this as being the result of 'vital aging' in an 'American social construct' (page 393), which implies better access to material goods and health care, and adherence to healthier life styles.

The current study showed lower average scores for the dimensions of role emotional and mental health within migrant groups. These dimensions cover mental health aspects. It was not possible to find the literature that discussed differences in these dimensions among migrants and native Germans and how to explain these. But it is assumed that differences are explained at least in part by culture. Differences can also be explained by the fact that different predictors are relevant for each of the national groups. Therefore, variables, such as the socio-economic status, may influence this multidimensional health construct.

The predictors age, gender, income, discrimination and social support were found to be significantly different between the different national groups.

Age was found to predict RE and PF in both the migrant and German group. Generally speaking, age had a negative impact on these two dimensions, with one exception: increasing age was associated with higher RE in the German group. Elderly populations were often found to show poorer health and HRQoL than younger age groups. Therefore, the results are partly consistent with other results showing that HRQoL decreases with age. These findings support those of Wiking et al. [24], which showed that the risk of poor self-reported health was primarily associated with age in the group of old migrants from Turkey and Poland. Lamkaddem et al. [41] found that the age of Turkish migrants was a significant predictor of physical health. Bayram et al. [6] compared the QoL of Turkish migrants living in Sweden and in their home country and attributed the moderate QoL of the Turkish migrants to age. Age differences in PF, BP and MH were also reported by Knurowski et al. [7]. This explains the differences in self-rated health with respect to bodily pain, vision abilities and depressive symptoms. The findings from this study also support the assumption of Morawa and Erim [42] as well as Wiking et al. [24] in that differences in QoL are not necessarily between migrants and nonmigrants but rather between age and gender groups. One possible explanation for poorer HRQoL with increasing age could be that physical and mental health problems usually arise as part of the natural ageing process.

RE) was different in all groups, this is because age was positively associated with their RE (the

Differences in mental health (MH) were found between German natives and migrants in terms of gender ( **Table 7**). In this dimension, gender played a significant role in the migrant groups, with women showing poorer MH than men. Discrimination was found to predict MH in the group of migrants (the higher the perceived discrimination, the better their MH). Social support was found to improve the MH of German natives (the higher the level of social support, the better their MH). However, income was found to predict MH in both groups (the

To the best of our knowledge, this was the first study assessing HRQoL among elderly Turkish and Polish migrants and German natives [39]. The hypothesis was that being a migrant is associated with disadvantages that lead to a poorer HRQoL, expressed by Sf-36 sum scores, compared to natives. However, the Sf-36 consists of eight dimensions and the hypothesis was confirmed in only two of the eight dimensions (elderly Turkish migrants show lower sum

The findings that some dimensions of HRQoL of migrants are poorer than that of natives confirmed the findings from previous studies showing that the HRQoL of Turkish and Polish migrants was lower than that of native Germans in Physical Functioning [40]. The authors of this study suggested that this was related to limitations in daily activities that corresponded to increasing age. However, the authors also mentioned that elderly migrants face several health disadvantages related to working and housing situations and physical health problems due to their living situation relating to migration. Another study explained the moderate quality of life (QoL) of Turkish migrants compared to a Turkish population living in Turkey as the result of differences in age, marital status and education [6]. Berdes and Zych [8] showed better QoL of Polish American elderly compared with Polish elderly migrants. They explained this as being the result of 'vital aging' in an 'American social construct' (page 393), which implies

better access to material goods and health care, and adherence to healthier life styles.

socio-economic status, may influence this multidimensional health construct.

nificantly different between the different national groups.

The current study showed lower average scores for the dimensions of role emotional and mental health within migrant groups. These dimensions cover mental health aspects. It was not possible to find the literature that discussed differences in these dimensions among migrants and native Germans and how to explain these. But it is assumed that differences are explained at least in part by culture. Differences can also be explained by the fact that different predictors are relevant for each of the national groups. Therefore, variables, such as the

The predictors age, gender, income, discrimination and social support were found to be sig-

Age was found to predict RE and PF in both the migrant and German group. Generally speaking, age had a negative impact on these two dimensions, with one exception: increasing age

older the person, the better the RE) in the German natives group.

68 People's Movements in the 21st Century - Risks, Challenges and Benefits

lower the level of income, the poorer the MH of the individuals).

scores in RE and MH compared to German natives).

**7. Discussion**

This study has shown that a significant negative association existed between gender and HRQoL. Women with a migration background were shown to be disadvantaged in relation to the dimensions of PF, VT and MH.

The finding that women's HRQoL is poorer than that of men has been confirmed in various studies. Bayram et al. [6] found the QoL of male migrants to be higher than that of female migrants, however, reasons for this were not given. Golicki et al. [43] showed that the percentage of Polish female respondents reporting problems such as pain, discomfort, anxiety and depression was considerably higher compared to Polish men. In another study, Turkish women living in Germany indicated poorer HRQoL than Turkish men living in Germany [42]. Wiking et al. [24] showed that the risk of poor self-reported health was five times higher for Turkish and Polish women living in Sweden.

One possible explanation for these gender differences could be that an understanding of the impact of migration on women's health has been neglected in the past. In addition, it was usually men who migrated for economic reasons. The migration of Turkish women to Germany was mainly the result of changes to German government policy allowing family reunification [44]. Therefore, these women did not have the same social status as men and for the most part arrived independently of their families. Another explanation could be that migrant women are particularly affected by health inequalities and inequities [45].

The link between a low SES and HRQoL has rarely been investigated in previous studies [46]. But, the current trends suggest that the poorer health and HRQoL of migrants compared to Germans is because they are disadvantaged in terms of their SES. In this study, income was the only significant negative predictor of GH and MH in Turkish and Polish migrants.

This presents a challenge in the context of migration studies because a low socio-economic profile per se does not result in poor HRQoL. Rather, a low SES correlates with other determinants of migration, e.g. poor working conditions, and low educational level, which can influence HRQoL. This present study supports the hypothesis that the HRQoL of migrants is poorer due to low income in only two of the eight dimensions. This indicates that income alone cannot be taken as a sole predictor of HRQoL.

It was shown that discrimination only had an influence on the MH of the Turkish and Polish migrants. Discrimination is often experienced by minority groups [47] and several studies have shown that it has a negative impact on the HRQoL of migrants. Morawa and Erim [42] as well as Wiking et al. [24] found this for both Turkish and Polish migrants. In addition, self-rated discrimination was associated with an increased number of unhealthy days, disability days, poor self-reported health and poor HRQoL among diverse groups (Whites, Blacks, Latinos) [48]. Wang et al. [49] recommended reducing discrimination in order to improve QoL of migrants.

In contrast, social support was reported to have a positive effect on the mental health and HRQoL of migrants because of the determinants influencing their health in a positive way, such as having strong family and ethnic networks. Past studies of Turkish populations have shown that social support can have a protective effect when it comes to affective disorders and stress and consequently to HRQoL [50].

The current study supported the positive influence on HRQoL for only the dimension of GH in the German group. This is in contrast to results from another study, which showed that social support was a significant predictor of HRQoL [51].

In summary, the results of this study were somewhat different from those of other previous studies. The assumptions were that low income and discrimination reduce HRQoL and social support improves HRQoL. Since the hypotheses could not be fully supported and considering the lack of explanatory research on this topic, this cannot be clarified in the context of this study. Instead, it must be assumed that the predictors influencing the HRQoL of Polish migrants, Turkish migrants and German natives either negatively or positively are different from the ones identified in this study.

This is the first study that offers relevant insights into the HRQoL of elderly Turkish and Polish migrants and German natives. The results have theoretical and practical implications for the health and HRQoL of migrants: the results reported should be investigated in other studies with larger study samples and other (minority) groups. In particular, the migrationspecific differences in HRQoL constructs should be considered by policy makers, researchers and health practitioners. The differences in this study show that it is necessary to consider group-specific factors when developing prevention and health promotion strategies. The results have some implications for policy makers as health promoting initiatives should not only address the disadvantages of migrant groups, but should consider their resources. This approach could lead to a strengthening of migrant's health and HRQoL.

## **8. Limitations of the study**

There are some limitations to this study, which should be considered when interpreting the results. Firstly, this study used a cross-sectional study design and this restricts the interHealth-Related Quality of Life (HRQoL) among Elderly Turkish and Polish Migrants and German Natives: The Role of Age, Gender, Income, Discrimination and Social Support http://dx.doi.org/10.5772/66931 71

pretation of the impact of migration on the HRQoL. A longitudinal approach would have offered more data relating to changes over time, but it was not possible to employ this type of design within the economic constraints of this study. Secondly, it should be borne in mind that this sample of Turkish and Polish migrants consists of elderly migrants living in specific areas of Hamburg/Germany and therefore the sample cannot be representative of all migrants in the whole city or even country. Therefore, the generalisation of the results is limited to these specific groups. Thirdly, it cannot be excluded that some of the Polish and Turkish migrants were reluctant to participate: the interviews were limited to the individuals found in public places and by friends or family members. This may have led to a selection or sampling bias. Fourthly, despite care being taken with the translation of the Sf-36 questionnaire there is the possibility that some items were interpreted differently by the three groups because of cultural interpretation of items. This potential limitation may have restricted the meaning of comparisons between the different cultural groups. Finally, the research team cannot discount the fact that, in spite that all the interviewers were native speakers of the relevant language, some questions may have been difficult to understand and led to misinterpretation.

## **9. Conclusion**

is poorer due to low income in only two of the eight dimensions. This indicates that income

It was shown that discrimination only had an influence on the MH of the Turkish and Polish migrants. Discrimination is often experienced by minority groups [47] and several studies have shown that it has a negative impact on the HRQoL of migrants. Morawa and Erim [42] as well as Wiking et al. [24] found this for both Turkish and Polish migrants. In addition, self-rated discrimination was associated with an increased number of unhealthy days, disability days, poor self-reported health and poor HRQoL among diverse groups (Whites, Blacks, Latinos) [48]. Wang et al. [49] recommended reducing discrimination in order to improve QoL

In contrast, social support was reported to have a positive effect on the mental health and HRQoL of migrants because of the determinants influencing their health in a positive way, such as having strong family and ethnic networks. Past studies of Turkish populations have shown that social support can have a protective effect when it comes to affective disorders

The current study supported the positive influence on HRQoL for only the dimension of GH in the German group. This is in contrast to results from another study, which showed that

In summary, the results of this study were somewhat different from those of other previous studies. The assumptions were that low income and discrimination reduce HRQoL and social support improves HRQoL. Since the hypotheses could not be fully supported and considering the lack of explanatory research on this topic, this cannot be clarified in the context of this study. Instead, it must be assumed that the predictors influencing the HRQoL of Polish migrants, Turkish migrants and German natives either negatively or positively are different

This is the first study that offers relevant insights into the HRQoL of elderly Turkish and Polish migrants and German natives. The results have theoretical and practical implications for the health and HRQoL of migrants: the results reported should be investigated in other studies with larger study samples and other (minority) groups. In particular, the migrationspecific differences in HRQoL constructs should be considered by policy makers, researchers and health practitioners. The differences in this study show that it is necessary to consider group-specific factors when developing prevention and health promotion strategies. The results have some implications for policy makers as health promoting initiatives should not only address the disadvantages of migrant groups, but should consider their resources. This

There are some limitations to this study, which should be considered when interpreting the results. Firstly, this study used a cross-sectional study design and this restricts the inter-

approach could lead to a strengthening of migrant's health and HRQoL.

alone cannot be taken as a sole predictor of HRQoL.

70 People's Movements in the 21st Century - Risks, Challenges and Benefits

and stress and consequently to HRQoL [50].

from the ones identified in this study.

**8. Limitations of the study**

social support was a significant predictor of HRQoL [51].

of migrants.

This study suggests that being a migrant does not necessarily entail poor HRQoL, individual differences within the whole concept of HRQoL were evident. Turkish migrants' perceptions of their own HRQoL were only worse than those of German natives in RE and MH, but the perceptions of Polish migrants were superior in PF and VT. Migrants' health is often seen from a deficit or problem-based perspective. However, the superior HRQoL of the Polish group, in two of the HRQoL dimensions, would imply the search for existing personal and social protective resources. We recommend, therefore, that future studies should adopt both, a deficit or problem-based approach as well as a strengths or resourcesbased approach when considering the perspective of migrants' health and HRQoL. Studies should aim to identify the range and role of possible mediators of HRQoL that arise from migration status and identify the underlying social determinants of the different HRQoL dimensions.

## **Author details**

Johanna Buchcik1 \*, Joachim Westenhöfer1 , Mick Fleming2 and Colin R. Martin3


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#### **Suicidal Behaviors in Patients Admitted to Emergency Department for Psychiatric Consultation: A Comparison of the Migrant and Native Italian Populations Between 2008 and 2015 Suicidal Behaviors in Patients Admitted to Emergency Department for Psychiatric Consultation: A Comparison of the Migrant and Native Italian Populations Between 2008 and 2015**

Carla Gramaglia, Eleonora Gambaro, Fabrizio Bert, Claudia Delicato, Giancarlo Avanzi, Luigi Mario Castello, Roberta Siliquini and Patrizia Zeppegno Carla Gramaglia, Eleonora Gambaro, Fabrizio Bert, Claudia Delicato, Giancarlo Avanzi, Luigi Mario Castello, Roberta Siliquini and Patrizia Zeppegno Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/67006

#### **Abstract**

In recent decades, Italy has become a desirable destination for immigrants. In 2014, five million people (8.2% of the population) were migrants (regular/irregular, documented/ undocumented). This study looks at psychiatric health, an important feature especially for first‐generation migrants and compares the new settlers with the native Italians. It should be noted that the organization of mental health services in Italy strongly relies on outpatient services, while the psychiatric wards, within the general hospitals, usu‐ ally accommodate patients in acute phases of their disorder. Nonetheless, migrants' first contact often happens in a psychiatry ward when they are in a severe and acute psy‐ chopathological condition. Research methods: Quantitative and qualitative; longitudi‐ nal research using official statistical and clinical data obtained from records of a public hospital as well as information obtained through professional interview. Results: In rela‐ tion to mental health, we found that the migrant patients referred for psychiatric consul‐ tation to the emergency department (ED) setting were younger, less frequently treated by psychiatric outpatient services, more commonly going to the ED for self‐injury and presenting with symptoms of substance abuse and alcohol‐related disorders. The native Italian population was older, more frequently retired and/or invalid, more frequently already treated by psychiatric outpatient services for any kind of psychiatric symptoms. Conclusion: The comparison of the sociodemographic and clinical features of immigrants and Italians referred for psychiatric consultation in the ED highlighted some differences. Implications are discussed in the light of the existing literature.

and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

**Keywords:** Italy, regular (documented) and irregular (undocumented) immigrants, native Italian population, suicidal behaviors, emergency department (ED), psychiatric consultation, Italian National Institute of Statistics, National Health Service, Community Mental Health Center

## **1. Introduction**

#### **1.1. Migration and mental health**

Migration is the process by which an individual moves from one cultural context to another, in order to settle for a long period of time or lifelong [1]. Migration can occur en masse or individually; people who emigrate for economic or academic reasons usually move alone and then are followed by their families, while those who emigrate for political reasons typically move in mass, with or without their own families [2].

The process of migration entails three phases: premigration, which includes the decision to migrate and the preparation for it; the actual migration, that is, the physical transfer of the person from one place to another; and post‐migration, defined as the process of migrants' integration in the new social and cultural context of the host country, where new rules and roles have to be learned [2]. Obviously, this is a simplification, and the migration process and the experiences might significantly vary from person to person [1].

Each phase of the migration process may represent a stressor eventually leading to an increased risk of developing psychiatric symptoms or disorders, including depression, anxiety, post‐ traumatic stress disorder, addiction to alcohol and drugs, loneliness, hopelessness and suicidal behaviors [2]. Overall, migrants might have higher rates of psychopathology than the host populations, due to the exposure to the stress of the migrating process, which may include one or more of the following: the end of the links with their country of origin, the loss of social status and network, a sense of inadequacy because of language barriers, unemployment, financial problems, a sense of not belonging, feelings of exclusion and loss of interest in enter‐ ing into a relationship with others. Migrants might experience a condition similar to bereave‐ ment, caused by the loss of their previous social network, relationships and culture. Language (especially colloquial language and dialect), attitudes, values and social support networks are missed the most. While painful feelings for these losses are a natural consequence of migra‐ tion, when these feelings turn into a clinically significant, long‐lasting distress or impairment, professional support may be necessary [3].

#### **1.2. Migration and suicidal behavior**

Migrant status may represent a risk factor for suicidal behavior, which is an important challenge in migrants' mental health care [4, 5]. Many authors observed that suicide rates increased among migrants and ethnic minorities [4, 5], probably in relation with some risk factor for suicidal behaviors, which are intrinsic to the migrant condition, such as poverty, war, traumatic experiences, political repression, torture, experiences of discrimination and marginalization in the host country. These stressors might act as triggers for a condition of vulnerability [6, 7]. However, migrants are also likely to be exposed to protective factors, like strong family networks or protective cultural or religious traditions, beneficial to overall mental health [7].

**Keywords:** Italy, regular (documented) and irregular (undocumented) immigrants, native Italian population, suicidal behaviors, emergency department (ED), psychiatric

Migration is the process by which an individual moves from one cultural context to another, in order to settle for a long period of time or lifelong [1]. Migration can occur en masse or individually; people who emigrate for economic or academic reasons usually move alone and then are followed by their families, while those who emigrate for political reasons typically

The process of migration entails three phases: premigration, which includes the decision to migrate and the preparation for it; the actual migration, that is, the physical transfer of the person from one place to another; and post‐migration, defined as the process of migrants' integration in the new social and cultural context of the host country, where new rules and roles have to be learned [2]. Obviously, this is a simplification, and the migration process and

Each phase of the migration process may represent a stressor eventually leading to an increased risk of developing psychiatric symptoms or disorders, including depression, anxiety, post‐ traumatic stress disorder, addiction to alcohol and drugs, loneliness, hopelessness and suicidal behaviors [2]. Overall, migrants might have higher rates of psychopathology than the host populations, due to the exposure to the stress of the migrating process, which may include one or more of the following: the end of the links with their country of origin, the loss of social status and network, a sense of inadequacy because of language barriers, unemployment, financial problems, a sense of not belonging, feelings of exclusion and loss of interest in enter‐ ing into a relationship with others. Migrants might experience a condition similar to bereave‐ ment, caused by the loss of their previous social network, relationships and culture. Language (especially colloquial language and dialect), attitudes, values and social support networks are missed the most. While painful feelings for these losses are a natural consequence of migra‐ tion, when these feelings turn into a clinically significant, long‐lasting distress or impairment,

Migrant status may represent a risk factor for suicidal behavior, which is an important challenge in migrants' mental health care [4, 5]. Many authors observed that suicide rates increased among migrants and ethnic minorities [4, 5], probably in relation with some risk factor for suicidal behaviors, which are intrinsic to the migrant condition, such as poverty, war, traumatic experiences, political repression, torture, experiences of discrimination and marginalization in the host country. These stressors might act as triggers for a condition of

consultation, Italian National Institute of Statistics, National Health Service,

Community Mental Health Center

78 People's Movements in the 21st Century - Risks, Challenges and Benefits

move in mass, with or without their own families [2].

professional support may be necessary [3].

**1.2. Migration and suicidal behavior**

the experiences might significantly vary from person to person [1].

**1. Introduction**

**1.1. Migration and mental health**

Suicide rates vary from country to country, and there seems to exist no generalizable pattern of suicide in migrants [5]. Suicide rates among migrants tend to follow those of their country of origin, showing a significant and positive correlation between the two values; in other words, at least for the initial period they spend in the host country, migrants seem to "bring along" their suicide risk [8–12]. Most of the research was performed in the United States, but the same type of evidence has been obtained in other host countries, such as Austria, Australia, Canada, Sweden and the United Kingdom [12, 13]. The similarity of suicide rates with those of the country of origin was also found in second‐generation migrants [12–14] and for suicide attempt rates [3]. The continuity highlighted by the correlation with suicidality in the migrants' countries of origin may be understood from either a cultural or a genetic per‐ spective. However, the results in this field are mixed, and while a recent review concluded that, overall, most migrant groups do not have an increased suicide risk relative to the local‐ born population, with some even experiencing substantially lower risks [15], another one reported higher rates of suicidal behaviors among migrants compared to host populations, which is likely due to difficulties in the acculturation and integration process [3].

An Austrian study found the lowest rates for suicidal behaviors among Turkish migrants and the highest among the Japanese, consistent with the rates of both countries of origin and with those observed in other host countries, for instance, the United States [12]. A similar trend was found in one of the studies mentioned above, which involved 10 European countries: Turkey, Switzerland, Belgium, Finland, Israel, the Netherlands, Italy, Sweden, Estonia and Germany. In this survey, the highest rates of suicide attempts among migrants generally corresponded to higher rates of suicide in the country of origin, and there was an overlap between the rates of suicide attempts of the same ethnic group in different host countries [3]. Similarly, a meta‐anal‐ ysis of 33 studies about the suicide rates in migrants from almost 50 nationalities, in 7 host coun‐ tries (Australia, Austria, Canada, England, the Netherlands, Sweden and the USA), supported the strong correlation between migrants' suicide rates and those of their countries of origin [12].

In most studies conducted in Europe, America and Australia, the highest risk of suicide was found in migrants from Northern and Eastern Europe, and the lowest in those from Southern Europe and the Middle East. A further complicating issue is the possibility that suicide rates may vary in relation to the country of origin on the one hand, but also according to gender, on the other. For instance, in migrants from Asian countries, the risk of suicide seems generally low for men but appreciably higher for women [2, 3, 8, 13, 16–18].

The high suicide rates among migrants from Northern and Eastern Europe might be related to the high alcohol consumption typical of these countries. For example, Finnish migrants who died of undetermined causes in Sweden tended to have high alcohol levels in their blood [29]. A similar trend was found in Russia, where suicide rates related to alcohol abuse are very high, and among Russian migrants who died by suicide in Estonia [8].

The low rates of suicide among migrants from Southern Europe, the Middle East and Asia may be due to some protective factors, such as the strong influence of traditional values, family and religious beliefs. These countries are more collectivist and have strong family ties and group identity outside their country of origin. Both in Catholic and in Muslim countries, religion may be a strong deterrent to suicide, which is considered as a sin in the Catholic reli‐ gion and as *haram*, or forbidden, by the Islamic law (*sharia*) [20]. The protective role of religion could also be enhanced by the ties with the religious community, which might represent a strong source of social support and sense of belonging [21, 22].

Migration exposes to mental health‐related risks not only the actual migrants but also their families who remained in the country of origin. For example, it has been observed that the next of kin of Mexican migrants in the United States were at greater risk of suicidal ideation and suicide attempts than Mexicans without a family history of emigration. Emigration could weaken family ties, lead to feelings of loneliness and insecurity, and thus increase the risk of suicide also among family members who remained at home [23].

#### **1.3. Italy and migration**

In recent decades, Italy has undergone major socio‐political changes that have deeply influ‐ enced the life of the country and its inhabitants. Like Ireland, Spain and Portugal, Italy in the last century was a country of emigrants. Anyway, Italy has currently become a desirable destination for migrants, who often come as refugees in poor health conditions, with the hope of finding "heaven" [24, 25]. Because of its position, Italy is now a disembarkation country for migrants sailing from North Africa across the Mediterranean Sea, as well as a destination for those coming from Eastern Europe. Please note that from now on, we will use the word "migrant" to mean both foreigners and naturalized people: the first are indi‐ viduals without Italian nationality, while the second are those born abroad, who acquired Italian citizenship [26].

At the end of year 2014, 5 million out of the 60.8 million inhabitants in Italy (8.2%) had a for‐ eign citizenship. Non‐ European Union (EU) foreigners holding a residence permit in Italy on 1 January 2015 were 3.929.916, with the following being the most represented countries of origin: Morocco, Albania, China, Ukraine and Philippines [27]. ISTAT (Istituto Nazionale di Statistica, National Institute of Statistics) data report an approximately 63% increase of the migrant population in Italy from 2008 to 2015 (from 3 to 4.9 million) [27]. This increase was from 284.191 migrants in 2008 to 425.523 in 2014 in Piedmont [23] and a similar trend was observed in the province of Novara (from 25.088 = 6.9% of the total population in 2008 to 37.453 = 10.1% in 2014). The largest migrant communities included the Moroccan, Albanian, Romanian and Ukrainian people [28].

#### *1.3.1. The Italian legislation about the healthcare needs of migrants*

Current Italian legislation about the healthcare of foreign citizens [19] requires that migrants legally residing in Italy or having ongoing regular working activities register for the National Health Service. These migrants share the same treatment options, the same rights and duties as Italian citizens, but it should be emphasized that also irregular (undocumented) migrants (with‐ out a residence permit) are offered and granted urgent or essential healthcare in outpatient and inpatient facilities, as well as preventative health programs. When irregular (undocumented) migrants ask for medical assistance, no authority will be notified. An exception is made relating to clinicians' obligations concerning crime notification. In 2010, the "Integration Agreement" and "Integration Plan" of the EU have been adopted to enhance migrants' integration, includ‐ ing measures to promote access to social and health services through advertisement, cultural mediators, as well as training for health and social workers. [30].

#### *1.3.2. Migrants and mental health services*

family and religious beliefs. These countries are more collectivist and have strong family ties and group identity outside their country of origin. Both in Catholic and in Muslim countries, religion may be a strong deterrent to suicide, which is considered as a sin in the Catholic reli‐ gion and as *haram*, or forbidden, by the Islamic law (*sharia*) [20]. The protective role of religion could also be enhanced by the ties with the religious community, which might represent a

Migration exposes to mental health‐related risks not only the actual migrants but also their families who remained in the country of origin. For example, it has been observed that the next of kin of Mexican migrants in the United States were at greater risk of suicidal ideation and suicide attempts than Mexicans without a family history of emigration. Emigration could weaken family ties, lead to feelings of loneliness and insecurity, and thus increase the risk of

In recent decades, Italy has undergone major socio‐political changes that have deeply influ‐ enced the life of the country and its inhabitants. Like Ireland, Spain and Portugal, Italy in the last century was a country of emigrants. Anyway, Italy has currently become a desirable destination for migrants, who often come as refugees in poor health conditions, with the hope of finding "heaven" [24, 25]. Because of its position, Italy is now a disembarkation country for migrants sailing from North Africa across the Mediterranean Sea, as well as a destination for those coming from Eastern Europe. Please note that from now on, we will use the word "migrant" to mean both foreigners and naturalized people: the first are indi‐ viduals without Italian nationality, while the second are those born abroad, who acquired

At the end of year 2014, 5 million out of the 60.8 million inhabitants in Italy (8.2%) had a for‐ eign citizenship. Non‐ European Union (EU) foreigners holding a residence permit in Italy on 1 January 2015 were 3.929.916, with the following being the most represented countries of origin: Morocco, Albania, China, Ukraine and Philippines [27]. ISTAT (Istituto Nazionale di Statistica, National Institute of Statistics) data report an approximately 63% increase of the migrant population in Italy from 2008 to 2015 (from 3 to 4.9 million) [27]. This increase was from 284.191 migrants in 2008 to 425.523 in 2014 in Piedmont [23] and a similar trend was observed in the province of Novara (from 25.088 = 6.9% of the total population in 2008 to 37.453 = 10.1% in 2014). The largest migrant communities included the Moroccan, Albanian,

Current Italian legislation about the healthcare of foreign citizens [19] requires that migrants legally residing in Italy or having ongoing regular working activities register for the National Health Service. These migrants share the same treatment options, the same rights and duties as Italian citizens, but it should be emphasized that also irregular (undocumented) migrants (with‐ out a residence permit) are offered and granted urgent or essential healthcare in outpatient and inpatient facilities, as well as preventative health programs. When irregular (undocumented)

strong source of social support and sense of belonging [21, 22].

80 People's Movements in the 21st Century - Risks, Challenges and Benefits

suicide also among family members who remained at home [23].

**1.3. Italy and migration**

Italian citizenship [26].

Romanian and Ukrainian people [28].

*1.3.1. The Italian legislation about the healthcare needs of migrants*

Overall, migrants tend to access mental health services less than the native population [31, 32]. Economic factors, a state of irregularity, poor understanding of local language, differ‐ ences in cultural background and in the expression of mental distress may hinder migrants' access to mental health facilities [2, 33, 34].

The organization of mental health services varies in different countries. In Italy, psychiatric care strongly relies on outpatient services, while the psychiatric wards within the general hospitals accommodate patients during the acute phases of their disorder, usually for short periods of time. A recent study [35] found that migrants and natives sharing similar pathways to access a Community Mental Health Center (CMHC) in Northern Italy, although migrants showed a higher frequency of treatment dropout. Migrants are more likely to turn to the hospital in the first place to seek help; therefore, their first contact with mental health often happens in a psychiatry ward in the general hospital [36–38].

In a previous research [39], we found that, compared to native Italians, migrants referred for psychiatric consultation in the ED setting were younger, less frequently treated by psy‐ chiatric outpatient services, more commonly attending emergency services for self‐injury, and presenting with symptoms of substance abuse and alcohol‐related disorders. Regarding intervention received in the ED (including medications) and outcome of the psychiatric con‐ sultation, we found several differences between Italian natives and migrants [39, 40].

The aim of the current study is to expand our previous research, gathering a larger sample for the migrant and native population. Furthermore, we aimed to compare the sociodemo‐ graphic, clinical and treatment features during and after a psychiatric consultation in the ED, with a specific focus on suicidal behaviors.

## **2. Methods**

## **2.1. Study setting**

This research was performed between 2006 and 2015 in the emergency department (ED) of the Maggiore della Carità Hospital, Novara, Italy, which has a high specialization ED, treat‐ ing about 60,000 adult people per year. The Maggiore della Carità Hospital is the second largest general hospital in Piedmont and the main hospital for all North‐Eastern Piedmont; its catchment area is representative for the whole region. In the ED of our hospital, all acute patients are assessed by the emergency medicine physician according to a priority code applied by the nurse through a triage evaluation. The emergency physician can request a consultation with other specialists, such as psychiatrists, after the patients' preliminary assessment, according to the patients' clinical features and according to the hospital guide‐ lines for the ED [40].

#### **2.2. Sample**

We collected data about consecutive patients assessed in the ED of the Maggiore della Carità Hospital, who were referred for psychiatric assessment after ED triage. The study period was from 1st January 2006 to 31st December 2015. From 1st January 2006 to 31st December 2007, only data for migrant patients (regular/irregular, documented/undocumented; *N* = 113) were available. From 1st January 2008 to 31st December 2015, data were available for all consecu‐ tive patients assessed in the ED (total *N* = 3780; immigrants *N* = 420). No exclusion criteria were applied except for age being <16 years, because in our country, these patients are treated by a separate pediatrics ED.

An experienced psychiatrist assessed patients by performing a clinical interview, including the assessment of suicidal intent, suicidal behaviors and attempts. The psychiatrist filled in a data sheet for each patient, reporting demographic data and clinical features. Moreover, variables relating to the ED access were recorded. This research project was approved by the Institutional Review Board of the Università del Piemonte Orientale as part of the research duties of the Psychiatry Institute.

#### **2.3. Statistical analysis**

Migrant patients recruited from 2006 to 2015 were analyzed using descriptive statistics. During this period of time, 3780 people receiving a psychiatric consultation in the ED setting from 2008 to 2015 were subdivided into two groups: migrants and Italian natives. Descriptive statistics were performed using frequencies, percentages, frequency tables for qualitative variables, mean using standard deviation (SD) and min‐max values for quantitative variables. The Chi‐squared test was used to evaluate the differences in proportions between groups (Italian natives/migrants). The covariates included in the final model were selected through the Hosmer and Lemeshow proce‐ dure, by inserting variables with a univariate *p* value <0.25 as the main criterion [41]. Results are expressed as odds ratio (OR) with 95% confidence intervals (95% CI). Statistical significance level was set at *p* value <0.05. Statistical analyses were performed with STATA 11 [42].

## **3. Results**

During the 10‐years period from 1st January 2006 and 31st December 2015, 533 migrants were assessed in the ED. In **Table 1**, we summarized details and statistically significant differences in the variables assessed between regular/documented and irregular/undocu‐ mented migrants recruited from 2006 to 2015. The distribution of the migrants' area of origin was the following: Europe 39.2%, Africa 28.8 %, Asia 14.7 %, and Central‐South America 17.3%.

Suicidal Behaviors in Patients Admitted to Emergency Department for Psychiatric Consultation: A Comparison... http://dx.doi.org/10.5772/67006 83


a consultation with other specialists, such as psychiatrists, after the patients' preliminary assessment, according to the patients' clinical features and according to the hospital guide‐

We collected data about consecutive patients assessed in the ED of the Maggiore della Carità Hospital, who were referred for psychiatric assessment after ED triage. The study period was from 1st January 2006 to 31st December 2015. From 1st January 2006 to 31st December 2007, only data for migrant patients (regular/irregular, documented/undocumented; *N* = 113) were available. From 1st January 2008 to 31st December 2015, data were available for all consecu‐ tive patients assessed in the ED (total *N* = 3780; immigrants *N* = 420). No exclusion criteria were applied except for age being <16 years, because in our country, these patients are treated

An experienced psychiatrist assessed patients by performing a clinical interview, including the assessment of suicidal intent, suicidal behaviors and attempts. The psychiatrist filled in a data sheet for each patient, reporting demographic data and clinical features. Moreover, variables relating to the ED access were recorded. This research project was approved by the Institutional Review Board of the Università del Piemonte Orientale as part of the research

Migrant patients recruited from 2006 to 2015 were analyzed using descriptive statistics. During this period of time, 3780 people receiving a psychiatric consultation in the ED setting from 2008 to 2015 were subdivided into two groups: migrants and Italian natives. Descriptive statistics were performed using frequencies, percentages, frequency tables for qualitative variables, mean using standard deviation (SD) and min‐max values for quantitative variables. The Chi‐squared test was used to evaluate the differences in proportions between groups (Italian natives/migrants). The covariates included in the final model were selected through the Hosmer and Lemeshow proce‐ dure, by inserting variables with a univariate *p* value <0.25 as the main criterion [41]. Results are expressed as odds ratio (OR) with 95% confidence intervals (95% CI). Statistical significance level

During the 10‐years period from 1st January 2006 and 31st December 2015, 533 migrants were assessed in the ED. In **Table 1**, we summarized details and statistically significant differences in the variables assessed between regular/documented and irregular/undocu‐ mented migrants recruited from 2006 to 2015. The distribution of the migrants' area of origin was the following: Europe 39.2%, Africa 28.8 %, Asia 14.7 %, and Central‐South

was set at *p* value <0.05. Statistical analyses were performed with STATA 11 [42].

lines for the ED [40].

82 People's Movements in the 21st Century - Risks, Challenges and Benefits

by a separate pediatrics ED.

duties of the Psychiatry Institute.

**2.3. Statistical analysis**

**3. Results**

America 17.3%.

**2.2. Sample**

**Table 1.** Comparison between migrants with and without residence permit (2006–2015): statistically significant results.

From 1st January 2008 to 31st December 2015, 3781 patients underwent psychiatric assess‐ ment in the ED. Our sample thus constituted 1640 men (43.38%) and 2141 women (56.62%). A total of 3247 patients were Italian natives and 421 were migrants, matching the inclusion criteria described above.

The sociodemographic features of ED referrals undergoing psychiatric consultation, compar‐ ing results of Italian natives and migrants in the period between 2008 and 2015 are summa‐ rized in **Table 2**.



**Table 2.** Comparison of the sociodemographic between Italian natives and migrants (2008–2015).

**Table 3** shows the clinical features of referrals undergoing psychiatric consultation in the ED, comparing Italian natives and migrants (2008–2015).


Suicidal Behaviors in Patients Admitted to Emergency Department for Psychiatric Consultation: A Comparison... http://dx.doi.org/10.5772/67006 85


**Table 3.** Clinical features in Italian natives and migrants (2008–2015).

**Table 3** shows the clinical features of referrals undergoing psychiatric consultation in the ED,

**Educational level** Primary or middle school 28.23 (810) 25.28 (89) 0.244

**Occupational status** Employed 28.67 (900) 28.57 (112) **<0.001**

**Residence** Novara 65.12 (2106) 67.78 (284) **<0.001**

**Residency permit (***N* **= 503)** No – 4.86 (19) –

**Health insurance card (***N* **= 502)** No – 22.51 (88) –

**STP code (***N* **= 129)** No – 11.76 (2) –

**Table 2.** Comparison of the sociodemographic between Italian natives and migrants (2008–2015).

High school or degree 71.77 (2059) 74.72 (263)

Unemployed§ 51.64 (1621) 67.09 (263) Retired/invalid§ 19.69 (618) 4.34 (17)

Extra Novara§ 33.06 (1069) 25.54 (107) Homeless§ 1.82 (59) 6.68 (28)

Yes – 95.14 (372)

Yes – 77.49 (303)

Yes – 88.24 (15)

**History of psychiatric disorders** 67.29 (2181) 43.20 (181) **<0.001**

**Previous contacts with addiction services** 12.12 (392) 12.92 (54) 0.641

**Previous psychiatric admissions** 42.16 (1361) 22.43 (94) **<0.001**

**Psychiatric admissions in the last 6 months** 19.05 (615) 11.22 (47) **0.001**

**Under the care of a psychiatrist** 55.15 (1763) 28.61 (119) **<0.001**

**Under the care of addiction services** 8.98 (281) 9.43 (38) 0.769

**Comorbidity with somatic disorders** 28.27 (911) 15.20 (64) **<0.001**

**Admission to other wards (last 6 months)** 6.24 (201) 5.00 (21) 0.317

**Relationship problems** 36.24 (1175) 47.27 (199) **<0.001**

**Treated with psychiatric medications** 60.35 (1954) 33.97 (143) **<0.001**

**Natives % (***N***) Migrants % (***N***)** *p*

**Natives % (***N***) Migrants % (***N***)** *p*

comparing Italian natives and migrants (2008–2015).

84 People's Movements in the 21st Century - Risks, Challenges and Benefits

§

Statistically significant difference.

**Table 4** shows patterns of access and main psychiatric symptoms of referrals undergoing psychiatric consultation in the ED setting, comparing results of Italian natives and migrants (2008–2015).



Note: \*Excluding substance‐related and organic causes; other includes cognitive impairment, delirium, memory deficits, extra‐pyramidal and neurological symptoms, etc. *§* Statistically significant difference.

**Table 4.** Pattern of ER access and main presenting psychiatric symptoms of Emergency Room referrals undergoing psychiatric consultation: results of the comparison between Italian natives and migrants (2008–2015).


**Table 5** describes Axis I and Axis II diagnoses according to DSM‐IV‐TR criteria [43] in migrants and Italian natives (2008–2015).

**Natives % (***N***) Migrants % (***N***)** *p*

15.94 (512) 11.46 (48)

**Accompanying person** Nobody§ 42.18 (1249) 37.06 (146) **<0.001**

**Referred by** Patient himself/herself§ 50.53 (1623) 45.82 (192) **<0.001**

General practitioner, emergency medical service, other specialist§

86 People's Movements in the 21st Century - Risks, Challenges and Benefits

Relatives, friends, educators 48.70 (1442) 48.98 (193) Police 5.78 (171) 11.17 (44) Doctor 3.34 (99) 2.79 (11)

Relatives, friends, educators 23.60 (758) 26.97 (113) Psychiatrist, addiction service 4.14 (133) 2.63 (11)

Another specialist 0.72 (23) 0.48 (2) Police§ 5.07 (163) 12.65 (53)

Day 57.75 (1874) 56.53 (238)

1 (October–March) 50.11 (1627) 48.22 (203)

2009§ 13.98 (454) 10.45 (44) 13.27 (431) 15.44 (65) 2011§ 9.27 (301) 12.35 (52) 17.80 (578) 16.15 (68) 11.89 (386) 8.79 (37) 7.45 (242) 5.94 (25) 9.30 (302) 10.21 (43)

**Access time** Night 42.25 (1371) 43.47 (183) 0.634

**Seasonality** 0 (April–September) 49.89 (1620) 51.78 (218) 0.466

**Year** 2008§ 17.03 (553) 20.67 (87) **0.022**

Congruity referral No 19.02 (558) 6.26 (46) **<0.001**

Priority code White§ 15.27 (448) 2.72 (20) **<0.001**

extra‐pyramidal and neurological symptoms, etc.

Statistically significant difference.

*§*

Yes 80.98 (2375) 93.74 (689)

Green§ 64.95 (1905) 45.99 (338) Yellow§ 18.99 (557) 49.12 (361) Red§ 0.78 (23) 2.18 (16) Note: \*Excluding substance‐related and organic causes; other includes cognitive impairment, delirium, memory deficits,

**Table 4.** Pattern of ER access and main presenting psychiatric symptoms of Emergency Room referrals undergoing

psychiatric consultation: results of the comparison between Italian natives and migrants (2008–2015).

**Table 5.** Axis I DSM IV‐TR diagnoses and Axis II DSM IV‐TR diagnoses in migrants and Italian natives groups (2008–2015).

**Table 6** describes the results of the comparison between Italian natives and migrants (2008– 2015) and the interventions and outcomes of the psychiatric consultations in the ED.



*Note*: BDZ: benzodiazepines; APS: antipsychotics; other includes for instance anticholinergics, flumazenil, etc.; PI: psychiatric interview; \*either voluntary or not. § Statistically significant difference.

**Table 6.** Intervention delivered in the ER and outcome of the consultation of emergency room referrals undergoing psychiatric consultation: results of the comparison between Italian natives and migrants (2008–2015).

**Table 7** summarizes self‐injury behaviors in migrants and Italian natives (2008–2015).


**Table 7.** Self‐injury behaviors in n migrants and Italian natives groups (2008–2015).

The results of the multivariate analysis performed to identify potential predictors of self‐ injury behaviors in the whole sample of patients admitted to the ED of the Maggiore della Carità Hospital in the period between 2008 and 2015 are presented in **Table 8**.

Suicidal Behaviors in Patients Admitted to Emergency Department for Psychiatric Consultation: A Comparison... http://dx.doi.org/10.5772/67006 89


**Table 7** summarizes self‐injury behaviors in migrants and Italian natives (2008–2015).

psychiatric consultation: results of the comparison between Italian natives and migrants (2008–2015).

**Consultation's outcome** Admission to psychiatric ward 3.30 (107) 4.99 (21) 0.449

**Acute treatment** Yes 89.10 (2887) 88.57 (372) 0.742 **Way of treatment** Intravenous or intramuscular 5.86 (178) 3.10 (12) **0.026**

Admission to other wards/assessment

by other specialist§

88 People's Movements in the 21st Century - Risks, Challenges and Benefits

psychiatric interview; \*either voluntary or not.

Statistically significant difference.

§

Brief stay/observation 0.28 (9) 0.00 (0) Discharge 95.38 (3097) 94.30 (397)

Outpatient care 0.40 (13) 0.24 (1) Voluntary discharge 0.37 (12) 0.24 (1)

Orally 94.14 (2862) 96.90 (375) *Note*: BDZ: benzodiazepines; APS: antipsychotics; other includes for instance anticholinergics, flumazenil, etc.; PI:

**Table 6.** Intervention delivered in the ER and outcome of the consultation of emergency room referrals undergoing

**Suicidal ideation** Yes 21.80 (138) 21.57 (22) 0.958 **Self‐injury behaviour** Yes 19.49 (633) 24.23 (102) **0.022 Short‐circuit reaction** Yes 79.62 (504) 78.43 (80) 0.783 **Type of self‐inflicted injury** Drugs ingestion 37.44 (237) 34.31 (35) 0.310

**Type of drugs ingestion** Benzodiazepines or barbiturates 36.69(62) 30.77 (8) 0.659

Cutting injuries 60.82 (385) 65.69 (67) Other (e.g. CO, caustic agents) 1.74 (11) 0.00 (0)

Antidepressants or SSRI 6.51 (11) 11.54 (3) Non psychiatric drugs 7.10 (12) 3.85 (1) Polydrugs 48.52 (82) 50.00 (13) APS 1.18 (2) 3.85 (1)

**Natives % (***N***) Migrants % (***N***)** *p*

**Natives % (***N***) Migrants % (***N***)** *p*

0.28 (9) 0.24 (1)

The results of the multivariate analysis performed to identify potential predictors of self‐ injury behaviors in the whole sample of patients admitted to the ED of the Maggiore della

Carità Hospital in the period between 2008 and 2015 are presented in **Table 8**.

**Table 7.** Self‐injury behaviors in n migrants and Italian natives groups (2008–2015).


**Table 8.** Potential predictors of self‐injury behaviors in patients admitted to the ER of the Maggiore della Carità Hospital (2008–2015).

## **4. Discussion**

**Adjusted OR 95% CI p**

1.11 (0.59–2.10) 0.747

1.48 (0.82–2.66) 0.188

1.62 (0.80–3.32) 0.183

0.87 (0.35–2.14) 0.763

1.01 (0.49–2.07) 0.980

1.76 (0.95–3.24) 0.071

0.40 (0.07–2.15) 0.286

0.28 (0.11–0.70) **0.006**

0.99 (0.43–2.30) 0.985

Yes 0.94 (0.42–2.08) 0.877

Yes 1.37 (0.92–2.05) 0.125

Yes 1.27 (0.80–2.04) 0.314

**Symptoms** Anxiety 1 – –

Psychomotor agitation, excluding forms of intoxication, abstinence or

Mood disorders and bipolar disorders

Schizophrenia and other psychotic disorders

Cognitive impairment (confusion, memory deficits, delirium)

Alcohol/substance intoxications or withdrawal

Negative psychiatric examination

Schizophrenia and other psychotic disorders

Mood disorders and bipolar disorders

**Psychiatric history** Yes 1.41 (0.60–3.32) 0.433

Neurocognitive disorders 1 – –

Substance use Disorders 0.68 (0.27–1.68) 0.400

Anxiety disorders 0.82 (0.35–1.93) 0.648 Somatoform disorders 0.89 (0.34–2.34) 0.814 Factitious disorders 0.57 (0.45–7.29) 0.667 Dissociative disorders 1.74 (0.51–6.07) 0.368 Eating disorders 0.27 (0.05–1.48) 0.130 Adjustment disorders 0.17 (0.19–1.61) 0.123

Yes 1.82 (1.20–2.76) **0.005**

**Table 8.** Potential predictors of self‐injury behaviors in patients admitted to the ER of the Maggiore della Carità Hospital

Other (e.g. EPS, neurological symptoms)

symptoms

dementia

90 People's Movements in the 21st Century - Risks, Challenges and Benefits

**Under the care of addiction Services**

**Co‐morbidity with somatic disorders**

**Axis I DSM IV‐TR diagnoses**

**Axis II DSM IV‐TR diagnoses**

(2008–2015).

**medications**

**Treated with psychiatric** 

#### **4.1. Migrants' features according to regularity state**

As shown in **Table 1**, we observed that only 78.41% of regular/documented migrants had a health insurance card, while, as expected, no one of the irregular/undocumented migrants was in possession of it (*p* < 0.001). As expected according to current laws, 91.67% of irregular/ undocumented migrants had an STP code (Stranieri Temporaneamente Presenti). This is an anonymous and free Italian code that irregular/undocumented migrants can obtain in order to access health services. It is valid for 6 months and renewable and ensures equal access to all "urgent and essential" care for irregular/undocumented migrants [44].

Compared to irregular/undocumented migrants, regular/documented migrants were more fre‐ quently employed, but self‐report more relationship problems. The educational level was high in both groups. Employment and educational status are likely to have an impact on migrants' health outcomes [45] in the long term [44]. Significant differences were found between regular/ documented and irregular/undocumented migrants as far as the following variables are con‐ cerned: Being under the care of a psychiatrist and treated with psychiatric medications, which were both more common in the former than in the latter. Irregular/undocumented migrants were more likely to self‐report a previous psychiatric diagnosis received in their country of ori‐ gin. Some estimations about the 2002–2008 period show that 1.9–3.8 million irregular/undocu‐ mented migrants lived in the EU, with possible difficulty to access basic healthcare and social services [45]. Furthermore, there are concerns about irregular/undocumented migrants' vulner‐ ability to physical and mental health risks, which may be worsened by difficult socioeconomic conditions and limited access to health services [46].

#### **4.2. Sociodemographic features**

In our study, the most represented migrants' area of origin was Europe, followed by Africa, consistently with the data reported by the ISTAT [26]. Consistent with our previous study [35], migrants assessed in the ED with a psychiatric consultation were younger than natives, with most of them belonging to the age classes <18 and 19–44 years, while most natives belonged to the age classes 45–64 years and >65 years. This finding is consistent with the demographic pro‐ file of the migrant population in Piedmont [47] and with another Italian study about emergency contacts of subjects who received a psychiatric diagnosis [48]. The educational status has been mentioned in the previous section and, as far as occupational status is concerned, migrants were more frequently unemployed than natives, and natives were more frequently retired and/ or invalid. This result could be partly expected considering the differences of patients' ages. It also supports previous research performed in our country [49]. No significant differences were found between migrants and native Italians in relation to living accommodation, marital status and educational level.

## **4.3. Clinical features (case history)**

We found several differences between migrants and native Italians. As expected, migrants were less frequently treated by a psychiatrist (including treatment with medication). Their history of psychiatric disorders and of previous admissions to a psychiatric ward during the 6 months prior to current consultation was also less frequent. Moreover, migrants were less likely than Italian natives to have a comorbid somatic disorder. This last finding probably depends on the differences we found in the patients' ages, with migrants being significantly younger than natives. As far as the other data are concerned, they may relate to possible barriers of migrants accessing Community Mental Health Centers, which is consistent with reporting their greater use of ED healthcare services. Interestingly, we found no difference between migrants and Italian natives regarding contacts with addiction services. As already pointed out, barriers may include service user views, difficulties in help‐seeking, accessing services and using primary care, in trusting a clinician with a different cultural background, difficulties in acknowledging mental health problems and perceived causes of mental health problems [50]. The lack of differences in the use of addiction services may be the consequence either of migrants' specific problems in this field or of a perception of greater acceptability of this kind of mental health service.

#### **4.4. Features of ED referral**

Migrants were less likely than native Italians to access the ED by themselves, upon self‐ referral or indication of a clinician (for instance, a general practitioner [GP]). No difference between the two groups was found as far as being accompanied to the ED by family members or friends. On the other hand, compared to natives, migrants were more likely to be brought in and referred to the ED by the police. These findings are consistent with studies showing significantly lower proportions of self‐referrals and a higher proportion of arrivals accompa‐ nied by the police in the Strong Migratory Pressure Countries (SMPC)‐born group [37, 48].

The reason for psychiatric consultation included psychiatric symptoms (of any kind), more frequently experienced in Italian natives than in migrants, while migrants were more likely to receive a consultation because of self‐injury and intoxication/withdrawal symptoms.

We can suggest some hypotheses for the reasons underlying the different pathways to psychi‐ atric consultation in the ED. First, these may depend on the fact that migrants may access psy‐ chiatric services when their mental distress is severe, requiring urgent and coercive measures [36, 48]. Second, migrants' pattern of access to psychiatric consultation in the ED may also be explained by the fact that in Italy, urgent care in this setting is offered also to irregular/undocu‐ mented migrants, who are not allowed to attend the services of general practitioners (GPs) [49].

Symptoms assessment on behalf of the consultant psychiatrist yielded some significant differ‐ ences between the two groups. Natives were more likely to show anxiety symptoms, cogni‐ tive impairment, delirium, memory deficits and neurological symptoms as main presenting symptoms. This greater frequency of cognitive impairment, memory deficits and neurological symptoms may depend on native's older age. Migrants were more likely to present with alco‐ hol/substance related symptoms, or, interestingly, with a negative psychiatric examination (i.e. no psychiatric symptoms could be identified). The finding about negative psychiatric examination deserves a reflection and is discussed in the next paragraph.

As described in the previous section, no differences were found between migrants and natives in previous or current contact with addiction services, although we observed more frequently alcohol/substance‐related symptoms among migrants. Maybe people with symptoms of alcohol and substance abuse using psychiatric consultations in ED instead of addiction services fosters the hypothesis of migrants' greater problems in this field.

Last, compared to natives, migrants were more likely to self‐report relationship problems, which suggest the importance of possible difficulties in creating a relational net in the host country or in cohabitation.

### **4.5. DSM‐IV‐TR diagnoses**

#### *4.5.1. Axis I*

6 months prior to current consultation was also less frequent. Moreover, migrants were less likely than Italian natives to have a comorbid somatic disorder. This last finding probably depends on the differences we found in the patients' ages, with migrants being significantly younger than natives. As far as the other data are concerned, they may relate to possible barriers of migrants accessing Community Mental Health Centers, which is consistent with reporting their greater use of ED healthcare services. Interestingly, we found no difference between migrants and Italian natives regarding contacts with addiction services. As already pointed out, barriers may include service user views, difficulties in help‐seeking, accessing services and using primary care, in trusting a clinician with a different cultural background, difficulties in acknowledging mental health problems and perceived causes of mental health problems [50]. The lack of differences in the use of addiction services may be the consequence either of migrants' specific problems in this field or of a perception of greater acceptability of

Migrants were less likely than native Italians to access the ED by themselves, upon self‐ referral or indication of a clinician (for instance, a general practitioner [GP]). No difference between the two groups was found as far as being accompanied to the ED by family members or friends. On the other hand, compared to natives, migrants were more likely to be brought in and referred to the ED by the police. These findings are consistent with studies showing significantly lower proportions of self‐referrals and a higher proportion of arrivals accompa‐ nied by the police in the Strong Migratory Pressure Countries (SMPC)‐born group [37, 48].

The reason for psychiatric consultation included psychiatric symptoms (of any kind), more frequently experienced in Italian natives than in migrants, while migrants were more likely to

We can suggest some hypotheses for the reasons underlying the different pathways to psychi‐ atric consultation in the ED. First, these may depend on the fact that migrants may access psy‐ chiatric services when their mental distress is severe, requiring urgent and coercive measures [36, 48]. Second, migrants' pattern of access to psychiatric consultation in the ED may also be explained by the fact that in Italy, urgent care in this setting is offered also to irregular/undocu‐ mented migrants, who are not allowed to attend the services of general practitioners (GPs) [49]. Symptoms assessment on behalf of the consultant psychiatrist yielded some significant differ‐ ences between the two groups. Natives were more likely to show anxiety symptoms, cogni‐ tive impairment, delirium, memory deficits and neurological symptoms as main presenting symptoms. This greater frequency of cognitive impairment, memory deficits and neurological symptoms may depend on native's older age. Migrants were more likely to present with alco‐ hol/substance related symptoms, or, interestingly, with a negative psychiatric examination (i.e. no psychiatric symptoms could be identified). The finding about negative psychiatric

As described in the previous section, no differences were found between migrants and natives in previous or current contact with addiction services, although we observed more frequently alcohol/substance‐related symptoms among migrants. Maybe people with symptoms of alcohol

receive a consultation because of self‐injury and intoxication/withdrawal symptoms.

examination deserves a reflection and is discussed in the next paragraph.

this kind of mental health service.

92 People's Movements in the 21st Century - Risks, Challenges and Benefits

**4.4. Features of ED referral**

In native Italians, we found higher proportions of schizophrenia and other psychotic disorders than in migrants. On the other hand, in migrants, we found higher proportions of substance abuse and adjustment disorders than in natives.

The literature reports a high incidence of schizophrenia and other delusional disorders in migrants than in host populations [51]. An explanation for the differences could be the pos‐ sible role of setting differences, for instance, ED psychiatric consultation vs. Community Mental Health Center. Our results are consistent with similar research performed in ED settings [48, 36].

As far as substance use disorders are concerned, this result seems to support what was hypoth‐ esized in the previous paragraphs. It is likely that alcohol and substance‐related disorders are important in the migrant population, deserving a more specific and targeted approach. It can be anticipated that the results would reduce pressure on the ED because treatment could be redirected.

The frequency of adjustment disorders was higher in migrants than in natives, but was lower than could be expected. Maybe, as already pointed out, the specific setting of this study plays a role in these results; we cannot exclude that migrant patients with adjustment disorder may lack the acute symptoms which usually lead to an ED consultation.

#### *4.5.2. Axis II*

Axis II diagnoses, including personality disorders and intellectual disabilities, were less fre‐ quent in migrants than in natives. Previous reports suggested that in the ED setting, where it is not possible to establish a post‐acute therapeutic relationship with the migrant patient, it is likely that personality disorders are underestimated [52].

#### **4.6. Intervention delivered in the ED and outcome of the psychiatric consultation**

Interestingly, and partially in contrast with a previous study we performed on a smaller sam‐ ple [35], we found only one difference in relation to drug administration, with the intravenous administration less frequent in migrants than in native Italians. This result is currently diffi‐ cult to explain. Overall, there was no statistically significant difference between migrants and natives in type of intervention received in the ED and outcome of the consultation. The finding of similar consultation outcomes in migrants and natives is interesting, considering that previ‐ ous studies found that migrants were more likely than natives to be admitted to a psychiatric ward or to be monitored in the ED with a short stay and observation after psychiatric consul‐ tation in the ED [48, 53, 35]. The literature reports mixed results concerning this issue: Some studies found a tendency to the underutilization of inpatient facilities among migrants, par‐ ticularly if they were coming from more distant countries to the host country [54].

As described in the previous paragraph, according to our data migrants and natives assessed by a psychiatrist in the ED show significant differences in symptoms and diagnoses. Therefore, the overlap of the intervention offered in the ED and of the psychiatric consultation raises some questions about cultural barriers, which may hinder an accurate understanding (and treatment) of the migrants' symptoms. Barriers to self‐disclosure or of a defensive atti‐ tude towards the psychiatrist may prevent migrants from receiving the most appropriate treatment for their symptoms. The high proportion of negative psychiatric examination in migrants and of relational problems may suggest either the need of a more thorough under‐ standing of the migrant patients' problems in order to properly classify and diagnose them or the need to target these problems (in case they are not the symptom of a disorder) in a differ‐ ent setting than the ED. While the first option points to the need for more trans‐cultural train‐ ing for psychiatrists, the second points to the need for better education of migrants as far as the use of the healthcare system is concerned. As already emphasized, migrants and natives show different patterns of attending psychiatric care, with the former being more likely to apply to acute mental health services (e.g. psychiatry wards in the general hospital) rather than to Community Mental Health Centers (CMHCs) [38].

#### **4.7. Suicidal behaviors**

The request for psychiatric consultation for self‐injury behaviors was more frequent in migrants than in natives, and actually, suicide attempts were more common in the first than in the latter group [40]. Despite this finding, no statistically significant difference emerged between the two groups as far as the intent to die and the type of suicide attempt (for instance, drug overdose, cutting, carbon monoxide intoxication, jumping from high places). Moreover, in our sample of patients admitted to ED and undergoing psychiatric consultation, the mul‐ tivariate analysis did not find that being a migrant is a potential predictor of suicide attempt. We believe that these findings should be understood in the light of cultural differences when expressing distress and suffering. Furthermore, as already pointed out, migrants may seek psychiatric help only when their distress has reached a severity that requires urgent inter‐ ventions [55, 48]. Lastly, as described in the first sections of this chapter, the literature on suicidal behaviors in migrants varies, but certain reviews have not found a higher suicide risk in migrants compared to the local‐born populations [5, 15].

#### **4.8. Multivariate analysis**

We will not describe here in detail the results of the multivariate analysis performed to identify the possible risk and protective factors for self‐injury behaviors, because it would be beyond the focus of this chapter. As expected, according to the epidemiology of suicide attempts, female gender was a risk factor (reference category: male gender) for self‐injury behaviors. Despite such behaviors being more common in migrants than in native Italians, the multivariate analysis did not find any significant result in relation to nationality. This result is consistent with the existing literature, as described in previous sections, and suggests that other factors might mediate sui‐ cidal behaviors in the migrant populations. While the fact of being a migrant can be considered a vulnerability factor for psychiatric symptoms and disorders, distress, and even suicidal behav‐ iors, it is widely acknowledged that vulnerability should be considered in the context of a stress‐ vulnerability model, see for instance [56, 57]. Moreover, the mediating and protective role of coping skills, resilience, family and social support should not be overlooked [57].

During the 8‐year period (2008–2015) of our study, we found that some years showed greater prevalence of suicidal risk than others. We found that the years 2013 and 2014 were posi‐ tive predictors of suicidal behaviors, compared to 2008 (reference category), probably due to the global economic crisis and the concurrent political instability. The financial crisis, which began in 2007, 2008, had a negative impact on working conditions and people's health [58, 59]. Most studies in this field of interest supported an increased prevalence of mental health prob‐ lems coinciding with the outbreak of the crisis [60]. Sometimes suicidal behaviors have been linked to economic reasons [61]. However, the literature also reports mixed results about the increase of suicide rates during economic crises. Some authors demonstrated an increase in the number of suicides during these times, especially in nations with lower levels of unem‐ ployment before the crisis itself [62]. Others found that the prevalence of suicide attempts and ideation had not increased significantly in 2011–2012 compared to other periods [63].

## **5. Limitations**

studies found a tendency to the underutilization of inpatient facilities among migrants, par‐

As described in the previous paragraph, according to our data migrants and natives assessed by a psychiatrist in the ED show significant differences in symptoms and diagnoses. Therefore, the overlap of the intervention offered in the ED and of the psychiatric consultation raises some questions about cultural barriers, which may hinder an accurate understanding (and treatment) of the migrants' symptoms. Barriers to self‐disclosure or of a defensive atti‐ tude towards the psychiatrist may prevent migrants from receiving the most appropriate treatment for their symptoms. The high proportion of negative psychiatric examination in migrants and of relational problems may suggest either the need of a more thorough under‐ standing of the migrant patients' problems in order to properly classify and diagnose them or the need to target these problems (in case they are not the symptom of a disorder) in a differ‐ ent setting than the ED. While the first option points to the need for more trans‐cultural train‐ ing for psychiatrists, the second points to the need for better education of migrants as far as the use of the healthcare system is concerned. As already emphasized, migrants and natives show different patterns of attending psychiatric care, with the former being more likely to apply to acute mental health services (e.g. psychiatry wards in the general hospital) rather

The request for psychiatric consultation for self‐injury behaviors was more frequent in migrants than in natives, and actually, suicide attempts were more common in the first than in the latter group [40]. Despite this finding, no statistically significant difference emerged between the two groups as far as the intent to die and the type of suicide attempt (for instance, drug overdose, cutting, carbon monoxide intoxication, jumping from high places). Moreover, in our sample of patients admitted to ED and undergoing psychiatric consultation, the mul‐ tivariate analysis did not find that being a migrant is a potential predictor of suicide attempt. We believe that these findings should be understood in the light of cultural differences when expressing distress and suffering. Furthermore, as already pointed out, migrants may seek psychiatric help only when their distress has reached a severity that requires urgent inter‐ ventions [55, 48]. Lastly, as described in the first sections of this chapter, the literature on suicidal behaviors in migrants varies, but certain reviews have not found a higher suicide risk

We will not describe here in detail the results of the multivariate analysis performed to identify the possible risk and protective factors for self‐injury behaviors, because it would be beyond the focus of this chapter. As expected, according to the epidemiology of suicide attempts, female gender was a risk factor (reference category: male gender) for self‐injury behaviors. Despite such behaviors being more common in migrants than in native Italians, the multivariate analysis did not find any significant result in relation to nationality. This result is consistent with the existing literature, as described in previous sections, and suggests that other factors might mediate sui‐ cidal behaviors in the migrant populations. While the fact of being a migrant can be considered

ticularly if they were coming from more distant countries to the host country [54].

than to Community Mental Health Centers (CMHCs) [38].

94 People's Movements in the 21st Century - Risks, Challenges and Benefits

in migrants compared to the local‐born populations [5, 15].

**4.7. Suicidal behaviors**

**4.8. Multivariate analysis**

We should highlight some limitations of the current research. Several differences among stud‐ ies, starting with the definition of "migrants," hinder the possibility to compare results in the lit‐ erature about migrants' mental health accurately [6]. The term "migrant" has many meanings, as discussed in our chapter and, unless more clearly defined, this makes comparisons difficult.

While the catchment area of our ED is representative of northern Italy, it is clear that a single‐ center design is also a limitation of our study, and that multicenter studies would increase the possibility to generalize results. Regarding suicide attempts, we should emphasize that, according to our ED guidelines, every suicide attempt is referred to the psychiatrist, but those patients who require life‐saving treatments because they have committed a "violent" suicide attempt (as shooting or jumping from high places) are not visited by the psychiatrist in the ED setting. Moreover, we obviously did not include in our study those patients who did not seek help from the ED after a suicide attempt.

Last, since the information we gathered through the psychiatric interviews and the data sheets strongly relies on self‐report, there is the possibility of a bias due to the fact that natives may feel more comfortable about self‐disclosure than migrants.

## **6. Conclusions**

In this chapter, we compared the sociodemographics, clinical and treatment features of Italian natives and migrants admitted to emergency department and receiving a psychiatric consultation in such setting. Our research started in 2006 and 2007 when we gathered data about regular/doc‐ umented and irregular/undocumented migrants who attended psychiatric consultations. From 2008 to 2015, we gathered data for both migrants and native Italians. We found that migrants were less frequently treated by a psychiatrist (including treatment with medication), reported less frequently a history of psychiatric disorders and previous admissions to a psychiatric ward. Migrants were more likely than native Italians to be brought in and referred to the ED by the police and were less likely to present by themselves, but upon self‐referral or indication of a clini‐ cian (for instance, a general practitioner) were accompanied by a member of the family and/or friend. Furthermore, migrants were more likely to receive a consultation because of self‐injury and intoxication/withdrawal symptoms. Migrants were more likely than Italian natives to present with alcohol/substance related symptoms, or, interestingly, with a negative psychiatric examina‐ tion (i.e. no psychiatric symptoms could be identified). As regards Axis I diagnoses, in migrants we found a lower proportion of schizophrenia and psychotic disorders, but higher incidence of substance abuse and adjustment disorders. Overall, there was no statistically significant differ‐ ence between migrants and natives in the type of intervention received in the ED and outcome of the psychiatric consultations. The request for psychiatric consultation for self‐injury behaviors was more frequent in migrants than in Italian natives, but no statistically significant difference emerged between the two groups as far as intent to commit suicide and the type of attempt. Moreover, the multivariate analysis did not find nationality as a risk factor for suicidal behaviors.

This research expanded our previous findings, which have been described elsewhere [35], and the larger sample size has allowed us to support some of the previous results, but opposes or refutes others. Overall, we believe that the current results add to the dearth of studies about migrants' use of mental health service in Italy, focusing on ED utilization.

Overall, the results of this study point to the need for a more thorough and trans‐culturally informed approach to migrants' mental health [64]. While the treatment received by migrants and native Italians substantially overlaps, it might not target the actual needs and symptoms of the migrant population. Education on mental health for migrants (regular/documented and irregular/undocumented) to decrease actual or perceived barriers is needed.

## **Author details**

Carla Gramaglia<sup>1</sup> , Eleonora Gambaro<sup>1</sup> , Fabrizio Bert<sup>2</sup> , Claudia Delicato1 , Giancarlo Avanzi<sup>3</sup> , Luigi Mario Castello<sup>3</sup> , Roberta Siliquini<sup>2</sup> and Patrizia Zeppegno1, 4\*

\*Address all correspondence to: patrizia.zeppegno@med.uniupo.it

1 Institute of Psychiatry, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy

2 Department of Public Health and Paediatric Sciences, University of Turin, Torino, Italy

3 Emergency Medicine, Department of Translational Medicine, University of Eastern Piedmont, University Hospital Maggiore della Carità, Novara, Italy

4 Complex Structure of the Psychiatry, Major University Hospital Company of Charity, Institute of Psychiatry, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy

## **References**

2008 to 2015, we gathered data for both migrants and native Italians. We found that migrants were less frequently treated by a psychiatrist (including treatment with medication), reported less frequently a history of psychiatric disorders and previous admissions to a psychiatric ward. Migrants were more likely than native Italians to be brought in and referred to the ED by the police and were less likely to present by themselves, but upon self‐referral or indication of a clini‐ cian (for instance, a general practitioner) were accompanied by a member of the family and/or friend. Furthermore, migrants were more likely to receive a consultation because of self‐injury and intoxication/withdrawal symptoms. Migrants were more likely than Italian natives to present with alcohol/substance related symptoms, or, interestingly, with a negative psychiatric examina‐ tion (i.e. no psychiatric symptoms could be identified). As regards Axis I diagnoses, in migrants we found a lower proportion of schizophrenia and psychotic disorders, but higher incidence of substance abuse and adjustment disorders. Overall, there was no statistically significant differ‐ ence between migrants and natives in the type of intervention received in the ED and outcome of the psychiatric consultations. The request for psychiatric consultation for self‐injury behaviors was more frequent in migrants than in Italian natives, but no statistically significant difference emerged between the two groups as far as intent to commit suicide and the type of attempt. Moreover, the multivariate analysis did not find nationality as a risk factor for suicidal behaviors. This research expanded our previous findings, which have been described elsewhere [35], and the larger sample size has allowed us to support some of the previous results, but opposes or refutes others. Overall, we believe that the current results add to the dearth of studies about

96 People's Movements in the 21st Century - Risks, Challenges and Benefits

migrants' use of mental health service in Italy, focusing on ED utilization.

, Eleonora Gambaro<sup>1</sup>

, Roberta Siliquini<sup>2</sup>

\*Address all correspondence to: patrizia.zeppegno@med.uniupo.it

Piedmont, University Hospital Maggiore della Carità, Novara, Italy

**Author details**

Carla Gramaglia<sup>1</sup>

Luigi Mario Castello<sup>3</sup>

Piedmont, Novara, Italy

Piedmont, Novara, Italy

and irregular/undocumented) to decrease actual or perceived barriers is needed.

Overall, the results of this study point to the need for a more thorough and trans‐culturally informed approach to migrants' mental health [64]. While the treatment received by migrants and native Italians substantially overlaps, it might not target the actual needs and symptoms of the migrant population. Education on mental health for migrants (regular/documented

, Fabrizio Bert<sup>2</sup>

1 Institute of Psychiatry, Department of Translational Medicine, University of Eastern

3 Emergency Medicine, Department of Translational Medicine, University of Eastern

4 Complex Structure of the Psychiatry, Major University Hospital Company of Charity, Institute of Psychiatry, Department of Translational Medicine, University of Eastern

2 Department of Public Health and Paediatric Sciences, University of Turin, Torino, Italy

and Patrizia Zeppegno1, 4\*

, Claudia Delicato1

, Giancarlo Avanzi<sup>3</sup>

,


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## **Migration and Health from a Public Health Perspective Migration and Health from a Public Health Perspective**

## Maurizio Marceca Maurizio Marceca

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/67013

#### **Abstract**

One of the main dimensions related to migration is that of health; this correlation is dynamic by nature and complex. Health is strongly related to the social determinants of health (job, income, education, and housing). When not properly supported by appropriate inter-sectoral policies, migration can expose the most vulnerable socioeconomic groups to significant problems. The protection of the health of migrants is an important investment of the public health because it promises benefits to both migrant population and natives. An essential aspect is to properly analyze the health needs of ethnic minorities. Both quantitative and qualitative research is necessary, and the involvement of the target communities is important. Another important aspect is the education and training of social and health workers involved in the care of migrants (with a multidisciplinary teamwork and "transcultural" approach), and the organization of services that can effectively be used. Finally, it is also essential to carry out an evaluation of health outcomes of the migrant population and the impact of adopted health policies. Protecting the health of ethnic minorities is both a challenge for governments and a test of the quality of their health systems.

**Keywords:** Italy, migration, immigration policies, legal/regular/documented migrants, illegal/irregular/undocumented migrants, health, right to health, health needs, health inequalities, public health policies, public health system

## **1. Introduction**

Since ancient times, migration has been practiced by our species. Some modern scientific technologies (in particular paleogenomic analysis on the haplogroups of mitochondrial DNA and Y chromosome) have enabled us to reconstruct approximate times, directions, and sequences of the movements of Homo sapiens across the planet. This migration, known as "Out of Africa II," seems to have started some 70,000 years ago in North-Eastern Africa and is likely to have been caused by the search for better living conditions, for example, plentiful food, a better

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

climate, more comfortable and safe environments, an impulse which continues to drive migration today [1, 2].

In the modern era, human migration has been one of the primary forces shaping the nation as we know it today, for example, in the case of the USA or Australia. In other countries and within other times and modalities, human migration was among one of the main social changes of the last century. This is especially relevant to the European continent. Where in some countries (such as England, France, the Netherlands, and Portugal), immigration has essentially represented a "returning" movement induced by colonialism, especially since the end of the nineteenth century. In other countries in the contemporary era, this phenomenon arose mainly in response to the need for foreign labor—initially a semi-skilled and unskilled workforce—and was embedded within older (e.g., in the cases of South Africa, Argentina, Uruguay, Brazil, Belgium, and Germany), or younger (e.g., in the cases of Italy, Spain, Sweden, and Greece) migratory dynamics. Different countries, such as Italy and Spain, passed through distinct historical migratory phases: from being countries of emigration to countries of destination. In this case, these shifts took place after an economic boom and the resulting social growth after the second half of the twentieth century.

While the migratory phenomenon has been widely examined from historical, social, economic, and cultural perspectives, health and healthcare perspectives are understudied. This is a problematic oversight because health is one of the most important aspects of migration. This correlation between "health" and "migration" is in itself dynamic and complex. It is dynamic because it is extremely heterogeneous (there are many different migrant communities) and it is variable, in both the diachronic and synchronic sense: prospective and evolving immigrant generations will experience different socioeconomic conditions in their country of origin and in the destination countries, and they will ensue different possibilities of integration. It is complex—as discussed by an editorial of the medical journal "the Lancet" in 2006—because its primary dynamics influence different migrant communities in various ways. A possible interpretation of this variety and complexity is that of gender because of a multiplicity of health risks linked, for example, to potentially dangerous and violent conditions in the workplace, different discrimination and racism in the destination countries, and so on [3].

Since the 1970s, some epidemiological studies comparing mortality and chronic diseases, especially the cardiovascular ones, between immigrants and natives,1 have revealed the effects of the environment (e.g., certain diets) and those of the socioeconomic conditions (e.g., income). These studies have contributed to the so-called social epidemiology, and continue today to fuel the scientific debate [4].

When contemplating how to ameliorate the health conditions of migrants, it is possible to adopt a logical framework which considers the various possible stages embedded within a migratory journey [5]. Schematically, the health of a migrant depends on his/her living conditions in the country of origin (pre-departure), on experiences during the travel and the even-

<sup>1</sup> Throughout the chapter, the term 'natives' is used in a general sense: i.e. "people who were already living in that place." Talking about Europe and the European Union, "native Europeans" are referred to; talking about Italy, "native Italians" are referred to.

tual intermediary stages of this travel (interceptions) and, lastly, on the living conditions in the destination country, the primary stage of interest in this analysis [6].

climate, more comfortable and safe environments, an impulse which continues to drive migra-

In the modern era, human migration has been one of the primary forces shaping the nation as we know it today, for example, in the case of the USA or Australia. In other countries and within other times and modalities, human migration was among one of the main social changes of the last century. This is especially relevant to the European continent. Where in some countries (such as England, France, the Netherlands, and Portugal), immigration has essentially represented a "returning" movement induced by colonialism, especially since the end of the nineteenth century. In other countries in the contemporary era, this phenomenon arose mainly in response to the need for foreign labor—initially a semi-skilled and unskilled workforce—and was embedded within older (e.g., in the cases of South Africa, Argentina, Uruguay, Brazil, Belgium, and Germany), or younger (e.g., in the cases of Italy, Spain, Sweden, and Greece) migratory dynamics. Different countries, such as Italy and Spain, passed through distinct historical migratory phases: from being countries of emigration to countries of destination. In this case, these shifts took place after an economic boom and the resulting social

While the migratory phenomenon has been widely examined from historical, social, economic, and cultural perspectives, health and healthcare perspectives are understudied. This is a problematic oversight because health is one of the most important aspects of migration. This correlation between "health" and "migration" is in itself dynamic and complex. It is dynamic because it is extremely heterogeneous (there are many different migrant communities) and it is variable, in both the diachronic and synchronic sense: prospective and evolving immigrant generations will experience different socioeconomic conditions in their country of origin and in the destination countries, and they will ensue different possibilities of integration. It is complex—as discussed by an editorial of the medical journal "the Lancet" in 2006—because its primary dynamics influence different migrant communities in various ways. A possible interpretation of this variety and complexity is that of gender because of a multiplicity of health risks linked, for example, to potentially dangerous and violent conditions in the workplace,

different discrimination and racism in the destination countries, and so on [3].

especially the cardiovascular ones, between immigrants and natives,1

today to fuel the scientific debate [4].

1

are referred to.

Since the 1970s, some epidemiological studies comparing mortality and chronic diseases,

effects of the environment (e.g., certain diets) and those of the socioeconomic conditions (e.g., income). These studies have contributed to the so-called social epidemiology, and continue

When contemplating how to ameliorate the health conditions of migrants, it is possible to adopt a logical framework which considers the various possible stages embedded within a migratory journey [5]. Schematically, the health of a migrant depends on his/her living conditions in the country of origin (pre-departure), on experiences during the travel and the even-

Throughout the chapter, the term 'natives' is used in a general sense: i.e. "people who were already living in that place." Talking about Europe and the European Union, "native Europeans" are referred to; talking about Italy, "native Italians"

have revealed the

tion today [1, 2].

growth after the second half of the twentieth century.

104 People's Movements in the 21st Century - Risks, Challenges and Benefits

In relation to the pre-departure phase, we have to consider the geopolitical and socioeconomic conditions in the country of origin, as well as the personal and familiar position of the migrant (with a specific focus on the level of education and income). This approach allows for an easy localization of the so-called push factors, those factors which trigger the decision to migrate. Talking for instance the tragic state of affairs in Syria at this time, we can say that the situation of the war has produced an exodus of millions of people, many of them having a medium to high level of education and good economic resources. In considering the possibility of existing diseases in the country of origin, although it is possible to find people already affected by diseases in populations forced to migrate due to wars or persecutions (which is generally the case where international protection is concerned), it is usually rare in those populations migrating for economic reasons. Indeed, a good state of health is usually a fundamental prerequisite for a migrant, especially in the case of first-generation economic migrant. This is due to the fact that being physically active and psychologically "strong" (especially when considering the capacity of adaptability to a new context) are the main sources of strength, which will determine the success of the migratory endeavor. This reasoning, which has been verified by epidemiological data (e.g., the minor mortality rate of migrants in relation to the local population [17]), is at the basis of the so-called healthy migrant (or immigrant) effect. This theory posits a kind of self-selection of the healthy individuals prior to the departure from the country of origin. This is of course not a universal and systematic mechanism. However, it is nevertheless evident that youth, a predominant feature of the larger majority of people migrating for economic reasons, provides a protective barrier for one's personal health. Moreover, within the logic of a larger non-nuclear family, it would make sense to allocate communal economic resources to those possessing good health and the capacities to face unexpected situations, generally the younger members of the family. Following this logic, these members would maximize the possibilities of migratory success, and, as a result, are most likely to return the support in the form of remittances from the destination to the origin country.

The phase of the travel can last from a few hours (e.g., a flight, or a ride on the bus or in a car) to many months. This diversity engenders a great variability in terms of health risks. Generally, a migrant who is in the condition to enter regularly and legally another country does not encounter any risks. Conversely, the travel of the so-called forced-migrant (seekers of international protection due to humanitarian and environmental threats) is full of latent dangers, which are usually unpredictable in their times and modalities. These dangers are usually minor if the person is able to pay the so-called human traffickers. In recent years, for example, the Mediterranean Sea has become a graveyard for thousands of people who tried to cross it through various makeshift means, or in overloaded and unsecure boats, leaving them at the mercy of the sea, storms, and ruthless "people smugglers." The blog "Fortress Europe," which compiled the accidents documented by the international press over the last 30 years, calculated that since 1988 to January 2016 27,000 people have died along European borders, with 4273 dying in the year 2015 alone. As news of shipwreck survivors has been extremely rare, it is possible that the real numbers of dead may be higher still [7]. According to the International Organization for Migration, of the total number of 250,000 people who landed on the Mediterranean coasts in 2016 (data updated at the end of July), more than 3000 died (to be exact 3034) [8]. When people do not perish while travelling over land or at sea (e.g., dying of exposure in cold storages, or asphyxiating inside commercial trucks where people place plastic bags over their heads so that the border police would not find any CO<sup>2</sup> emissions), the extreme conditions of travel still place a person's health at high risk. For instance, extreme dehydration (when a migrant does not have sufficient liquid intake), or immersion in gasoline while travelling by boat (liquid usually mixed with urine which becomes a particularly aggressive irritant for the skin) often generates severe burns [9]. Other times, health risks are magnified by the intrinsic vulnerability of the migrant during travel, for example, in cases of pregnant women, infants, and disabled people.

Frequently, some "obligatory" **i**nterceptions occur when migratory routes are not agreed upon between countries of origin and destination, the circumvention of which then depends upon the contractual economic power and organizational skill of the migrant him/herself. These "obligatory" interceptions are generally dangerous for the life and the health of the migrant who risks exposure to various forms of exploitation and extreme violence. For example, a large majority of the migratory routes from Sub-Saharan Africa must pass through Libya, where many people are taken and imprisoned in inhumane conditions, held captive until a ransom is paid by the relatives of the migrant (who are contacted by phone with the desired demands). Many women face individual or collective rape, which may be repeated over time. Beyond the unintended pregnancies, the reason for which many female migrants start taking hormonal contraception before departure, there is also the serious risk of contracting sexually transmitted diseases. A less severe form of suspended migration, which is nevertheless a source of deterioration of the migrant's health, happens when, following the Regulation of Dublin III, the asylum seeker is kept in (or taken back to) the first country of entry in Europe [10]. The inability to arrive at the initially planned destination, a decision usually dictated by the intention to reunite with family members living in European countries, can have negative impacts on the health of a migrant. The same situation of the "undesired stop" can happen to economic migrants who are not allowed to cross a European border, especially when the politics and application of European norms are particularly rigid. Historically, different migratory "waves" organized their intermediary stops depending on various strategic or logistical opportunities. This is, for example, the case with a consistent portion of Polish emigrants in the 1980s and 1990s. Although they wanted to reach North America, they passed through Italy because there was a strong network of religious institutions sympathetic to the Polish people because at that historical moment the Pope was one of their fellow countrymen, Kairol Jozef Wojtyla.

The last migratory phase takes place in the country of destination. There, in most cases, new generations will be born, family reunions will happen, and newly arrived migrants will join preexisting communities. Here, the health of the migrant will be determined largely by the outcome of his/her social integration and by the success (or lack thereof) of his/her migratory project.

The most effective theory to analyze health dynamics of migrant communities in destination countries is using the "social determinants of health." This examines the impact that fundamental socioeconomic and cultural factors have on the health of a person, for example, education, income, type of work, housing conditions, diet, access to water and hygienic services, the possibility to access sanitary services, the presence and strength of a social network (social cohesion) [11]. When the exposure of the migrant to these determinants (in particular the income) is positive, a kind of virtuous circle is activated, supporting and protecting the health of the person. For example, when employment is found quite rapidly, so as to become a stable source of income, the migrant is able to sustain a dignified living. If he migrated by himself, there is the possibility to bring his family to join him, pay for living expenses (e.g., food, children's education, public or private transportations, etc.). *Vice versa*, when the socioeconomic integration is difficult, and it is usually worsened by an inadequate knowledge of the language of the host country, the migrant will be exposed to physical and psychological risks and experience health inequalities [12]. Inadequate nutrition, precarious housing with poor hygienic conditions, and the emerging feelings of failure, solitude and anxiety, concerns about the family living far away, are difficulties that need to be dealt with. In these cases, it is important to remember that many migrants have undertaken significant debts to pay for their travel, debts from which they must extricate themselves precisely when the state of their settling is at its most delicate and precarious. In the end, the accumulation of all these difficulties and obstacles (sometimes exacerbated by exposure to exploitation, discrimination, violence, and racism) produces what is known as the "exhausted migrant effect." Whether the migratory project is successful or not, the objective criteria of sanitary protection are extremely important, in terms of both prevention and assistance in the host country. This usually depends on the concrete juridical recognition of the right to health and of its eventual limitations.

In other words, health and its promotion depend upon the capacity to express inter-sectoral protective and convergent policies. Beyond this, the health sector alone could play an important role in favoring and guaranteeing access to usable services.

As we will attempt to demonstrate in this chapter, the protection of the health of migrants (independently of their juridical status!) is a form of investment typical of a National Public Health System. This investment generally produces positive spillovers on both the direct subjects (migrants) and the local communities (natives).

## **2. Migrants' right to health at the international level**

International Organization for Migration, of the total number of 250,000 people who landed on the Mediterranean coasts in 2016 (data updated at the end of July), more than 3000 died (to be exact 3034) [8]. When people do not perish while travelling over land or at sea (e.g., dying of exposure in cold storages, or asphyxiating inside commercial trucks where people place

extreme conditions of travel still place a person's health at high risk. For instance, extreme dehydration (when a migrant does not have sufficient liquid intake), or immersion in gasoline while travelling by boat (liquid usually mixed with urine which becomes a particularly aggressive irritant for the skin) often generates severe burns [9]. Other times, health risks are magnified by the intrinsic vulnerability of the migrant during travel, for example, in cases of

Frequently, some "obligatory" **i**nterceptions occur when migratory routes are not agreed upon between countries of origin and destination, the circumvention of which then depends upon the contractual economic power and organizational skill of the migrant him/herself. These "obligatory" interceptions are generally dangerous for the life and the health of the migrant who risks exposure to various forms of exploitation and extreme violence. For example, a large majority of the migratory routes from Sub-Saharan Africa must pass through Libya, where many people are taken and imprisoned in inhumane conditions, held captive until a ransom is paid by the relatives of the migrant (who are contacted by phone with the desired demands). Many women face individual or collective rape, which may be repeated over time. Beyond the unintended pregnancies, the reason for which many female migrants start taking hormonal contraception before departure, there is also the serious risk of contracting sexually transmitted diseases. A less severe form of suspended migration, which is nevertheless a source of deterioration of the migrant's health, happens when, following the Regulation of Dublin III, the asylum seeker is kept in (or taken back to) the first country of entry in Europe [10]. The inability to arrive at the initially planned destination, a decision usually dictated by the intention to reunite with family members living in European countries, can have negative impacts on the health of a migrant. The same situation of the "undesired stop" can happen to economic migrants who are not allowed to cross a European border, especially when the politics and application of European norms are particularly rigid. Historically, different migratory "waves" organized their intermediary stops depending on various strategic or logistical opportunities. This is, for example, the case with a consistent portion of Polish emigrants in the 1980s and 1990s. Although they wanted to reach North America, they passed through Italy because there was a strong network of religious institutions sympathetic to the Polish people because at that

historical moment the Pope was one of their fellow countrymen, Kairol Jozef Wojtyla.

The last migratory phase takes place in the country of destination. There, in most cases, new generations will be born, family reunions will happen, and newly arrived migrants will join preexisting communities. Here, the health of the migrant will be determined largely by the outcome of his/her social integration and by the success (or lack thereof) of his/her migratory

The most effective theory to analyze health dynamics of migrant communities in destination countries is using the "social determinants of health." This examines the impact that

emissions), the

plastic bags over their heads so that the border police would not find any CO<sup>2</sup>

pregnant women, infants, and disabled people.

106 People's Movements in the 21st Century - Risks, Challenges and Benefits

project.

The ethical-legal perspective is inevitable when addressing the issue of migrants' health [13]. It is clear that the recognition of the protection of health as a universal right, unconditionally held by every individual without the constraints of meeting specific requirements (such as citizenship or residence permit), is the basis of policies and of any possible forms of protection at both global and local level.

There is an identifiable thread, connecting the different statements from various important institutions regarding the issue of immigrants' health expressed at an international level [14]. Some deal with this issue indirectly, for example, the various conventions, recommendations, declarations, action plans, which, from the 1950s until the present, have included different categories of subjects (e.g., workers) and "vulnerable" populations (e.g., women, children, the disabled, the elderly, refugees, and displaced persons), and stress the need to avoid discrimination of these groups [13, 15]. Other documents deal with this issue, again indirectly, by considering health as one of the various dimensions that characterize international immigration and development.

Others identify this theme as a central and specific issue. Among them, and of particular prominence, is the Resolution of the 61st World Assembly of Health, which invites the Member States to promote and support various lines of intervention. Among these lines is an invitation *"to promote equitable access to health promotion, disease prevention and care for migrants, subject to national laws and practice, without discrimination on the basis of gender, age, religion, nationality or race"* [16].

Focusing solely on the European context, it would be useful to recall, inter alia [17–19], three documents.

In September 2007, the Conference "Health and Migration in the EU: better health for all in an inclusive society" took place in Lisbon (during the period in which Portugal held the Presidency of the European Union (EU)). The Conference produced some very interesting Conclusions and Final Recommendations. It upheld the following assertions:


The final messages of the Conference can be summarized as follows:

global problems require global solutions, and health and migration are two global phenomena which require urgent global responses of which the EU should assume a leading role, and the reduction of poverty and the promotion of the integration of immigrants are key initiatives which must be undertaken.

Given that the lack of access to qualified health care is a central issue for immigrants, the Conference recommended the prioritization of equal and culturally sensitive access for all immigrants. Strengthening cooperation with the aim of fulfilling essential health needs is crucial for preventing disease and ensuring better health everywhere in today's globalized world context, and urgent political decisions should open the way to practical solutions [20].

Less than 2 months later, the Eighth Conference of the Ministers of Health of the 47 countries of the Council of Europe took place in Bratislava in November 2007, with the title "People on the Move: Human Rights and Challenges for Health Care Systems," at which the "Bratislava Declaration on health, human rights and migration" was approved [21]. The Declaration, recalling other statements such as the European Social Charter, and demonstrating a systematic interpretation of the binomial "health and migration," set out 20 areas of duties *"to address the challenges that human mobility generates for human rights within the health field and for health care systems…"*

With reference to the right to health, the Charter stresses that:

*We, the Ministers of Health of the forty seven member states of the Council of Europe* […],

#### *ARE RESOLVED TO*:

categories of subjects (e.g., workers) and "vulnerable" populations (e.g., women, children, the disabled, the elderly, refugees, and displaced persons), and stress the need to avoid discrimination of these groups [13, 15]. Other documents deal with this issue, again indirectly, by considering health as one of the various dimensions that characterize international immigra-

Others identify this theme as a central and specific issue. Among them, and of particular prominence, is the Resolution of the 61st World Assembly of Health, which invites the Member States to promote and support various lines of intervention. Among these lines is an invitation *"to promote equitable access to health promotion, disease prevention and care for migrants, subject to national laws and practice, without discrimination on the basis of gender, age, religion,* 

Focusing solely on the European context, it would be useful to recall, inter alia [17–19], three

In September 2007, the Conference "Health and Migration in the EU: better health for all in an inclusive society" took place in Lisbon (during the period in which Portugal held the Presidency of the European Union (EU)). The Conference produced some very interesting

• immigrants represent a resource for the European Union; European migration policies

• universal access to healthcare assistance has to be seen as a prerequisite for European public health and is an essential element for its social, economic, and political development

• immigrants' health protection must not be seen solely as a humanitarian cause, but principally in terms of the need to reach the highest level of health and well-being for all in

global problems require global solutions, and health and migration are two global phenomena which require urgent global responses of which the EU should assume a leading role, and the reduction of poverty and the promotion of the integration of immigrants are key initia-

Given that the lack of access to qualified health care is a central issue for immigrants, the Conference recommended the prioritization of equal and culturally sensitive access for all immigrants. Strengthening cooperation with the aim of fulfilling essential health needs is crucial for preventing disease and ensuring better health everywhere in today's globalized world context, and urgent political decisions should open the way to practical solutions [20]. Less than 2 months later, the Eighth Conference of the Ministers of Health of the 47 countries of the Council of Europe took place in Bratislava in November 2007, with the title "People on the Move: Human Rights and Challenges for Health Care Systems," at which the "Bratislava Declaration on health, human rights and migration" was approved [21]. The Declaration, recalling other statements such as the European Social Charter, and demonstrating a systematic

Conclusions and Final Recommendations. It upheld the following assertions:

The final messages of the Conference can be summarized as follows:

tion and development.

108 People's Movements in the 21st Century - Risks, Challenges and Benefits

*nationality or race"* [16].

have to be re-defined;

tives which must be undertaken.

and for the promotion of human rights;

documents.

Europe.


Finally, in March 2011—due in part to the support of various NGOs [22–24]—the European Parliament approved a "Report on reducing health inequalities in the European Union," exhorting the Member States to confront the inequalities in access to health care, including those faced by illegal/irregular/undocumented immigrants, especially pregnant women and children [25]. It emphasized that

*"… health inequalities are not only the result of a host of economic, environmental and lifestyle-related factors, but also of problems relating to access to healthcare"* (point P)

#### and that

*"… in many EU countries equitable access to healthcare is not guaranteed, either in practice or in law, for illegal / irregular / undocumented migrants"* (point AD). Among other recommendations, the European Parliament called upon the Member States

*"…to ensure that the most vulnerable groups, including undocumented migrants, are entitled to and are provided with equitable access to healthcare*;

*…to assess the feasibility of supporting healthcare for illegal / irregular / undocumented migrants by providing a definition based on common principles for basic elements of healthcare as defined in their national legislation"* (point 5);

*"…to promote access to high-quality legal advice and information in coordination with civil society organizations to help ordinary members of the public, including undocumented migrants, to learn more about their individual rights"* (point 8);

and

*"…to ensure that all pregnant women and children, irrespective of their status, are entitled to and actually receive social protection as defined in their national legislation"* (point 22).

In summary, it would appear that, in light of the events of the last decade, a common understanding has developed at an international, and, more specifically, the European level, regarding the complex background and consequences of human mobility and health. This vision may be interpreted as being based upon the principle of the right to health, conscious of the significance of incorporating within government policies not only an ethical but also a social dimension, and paying special attention to the most vulnerable groups of immigrants. The perspective has to be culturally sensitive and inter-sectoral [14].

In spite of the clarity and completeness of this vision of the migratory phenomenon, when it comes to its implications it is necessary to emphasize the precariousness and the uncertainty of the processes of implementation at the local level, taking into account the non-binding nature of these pronouncements. More specifically, the European Union does not have any coercive influence upon the individual Member States in regard to the health protection of immigrants, due to the "principle of subsidiarity," which implies that intervention by the European Community is only mandated when the goals of the planned action cannot be sufficiently achieved by the single Member States acting alone [26].

Moreover, it has been noted that the current economic and financial crisis regrettably poses a significant risk to the application of these statements regarding the right to health. An example of this problem is the restriction of health care for immigrants and, even more notably, the stigmatizing approach of labeling immigrants as a source of infectious risk for the native population, including health as a pretext for deportation to the countries of origin, as occurred around 2012 in Greece, a country that is the "symbol" of the current European crisis [27]. More generally, it must be recognized that the right to health and to health protection of migrants are adversely affected by demagogic and populist, if not openly racist, ideological orientations [4].

In several countries, the purported non-sustainability of healthcare costs for migrants is used to justify closure policies, which are more concerned with electoral response than actual policy reform. In reality, it is more often the case that immigrants, through the payment of taxes, contribute more to the socioeconomic well-being of their host countries than what they receive in terms of services, including publically provided health care [28]. In other countries, racist announcements are circulated to attract large groups of people who are drawn in by sensational and dramatic media coverage, and consequently frightened in adopting an "us versus them" mentality.

In modern and contemporary history, the phenomenon of human mobility has met, and continues to meet, obstacles and resistance that have obvious repercussions on the health promotion and healthcare provision. These complications are particularly related to defining and protecting boundaries, which consequentially draws on the idea of the Nation-State, to the perception of a threat to cultural, ethical, and religious values of the host society and to its socioeconomic stability, to fear, or to open hostility toward those who are different. This, paradoxically, is often done without distinguishing the different types of migrants, even involving asylum seekers and refugees, which should be better protected by international conventions and laws.

### **2.1. General considerations regarding the approach to the health needs of migrant communities**

*"…to ensure that all pregnant women and children, irrespective of their status, are entitled to and actu-*

In summary, it would appear that, in light of the events of the last decade, a common understanding has developed at an international, and, more specifically, the European level, regarding the complex background and consequences of human mobility and health. This vision may be interpreted as being based upon the principle of the right to health, conscious of the significance of incorporating within government policies not only an ethical but also a social dimension, and paying special attention to the most vulnerable groups of immigrants. The

In spite of the clarity and completeness of this vision of the migratory phenomenon, when it comes to its implications it is necessary to emphasize the precariousness and the uncertainty of the processes of implementation at the local level, taking into account the non-binding nature of these pronouncements. More specifically, the European Union does not have any coercive influence upon the individual Member States in regard to the health protection of immigrants, due to the "principle of subsidiarity," which implies that intervention by the European Community is only mandated when the goals of the planned action cannot be suf-

Moreover, it has been noted that the current economic and financial crisis regrettably poses a significant risk to the application of these statements regarding the right to health. An example of this problem is the restriction of health care for immigrants and, even more notably, the stigmatizing approach of labeling immigrants as a source of infectious risk for the native population, including health as a pretext for deportation to the countries of origin, as occurred around 2012 in Greece, a country that is the "symbol" of the current European crisis [27]. More generally, it must be recognized that the right to health and to health protection of migrants are adversely affected by demagogic and populist, if not openly racist, ideological

In several countries, the purported non-sustainability of healthcare costs for migrants is used to justify closure policies, which are more concerned with electoral response than actual policy reform. In reality, it is more often the case that immigrants, through the payment of taxes, contribute more to the socioeconomic well-being of their host countries than what they receive in terms of services, including publically provided health care [28]. In other countries, racist announcements are circulated to attract large groups of people who are drawn in by sensational and dramatic media coverage, and consequently frightened in adopting an "us

In modern and contemporary history, the phenomenon of human mobility has met, and continues to meet, obstacles and resistance that have obvious repercussions on the health promotion and healthcare provision. These complications are particularly related to defining and protecting boundaries, which consequentially draws on the idea of the Nation-State, to the perception of a threat to cultural, ethical, and religious values of the host society and to its socioeconomic stability, to fear, or to open hostility toward those who are different. This, paradoxically, is often done without distinguishing the different types of migrants, even

*ally receive social protection as defined in their national legislation"* (point 22).

110 People's Movements in the 21st Century - Risks, Challenges and Benefits

perspective has to be culturally sensitive and inter-sectoral [14].

ficiently achieved by the single Member States acting alone [26].

orientations [4].

versus them" mentality.

Together with the importance to recognize the right of migrants to the protection of their health (the ethical-legal dimension) by various countries, the health of migrants' communities is linked to the level of efficiency regarding the interventions targeting them, the socalled techno-operational dimension. These interventions (which make up the "health service offer") should be consistent with the "health needs" and healthcare needs of the immigrants and with a verified clinical efficiency, which is valid from an appropriate scientific point of view.

The possibility of obtaining reliable data on migrants' health, based on health determinants and on the usage of sanitary services, and being able to correctly interpret these data, is an essential pre-condition to identify their health needs in order to offer appropriate and accessible sanitary services [19, 29].

Collecting the different levels of "demand for assistance" is not sufficient by itself, nor does it generally reflect the true health needs of foreigners. Aside from the fact that the demand for sanitary assistance can stem from people who usually have no medical or scientific knowledge, this demand can also be influenced by sociocultural and psychological variables. This implies that the demand itself is affected by the level of language competency, "health literacy," and the diversified knowledge of the sanitary system's organization (which determines the configuration of the "offer"). This is also evident for native groups, but in the case of immigrants, the influence can be even greater. For example, within immigrant populations, a higher level of inadequate usage of sanitary services has been recorded (both in the cases of over- or under-usage) [30]. When considering primary and secondary preventive care, the offer of sanitary services cannot be contingent upon the demand. In other words, when people are healthy (whether in appearance or in fact) they do not perceive any health needs, particularly if they lack available information and knowledge. But the preventive care culture varies from country to country, and normally it is weak or even absent in the countries of origin of most migrants. For example, it has been demonstrated that some groups of migrant women have minimal familiarity with oncological prevention, which is widely practiced in the receiving countries, such as screening for the presence of a carcinoma of the uterine cervix by performing the Pap test. It has been observed that, in the case of a positive test result, the carcinoma of a migrant woman is at a more advanced stage than that in a native woman, due to the delay of screening [31]. Therefore, it is important that sanitary systems implement "active offer" interventions, which is provided by the sanitary system and is free of charge for these so-called hard to reach groups in order to reduce or eliminate the greater risks they usually face. Another example, where better information and prevention would improve health outcome, relates to occupational health risks (especially occupational health hazards in the construction sector in the timber or leather industries). In this case as well, it has been demonstrated by studies enquiries that migrant workers are more vulnerable than the local populations [19, 30].

In both examples and in the international context, the availability of data of a current health information system has made it possible to gather evidence that migrants encounter greater health risks than natives. In fact, using this system, it was possible to disaggregate reliable data relating to immigrants and compare them with the group of natives or with specific subgroups of immigrants. The publication of these data is the fundamental basis for expressing scientific evidence-based guidelines, diversifying them for different immigrant groups [32–34].

It is no coincidence that the Resolution of the 61st World Health Assembly cited above mentions in its invitations to the Member Countries the following aims: *"to establish health information systems in order to assess and analyse trends in migrants' health, disaggregating health information by relevant categories"* […] and *"to gather, document and share information and best practices for meeting migrants' health needs in countries of origin or return, transit and destination"* [16].

The possibility of conducting quantitative research, which could allow for an evaluation of the health needs of migrants, depends on the following:


This need can clash with a scarce epidemiological culture or with techno-managerial difficulties (e.g., the unavailability of adequate computer systems), with institutional public concerns related to the right to privacy and the correct usage of sensitive data, or with resistance by health personnel to correctly and systematically register information. Although extreme caution on the part of competent authorities is understandable, it is necessary to convince the authorities that, in relation to the right to privacy and to the legal usage of sensible data, this information can allow for preventive care intervention, and thus protects the migrant communities. For example, the registration of a familial migratory history of third-generation subjects could pinpoint to psychological risk factors. Without collecting these data, these factors would not be highlighted. This transparency of data would permit certain targeted sociosanitary interventions to be realized.

Another aspect of interest is the homogeneity of information registration to allow for a comparison of the data at the international level. Regarding this issue, there are some generally well-consolidated data gathering practices concerning certain health variables and areas, for example, general or case-specific mortality rates, data on the frequency of transmissible or non-transmissible diseases, data related to hospital admissions or vaccination practices, and so on. There are other areas that are less "explored" due to lack or limits of specific information sources, for example, that of primary care or rehabilitation.

has been demonstrated by studies enquiries that migrant workers are more vulnerable than

In both examples and in the international context, the availability of data of a current health information system has made it possible to gather evidence that migrants encounter greater health risks than natives. In fact, using this system, it was possible to disaggregate reliable data relating to immigrants and compare them with the group of natives or with specific subgroups of immigrants. The publication of these data is the fundamental basis for expressing scientific evidence-based guidelines, diversifying them for different immigrant groups

It is no coincidence that the Resolution of the 61st World Health Assembly cited above mentions in its invitations to the Member Countries the following aims: *"to establish health information systems in order to assess and analyse trends in migrants' health, disaggregating health information by relevant categories"* […] and *"to gather, document and share information and best practices for meeting migrants' health needs in countries of origin or return, transit and* 

The possibility of conducting quantitative research, which could allow for an evaluation of

• the local cultural sensitivity in relation to the importance of data/information; the avail-

• the activation and the maintenance of qualitatively good and reliable sources of sanitary

• the presence—in the abovementioned informative systems or in other "record-linkage" systems—of useful information to more appropriately interpret existing sanitary data (e.g., aside from the country of origin, citizenship, and nationality/ethnicity, also religion and

• the identification and construction of valid and powerful indicators to be used internation-

This need can clash with a scarce epidemiological culture or with techno-managerial difficulties (e.g., the unavailability of adequate computer systems), with institutional public concerns related to the right to privacy and the correct usage of sensitive data, or with resistance by health personnel to correctly and systematically register information. Although extreme caution on the part of competent authorities is understandable, it is necessary to convince the authorities that, in relation to the right to privacy and to the legal usage of sensible data, this information can allow for preventive care intervention, and thus protects the migrant communities. For example, the registration of a familial migratory history of third-generation subjects could pinpoint to psychological risk factors. Without collecting these data, these factors would not be highlighted. This transparency of data would permit certain targeted socio-

Another aspect of interest is the homogeneity of information registration to allow for a comparison of the data at the international level. Regarding this issue, there are some generally

the health needs of migrants, depends on the following:

ability of reliable databases (e.g., a national statistics institution);

the local populations [19, 30].

112 People's Movements in the 21st Century - Risks, Challenges and Benefits

[32–34].

*destination"* [16].

information;

language); and

sanitary interventions to be realized.

ally [35].

Importantly, the possibility of connecting certain health variables, such as suicide or psychological problems with socioeconomic variables, for instance education, income, residence, length of permanence, level of language, social networks and degree of social connection would be extremely useful. Unfortunately, this is often impossible to implement because of a lack of attention to the importance of social determinants of health. It would have great potential allowing research in the field of so-called social epidemiology to be conducted. It would reveal the existence of inequalities in relation to health and sanitary assistance and interpret their dynamics when considering migrant communities.

Aside from the continuous availability of databases and related health information systems, it can be useful to conduct occasionally "ad hoc" enquiries in order to evaluate health needs. For example, some enquires can help to evaluate self-perceptions of health within some groups of migrants, identified by nationalities or variables such as employment categories (e.g., caregivers for the elderly), initiate epidemiological enquiries in order to identify the health status in a certain context (e.g., jail), conduct research in relation to specific lifestyles (e.g., eating habits of teenagers belonging to certain migrant communities), or examine some characteristics of the usage of certain sanitary services (e.g., maternal and child health care).

Acknowledgment of the effectiveness of using a mixed methods approach (quantitative and qualitative) is also growing. Qualitative methodology often offers valuable insight into how to interpret the results of the quantitative data and vice versa. In the case of abortion, Italian standardized data established that the rates were three times higher in migrant women than in Italian women [36]. Conducting interviews with women belonging to prevalent foreign communities has established certain variables and sociocultural conditions, which were identified as motivating factors for abortion services [36].

An intrinsic strategic value of qualitative research is to strongly favor the involvement of migrant communities within the research, for example, through focus groups, structured interviews, or questionnaires. Indeed, despite the impossibility to generalize from single experiences, the direct expression of the health needs of the immigrants themselves offers helpful suggestions for decision makers. This information does not necessarily translate directly into specific interventions, but rather suggest more appropriate modalities in which to implement them.

#### **2.2. General considerations regarding the definition of health policies and the organization of health services**

According to the aforementioned 2008 World Health Assembly Resolution on the Health of Migrants, Member States have an obligation to implement on migrant-sensitive health policies and practices (see Box 1) [16]. One of the most significant lines which calls for action claims that members should: *"devise mechanisms for improving the health of all populations, including migrants, in particular through identifying and filling gaps in health service delivery."*

The 61st WHA Assembly calls upon Member States:


**Box 1.** Recommendations of the resolution of the 61st World Health Assembly (2008).

The value of this call for action is not only to identify existing discrepancies in delivering welfare health services and making these known to decision makers, managers, and professionals, but also to remind them that migrants may be one of the various population groups left vulnerable by those inequities. It is implied that interventions on behalf of the immigrant population should not exclude other groups of the population that can be similarly disadvantaged.

Together with this directive line of action, there is another one outlined in the Bratislava Declaration of 2007. This latter invites members to: *"Work toward overcoming the barriers to the enjoyment of the access to protection of health for people on the move through capacity building and awareness raising for health providers, policy makers, health management planners and health educators as well as other professions allied to health services delivery"* (see Box 2) [21].

Work toward overcoming the barriers to the enjoyment of the access to protection of health for people on the move through capacity building and awareness raising for health providers, policy makers, health management planners, and health educators as well as other professions allied to health services delivery

that members should: *"devise mechanisms for improving the health of all populations, including* 

**2.** To promote equitable access to health promotion, disease prevention and care for migrants, subject to national laws and practice, without discrimination on the basis of gender, age,

**3.** To establish health information systems in order to assess and analyze trends in migrants'

**4.** To devise mechanisms for improving the health of all populations, including migrants, in

**5.** To gather, document, and share information and best practices for meeting migrants'

**6.** To raise health service providers' and professionals' cultural and gender sensitivity to

**7.** To train health professionals to deal with the health issues associated with population

**8.** To promote bilateral and multilateral cooperation on migrants' health among countries

**9.** To contribute to the reduction of the global deficit of health professionals and its consequences on the sustainability of health systems and the attainment of the Millennium

The value of this call for action is not only to identify existing discrepancies in delivering welfare health services and making these known to decision makers, managers, and professionals, but also to remind them that migrants may be one of the various population groups left vulnerable by those inequities. It is implied that interventions on behalf of the immigrant population should not exclude other groups of the population that can be similarly

Together with this directive line of action, there is another one outlined in the Bratislava Declaration of 2007. This latter invites members to: *"Work toward overcoming the barriers to the enjoyment of the access to protection of health for people on the move through capacity building and awareness raising for health providers, policy makers, health management planners and health educa-*

*tors as well as other professions allied to health services delivery"* (see Box 2) [21].

disadvantaged.

*migrants, in particular through identifying and filling gaps in health service delivery."*

health, disaggregating health information by relevant categories

particular through identifying and filling gaps in health service delivery

health needs in countries of origin or return, transit, and destination

**Box 1.** Recommendations of the resolution of the 61st World Health Assembly (2008).

The 61st WHA Assembly calls upon Member States:

114 People's Movements in the 21st Century - Risks, Challenges and Benefits

**1.** To promote migrant-sensitive health policies

religion, nationality, or race

migrants' health issues

Development Goals

involved in the whole migratory process

movements

Support public health research to enhance and strengthen national and international surveillance and information systems and to strengthen and support evidence-based programs for the health of people on the move

Take steps to reinforce and incorporate the health dimension into development and cooperation policy following the principle of "health in all policies"

Promote migrants' participation in program planning, health services delivery, and evaluation

Take steps to train and educate healthcare providers, policy makers, health management planners, and health educators, as appropriate, on addressing healthcare issues associated with population mobility and disparities in health services between geographical locations

Encourage host countries to consider the invitation of the Parliamentary Assembly in the Resolution 1509 (2006) to eliminate any requirement on health service providers and school authorities to report the presence of irregular migrants to the authorities

**Box 2.** The "Bratislava Declaration on health, human rights and migration" (2007) Extracted from the duties.

This reference to potential barriers is particularly important: aside from those regulations (as linked above to the right to health protection), immigrants can encounter bureaucratic, economic, organizational, lingual, psychological, and cultural barriers. Confronting these barriers can become a turning point in achieving full health protection for migrants and the promotion of equity in relation to their health [6, 14].

This change would involve promoting the so-called availability (functioning public health and health facilities, goods, services, and programs in sufficient quantity), "accessibility" (non-discrimination, physical accessibility, economic accessibility or affordability, information accessibility), "acceptability" (respect for medical ethics and culturally appropriateness, sensitivity to age, and gender), and "quality" (scientific and medical suitability) of health services [6]. Of course, ensuring that migrants are aware of their rights and of the nature and operation of the health system of the host country is fundamental, although not always sufficient. Proper information of all public health services should go hand in hand with continuous care for all the processes of integration and make the most of all meetings during which contact is being made with migrants. Aside from the formal channels (TV, radio, newspapers, institutional websites, and advertisements on public transport), information regarding health services should be spread by key figures of these communities (leaders, speakers, religious representatives, teachers in the community), and by schools. Important figures in healthcare systems are general practitioners, community nurses, obstetricians, pediatricians, and cultural-linguistic mediators.

Another strategic element is the adequate training and regular updating of the health, social, and administrative personnel of the health system, which is (or can become) a point of access to the migrants' community, in order to promote the so-called cultural competency and challenge discriminatory behaviors and attitudes [16, 20]. This training should take place in groups of small numbers (30–40 people) with various professional figures present at the same time (interprofessional education). There needs to be a systemic, complex, and multidisciplinary approach "built" on the educational needs outlined ahead of time with the collaboration of those operators toward whom the services are also addressed. If possible, it is useful to adopt types of education and training more engaging, such as training on the work site, education based on experience, working groups, or "role playing." Having acknowledged the peculiarity of the theme and its important communicative and relational implications, it is advisable to limit distance training. Where distance training is necessary, it needs to be supported by meetings and discussions.

Cultural-linguistic mediation in health is also relevant. First of all, it must be said that, from the linguistic perspective and, following the empowerment of the migrant and his/her community, the principal instrument of autonomy possesses a sufficient knowledge and capacity to speak the language of the host country. In this sense, a special effort should be made to encourage learning of the language. We consider basic language examinations necessary to receive some rights, in particular that of citizenship. However, there remains the fact that especially in the first phase of immigration, many migrants would still need people to mediate between themselves and the health system, whether this is in an administrative-bureaucratic organization, a clinical service, or consulting a healthcare professional.

Aside from the possibility of finding individuals to fill the specific role of cultural-linguistic mediator, we think they should not necessarily belong to the specific community of the patient, a viable option would be to draw upon professional figures who already work within the health services and are of foreign origin and create a connection between the patient and his/her required services. The utility of the linguistic-cultural mediator is beyond question. However, this person should not be identified as a "*deus ex machina*." It would be wrong (and even dangerous) to assign all the functions of welcoming, listening, interpreting, informing/ explaining, and supporting to the sole figure of the cultural-linguistic mediator. From the perspective of inclusivity, it is essential to create the mediating function of the system so that it encompasses all services' operators, from the administrative desk to surgery. In other words, the cultural competence should be stimulated in all operators.

The development of policies and resulting actions (and even earlier, the analysis of health needs) cannot leave aside the necessary involvement of the migrants' communities and of the civil society organizations working with these communities (NGOs included), and at the technical-scientific level, the scientific societies, all of whom are involved in different ways. Such involvement should be ongoing, not occasional; requested and supported from within the organizations and their teams, for example, inside the "local observatories" or within "working groups" on migrants' health; and for allowing discussions between the different actors on equal footing. This "bottom-up" approach and network logic have been proven to increase efficiency in practice. This is so because the interventions necessitate active collaboration between the recipients and the other stakeholders, making it more functional and consistent in terms of "accountability," as well as answering a call for democratically managing of public resources.

In order to promote migrants' health as part of the international agenda, the World Health Organization (WHO), in collaboration with the International Organization for Migration (IOM) and the Spanish Ministry of the Social and Health Policies, organized a global meeting on migrants' health in Madrid during March 2010. From this meeting, the report "WHO-IOM. The way forward" [35] was produced.

In particular, this report presents an outline for an operational framework to guide action by key stakeholders, which suggests key priorities and corresponding actions in each of the following thematic areas:

• Monitoring migrant health

Another strategic element is the adequate training and regular updating of the health, social, and administrative personnel of the health system, which is (or can become) a point of access to the migrants' community, in order to promote the so-called cultural competency and challenge discriminatory behaviors and attitudes [16, 20]. This training should take place in groups of small numbers (30–40 people) with various professional figures present at the same time (interprofessional education). There needs to be a systemic, complex, and multidisciplinary approach "built" on the educational needs outlined ahead of time with the collaboration of those operators toward whom the services are also addressed. If possible, it is useful to adopt types of education and training more engaging, such as training on the work site, education based on experience, working groups, or "role playing." Having acknowledged the peculiarity of the theme and its important communicative and relational implications, it is advisable to limit distance training. Where distance training is necessary, it needs to be supported by

Cultural-linguistic mediation in health is also relevant. First of all, it must be said that, from the linguistic perspective and, following the empowerment of the migrant and his/her community, the principal instrument of autonomy possesses a sufficient knowledge and capacity to speak the language of the host country. In this sense, a special effort should be made to encourage learning of the language. We consider basic language examinations necessary to receive some rights, in particular that of citizenship. However, there remains the fact that especially in the first phase of immigration, many migrants would still need people to mediate between themselves and the health system, whether this is in an administrative-bureau-

Aside from the possibility of finding individuals to fill the specific role of cultural-linguistic mediator, we think they should not necessarily belong to the specific community of the patient, a viable option would be to draw upon professional figures who already work within the health services and are of foreign origin and create a connection between the patient and his/her required services. The utility of the linguistic-cultural mediator is beyond question. However, this person should not be identified as a "*deus ex machina*." It would be wrong (and even dangerous) to assign all the functions of welcoming, listening, interpreting, informing/ explaining, and supporting to the sole figure of the cultural-linguistic mediator. From the perspective of inclusivity, it is essential to create the mediating function of the system so that it encompasses all services' operators, from the administrative desk to surgery. In other words,

The development of policies and resulting actions (and even earlier, the analysis of health needs) cannot leave aside the necessary involvement of the migrants' communities and of the civil society organizations working with these communities (NGOs included), and at the technical-scientific level, the scientific societies, all of whom are involved in different ways. Such involvement should be ongoing, not occasional; requested and supported from within the organizations and their teams, for example, inside the "local observatories" or within "working groups" on migrants' health; and for allowing discussions between the different actors on equal footing. This "bottom-up" approach and network logic have been proven to increase efficiency in practice. This is so because the interventions necessitate

cratic organization, a clinical service, or consulting a healthcare professional.

the cultural competence should be stimulated in all operators.

meetings and discussions.

116 People's Movements in the 21st Century - Risks, Challenges and Benefits


We are convinced that the recommendations provided in this report present the right direction in which to move forward. The central point is the cultural dimension.

#### **2.3. A case study: health protection's policies for immigrants in Italy**

#### *"The Republic safeguards health as a fundamental right of the individual and as a collective interest, and guarantees free medical care to the indigent…" . (The Italian Constitution, 1948 - 32nd Article).*

Situated in the South of Europe in the center of the Mediterranean Sea, Italy is a country of more than 60 million inhabitants. It is one of the founding and current members of the European Union. For more than 100 years, starting from the second half of the nineteenth century, Italians have settled around the world, particularly in North and South America and Central Northern Europe. Since 1861, when the Kingdom of Italy was proclaimed, more than 24 million Italians have emigrated, a population size almost equivalent to that of the nation itself following unification. From no other European country, and for over such a period of time, has a constant stream of emigration occurred. According to estimates by the Italian Minister of Foreign Affairs, there are currently between 60 and 70 million people of Italian descent living outside of Italy (the so-called oriundi). The countries where they are most dominant are Brazil (with more than 27 million), Argentina (with almost 20 million), the United States (with more than 17 million), France (with four million), Colombia (with two million), Canada (with nearly 1.5 million), Peru (with 1.4 million), Uruguay (with 1.2 million), Venezuela (with one million), and Australia (with more than 900,000). While in the United States and in France Italian descendants make up around 6% of the total population, in Colombia, Canada, and Australia they are almost 4%, in Argentina and Brazil the "Italians oriundi" are estimated to represent around 47% and 13% of the total population, respectively. Furthermore, the number who reside abroad, but still hold Italian citizenship (and have the right to vote in Italy), are estimated to be five million, of whom almost 85% are equally distributed between North and South America and Europe [37].

For the first time in 1973, a "positive net migration" was registered, and the number of immigrants in Italy was found to be higher, by a small percentage, than the number of emigrants. Since then, immigration in Italy has grown constantly, and sometimes exponentially, going from hundreds of thousands of people in the 1980s to the current presence of five million foreigners, equaling 8.3% of the total resident population [38]. Their distribution across the nation is uneven and largely determined by opportunities for work: almost 60% of the immigrants live in the north, 25% in the center, and 15% in the south. Because of the recent global economic crisis there was a decline of immigrants to Italy and an increase of people leaving Italy, this added to the growing number of Italians who migrated mainly to other European countries. Although the social perception of immigration, as broadcasted by the media, is one of "invasion," according to accurate statistical predictions, new entries of foreigners into Italy (only a relatively small part remains permanently) cannot guarantee any demographic equilibrium of the Italian population (which decreased by 150,000 people in 2015) [39].

The geography of Italy (a peninsula with almost 7500 km of coasts, but less than 2000 km of inland borders, all in the North) has made it, together with Greece, a central position of the migratory fluxes passing across the Mediterranean Sea. The principal routes originates from Africa (Horn of Africa, North Africa, and a part of Sub-Saharan Africa) and from the Middle East and Asia (Afghanistan, Syria, Pakistan, and Bangladesh). In 2015, almost 154,000 people, a combination of asylum seekers and economic migrants landed in Italy [39]. As in 2014, the large majority of these migrants did not see Italy as their final destination, but countries in Central-Northern Europe such as Germany, France, the United Kingdom, and Sweden were their destinations. Due to the current European regulations, which draws upon the Schengen treaty (specifically with "Dublin III"), these people have the right to apply for asylum only within the country of entrance in Europe [10]. In the case that they reach a second country of the European Union and apply for asylum there, they are sent back to the first country were they arrived. The current situation is an acute crisis, mainly linked to the conflict in Syria. Italy's request to redistribute migrants across the different European countries has created strong tension within the EU. In fact, a bloc of countries from Central-Eastern Europe, where nationalist parties, sometimes of a xenophobic nature, have a stronghold, have refused to accept their share of the relocations as decided by the EU, and have physical barriers, such as barbed-wire fences and walls, as well as turning a blind eye to the high degree of violence by their armed forces, in order to reinforce their resistance [39].

A peculiar characteristic of the Italian situation is the diversity of the foreign communities; there are almost 200 of them, and the resulting variety of languages and sociocultural backgrounds. This distinctive feature has different spillover effects, for example, in creating the concrete possibility of using a cultural-linguistic mediator in providing public services.

The first systematic national law on immigration in Italy dates back to the early 1990s; previous laws only partially regulated immigration in some aspects, for example, in the work sector. This set of regulations was revised in 1998, and again in 2002. Without looking at any of the complex technical-juridical aspects, it is evident that the core of these regulations has been conditioned by both the prevailing social feeling of the population during those years and the government's position at the time of the juridical revision. In analyzing the various laws and regulations, it is possible to discern that the image of the typical immigrant in Italy varies greatly. The images include that of the worker (being useful in the production sector), to that of a person who, apart from participating in the socioeconomic growth of the country, also has the right to have a family (or start family reunions' practices), participate in public life, and integrate into society.

Furthermore, the number who reside abroad, but still hold Italian citizenship (and have the right to vote in Italy), are estimated to be five million, of whom almost 85% are equally dis-

For the first time in 1973, a "positive net migration" was registered, and the number of immigrants in Italy was found to be higher, by a small percentage, than the number of emigrants. Since then, immigration in Italy has grown constantly, and sometimes exponentially, going from hundreds of thousands of people in the 1980s to the current presence of five million foreigners, equaling 8.3% of the total resident population [38]. Their distribution across the nation is uneven and largely determined by opportunities for work: almost 60% of the immigrants live in the north, 25% in the center, and 15% in the south. Because of the recent global economic crisis there was a decline of immigrants to Italy and an increase of people leaving Italy, this added to the growing number of Italians who migrated mainly to other European countries. Although the social perception of immigration, as broadcasted by the media, is one of "invasion," according to accurate statistical predictions, new entries of foreigners into Italy (only a relatively small part remains permanently) cannot guarantee any demographic equi-

librium of the Italian population (which decreased by 150,000 people in 2015) [39].

The geography of Italy (a peninsula with almost 7500 km of coasts, but less than 2000 km of inland borders, all in the North) has made it, together with Greece, a central position of the migratory fluxes passing across the Mediterranean Sea. The principal routes originates from Africa (Horn of Africa, North Africa, and a part of Sub-Saharan Africa) and from the Middle East and Asia (Afghanistan, Syria, Pakistan, and Bangladesh). In 2015, almost 154,000 people, a combination of asylum seekers and economic migrants landed in Italy [39]. As in 2014, the large majority of these migrants did not see Italy as their final destination, but countries in Central-Northern Europe such as Germany, France, the United Kingdom, and Sweden were their destinations. Due to the current European regulations, which draws upon the Schengen treaty (specifically with "Dublin III"), these people have the right to apply for asylum only within the country of entrance in Europe [10]. In the case that they reach a second country of the European Union and apply for asylum there, they are sent back to the first country were they arrived. The current situation is an acute crisis, mainly linked to the conflict in Syria. Italy's request to redistribute migrants across the different European countries has created strong tension within the EU. In fact, a bloc of countries from Central-Eastern Europe, where nationalist parties, sometimes of a xenophobic nature, have a stronghold, have refused to accept their share of the relocations as decided by the EU, and have physical barriers, such as barbed-wire fences and walls, as well as turning a blind eye to the high degree of violence by

A peculiar characteristic of the Italian situation is the diversity of the foreign communities; there are almost 200 of them, and the resulting variety of languages and sociocultural backgrounds. This distinctive feature has different spillover effects, for example, in creating the concrete possibility of using a cultural-linguistic mediator in providing public services.

The first systematic national law on immigration in Italy dates back to the early 1990s; previous laws only partially regulated immigration in some aspects, for example, in the work sector. This set of regulations was revised in 1998, and again in 2002. Without looking at any

tributed between North and South America and Europe [37].

118 People's Movements in the 21st Century - Risks, Challenges and Benefits

their armed forces, in order to reinforce their resistance [39].

As in the rest of the world, the possibility of entrance and integration into the new society in Italy for a migrant is strongly linked to the juridical environment, and to aspects such as the educational level, income, knowledge of the language of the host country, and the presence of his/her community. However, it must be noted that, unlike other countries, the set of regulations adopted in Italy made many immigrants vulnerable to instability regarding their status as legal immigrants. This is due to the fact that there were, and still are at present, certain difficulties in both getting a regularized permit to remain in the country and renewing it periodically. Reasons are that it is often impossible to provide proof of income, or are cases where a family member needs to be taken care of. Overall immigrants are more likely forced to turn to the "black" market, the informal labor sector, than native Italians. Sometimes, because of language difficulty immigrants find it hard to compete in the open market.

The principal distinction used, aside from the general one of "asylum seeker" and "economic migrant," is that of the "legal," "regular," "documented" and "illegal," "irregular," "undocumented," or even "clandestine" immigrant. The latter, including the "clandestine" immigrant, never received a residence permit to stay. On the semantic level, it must also be noted that the usage of the term "clandestine" is heavily charged with moral judgment. This is unlike other countries, such as France or the United Kingdom, where the lack of permit is the only characteristic highlighted without distinguishing within that category: "Sans papier" or "undocumented," which does not carry the negative connotation.

The ordinary person, with limited information, has great difficulty recognizing the variety of types or descriptions of migrants. Recent explanations have cleared up the difference between "asylum seekers" and the "economic migrant." However, paradoxically, the result was the legitimation of the former and the delegitimization of the latter, strengthening an incomprehensible stigma where emigrating to escape economic misery is not a justified (and thus legitimized) reason in comparison with escaping violence and persecution.

In the past 30–40 years, the social dynamics of integration have developed in nonlinear ways and today we have large numbers of second-generation immigrants (third generation of those communities who had arrived in Italy previously). The lack of reform in citizenship law is evident: unlike most other countries in the world, Italy does not automatically recognize any person born on its soil (*ius soli*) as a citizen. This originates from the past when it was prudent to favor Italian descendants with the rights of citizenship (*ius sanguinis*). In terms of citizenship rights, immigrants who are regularized as residents (legal, regular, documented) but not citizens have no right to vote (active or passive) if they are not EU immigrants. In relation to social integration, it is useful to see how, unlike other countries accepting immigrants where the official language is internationally widespread (notably English, Spanish, and French), Italian is a language scarcely used outside of its homeland and quite difficult to learn. Italian public schools have played a fundamental role in improving integration by upholding every individual's right to be educated, regardless of race, nationality, or culture, and by opening its doors (without economic barriers) to the children of irregular (illegal, undocumented) immigrants. We have today in Italy more than 800,000 "foreign" minors registered in the Italian schools; more than half of them were born in Italy.

Following this overview of the context, history, and principal characteristics of the migratory processes in Italy, we turn to the policies pertaining to the health of immigrants.

The current regulations on the available healthcare services for immigrants date back to a comprehensive law, entitled "Single Text on Immigration" (D.Lgs. 286, articles 34th, 35th and 36th) which was approved in 1998, and successive regulatory provisions (mainly the DPR 394/1999, articles 42nd, 43th and 44th and the Circular n. 5/2000 of the Health Department) [14]. First of all, it must be emphasized that the "philosophy" of these deliberately "inclusive" health policies can be summarized in two major statements:


These laws pose in fact Italy in an "advanced" position in the international scene: in no other country in the world, we understand, immigrants without a stay/residence permit have the right to be assisted without being reported to the police.2 Undocumented, illegal, irregular immigrants have the right to receive the necessary treatment, even for prolonged periods of time, free of charge if they do not have the economic resources to pay for the services.

However, this "inclusive" health policy is based on the willingness of part of the local authorities to collaborate. The local authorities, that is, the 21 Italian regions and autonomous provinces, have over time acquired a fundamental role in the provision of social and health services for foreigners, and in maintaining its effectiveness. Indeed, as a result of the changes introduced in 2001 in the Italian Constitution by a Constitutional Law (article 117 of the Constitutional Law n. 3), the Regions and Autonomous Provinces are empowered to define regulations on health issues for all residents, including immigrants, while migration remains one of the issues in which the state maintains complete legal authority. The theme "health and immigration" seems ambiguously suspended between the "exclusive" legislation

<sup>2</sup> In Italy, "stay permit" and "residence permit" are two distinct situations. The possession of "Stay permit" (in Italian "permesso di soggiorno") means the institutional recognition of the legitimacy of the presence of the person on the national territory (and it is a condition that is associated first of all to the migrant); the "Residence permit" (in Italian "permesso di residenza") is linked to the stability of the life of a person in the place where s/he dwells. From an administrative point of view, the two are treated separately, although to get the second permit it is necessary to have already been granted the first permit.

of the state and the "competing" legislation of the autonomous regions and provinces. The complex process of decentralization named "health federalism," which implies interconnection between the various institutional levels involved in the health system, results in uncertain pathways of responsibility, which can jeopardize the successful application of healthcare policies, preventing them from achieving their institutional mission (as may indeed also occur in matters of health care for Italian citizens) [14].

the official language is internationally widespread (notably English, Spanish, and French), Italian is a language scarcely used outside of its homeland and quite difficult to learn. Italian public schools have played a fundamental role in improving integration by upholding every individual's right to be educated, regardless of race, nationality, or culture, and by opening its doors (without economic barriers) to the children of irregular (illegal, undocumented) immigrants. We have today in Italy more than 800,000 "foreign" minors registered in the Italian

Following this overview of the context, history, and principal characteristics of the migratory

The current regulations on the available healthcare services for immigrants date back to a comprehensive law, entitled "Single Text on Immigration" (D.Lgs. 286, articles 34th, 35th and 36th) which was approved in 1998, and successive regulatory provisions (mainly the DPR 394/1999, articles 42nd, 43th and 44th and the Circular n. 5/2000 of the Health Department) [14]. First of all, it must be emphasized that the "philosophy" of these deliberately "inclusive"

**1.** Equality of rights and obligations, regarding both health and rights to health care, of Italian citizens and foreigners who are legally present (with stay/residence permit, documented, regular migrants), with complete healthcare coverage by the National Public Health System.

**2.** Broad possibility of health protection and health assistance also for the undocumented (irregular, illegal) immigrants, especially for women and children, and in relation to infec-

These laws pose in fact Italy in an "advanced" position in the international scene: in no other country in the world, we understand, immigrants without a stay/residence permit have the

immigrants have the right to receive the necessary treatment, even for prolonged periods of

However, this "inclusive" health policy is based on the willingness of part of the local authorities to collaborate. The local authorities, that is, the 21 Italian regions and autonomous provinces, have over time acquired a fundamental role in the provision of social and health services for foreigners, and in maintaining its effectiveness. Indeed, as a result of the changes introduced in 2001 in the Italian Constitution by a Constitutional Law (article 117 of the Constitutional Law n. 3), the Regions and Autonomous Provinces are empowered to define regulations on health issues for all residents, including immigrants, while migration remains one of the issues in which the state maintains complete legal authority. The theme "health and immigration" seems ambiguously suspended between the "exclusive" legislation

In Italy, "stay permit" and "residence permit" are two distinct situations. The possession of "Stay permit" (in Italian "permesso di soggiorno") means the institutional recognition of the legitimacy of the presence of the person on the national territory (and it is a condition that is associated first of all to the migrant); the "Residence permit" (in Italian "permesso di residenza") is linked to the stability of the life of a person in the place where s/he dwells. From an administrative point of view, the two are treated separately, although to get the second permit it is necessary to have already

time, free of charge if they do not have the economic resources to pay for the services.

Undocumented, illegal, irregular

processes in Italy, we turn to the policies pertaining to the health of immigrants.

schools; more than half of them were born in Italy.

120 People's Movements in the 21st Century - Risks, Challenges and Benefits

health policies can be summarized in two major statements:

right to be assisted without being reported to the police.2

tious diseases [14].

2

been granted the first permit.

As an example of the ambiguity that is created between the migration policies and the healthcare policies, we can provide the introduction, of the crime of irregular entrance and stay through the approval of the law n. 94/2009, which is the so-called Security Package. During the parliamentary discussion about the Security Package, there was an attempt, by a notoriously anti-immigration Italian party, to repeal the provision that prohibits health and administrative personnel from reporting illegal immigrants who use health services. This was mainly motivated by ideological reasons. It represented a serious interference in the health sector, and could have posed a serious threat to immigrants' right to health care. Although the proposal was abandoned, and therefore the prohibition of denouncement remains in effect, the introduction of illegal entrance and sojourn being a criminal act and pursuable by the authorities has placed the health professionals (doctors, nurses, administrative staff, etc.) in a difficult practical, ethical, and deontological situation. According to one legal interpretation, a public officer should be obliged to make a denouncement to the public authorities if, during the exercise of his or her profession, the irregular, illegal, undocumented status of an immigrant comes to light. But this is contradicted by another law of the state, the aforementioned "Single Text on Immigration" [14], which sets out the rules on health care for irregular, illegal, undocumented immigrants. These two contrasting laws, regarding the prohibition to and, conversely, the obligation to denounce, have given rise to confusion, ambiguity, and the use of discretion. The regions, which had in part also taken a stance against the proposal for the repeal of the prohibition of denouncement, therefore had to provide prompt clarification of its validity. The Ministry of the Interior subsequently issued a circular confirming that the law on public security had not repealed the previous rules and that, as a consequence, doctors and other workers within the healthcare sector remained obliged to observe the prohibition on reporting irregular, illegal, undocumented immigrants seeking healthcare services, with some limited general exceptions (e.g., firearm injuries) [14].

As a demonstration of the ambiguity that has arisen between state jurisdiction (center) and regional administration (peripheral), we can mention the appeals presented by the Government to the Supreme Court, between 2009 and 2010, on the presumed constitutional illegitimacy of the regional laws on migration in three Italian regions (Tuscany, Puglia, and Campania). These regional provisions were contested by the government on the grounds that they exceeded the competences of the regions. According to the Italian government then in office, local provisions for the protection of the right to health care, if extended to illegal, irregular, undocumented immigrants, would be considered to affect the regulation of the entry and sojourn of such immigrants. These were matters for the exclusive competence of the state. However, the Supreme Court rejected, with regard to health care for immigrants, the government's appeal in all three cases, reaffirming the *"irreducible nucleus"* of the right to health, even with reference to foreigners without a valid stay/residence permit. Indeed, this right to health is *"protected by the [Italian] Constitution as an inviolable aspect of human dignity"* (Sentence No. 252 of 2001), in conformity with the view already expressed by the Court, according to which *"the foreigner is […] entitled to all the fundamental rights that the Constitution recognizes as owned by the person"* (Sentence No. 148 of 2008) [14].

In February 2007, by means of Legislative Decree No. 30 of 2007, Italy implemented the European Resolution 2004/38/CE in relation to the right of European citizens and their families to move and settle freely within the territory of the Member States. The untimeliness of the measure, nearly 3 years after the European Resolution, and the concomitant entrance (1st of January 2007) of Romania and Bulgaria into the EU, created considerable confusion and widespread use of discretion within the health services. Not only were tens of thousands of "neo-communitarian citizens" immediately excluded from health protection, as they were unable to meet the necessary conditions in order to obtain health assistance (possession of the European Health Insurance Card or legal work and/or registered residency), but the directions later on provided by the central government were unclear and in some cases contradictory (Circular issued by the Ministry of Health on 3 August 2007, 19 February 2008, 24 July 2009, and 11 more in less than a year). For these reasons, the different Italian regions had provided very different answers, not only in relation to procedure but also with regard to possible levels of health care, especially with reference to the socially and economically disadvantaged.

This "pendulum of competences" generates a high level of risk in terms of creating inequalities, not only in the terms of access to health services but also in terms of the health profile of the immigrant population. As a result of the above considerations, at the end of 2008 an Inter-Regional Committee was established by the Health Commission of the Conference of Regions, in order to create a stable form of collaboration among the regions, as well as a form of negotiation between the regions and the state, on the issues of immigrants' health and healthcare assistance, and to reduce the discretionary interpretation of national laws. After 2 years of work, the Committee produced the document "*Directions for the correct application of legislation for health care assistance to the foreign population by the Italian Regions and the Autonomous Provinces*," which was first approved by the Assembly of the Regional Health Authorities and then ratified at national level [14]. Despite all these efforts, differences in the interpretation and practical application of the rules remain between the different Italian regions, often bureaucratic attitudes threaten to override the right to health care for immigrants. A recent advocacy action successfully exercised, in particular by the Italian Society of Migration Medicine - S.I.M.M. (the only Scientific Society in the world with this mission), is the recognition of the right to have a permanent pediatrician, chosen by the parents, for the children of immigrants without stay/residence permits.

## **3. Conclusion**

Migration is a complex phenomenon and the determinants of health can help us to analyze the issue. The success of the migration project usually translates into better health and access to healthcare opportunities, which show the positive impact of the social determinants of health such as education, employment, income, and housing. These are not mechanical and linear processes, nor immediate developments. The migration process may in fact represent a phase of stress and risks to mental and physical health, particularly accentuated in asylum seekers, refugee unaccompanied immigrant children, and those who are victims of trafficking and, more generally, victims of physical and/or psychological violence [40, 41]. Of particular importance, in addition to the individual resources of the immigrant (e.g., his/her "coping" mechanisms, ability to adapt to changes and unforeseen, adverse situations, presence of a social network) is the ability of the host society to welcome and integrate the newcomers.

A careful analysis of the health needs of the immigrant communities represents the fundamental precondition for identifying appropriate health and social policies. This involves a commitment to quantitative and qualitative research, possibly with the involvement of the same migrant communities. When not properly supported by appropriate inter-sectoral policies, immigrants will be exposed to hostile circumstances that leave them vulnerable to negative experiences which, in turn, influence their life chances.

Today, public health is facing the effects of these dynamics, in particular with respect to the prevalence of chronic diseases in the most disadvantage populations. This involves the planning of interventions, possibly "community-based," capable of reaching all the present populations, without discrimination, and in some cases the realization of interventions targeted at "hard to reach" groups.

As recommended by many international statements and by extensive medical-scientific literature of the field [3, 4, 6, 12–26, 31–35], it is important that countries recognize health as an unconditional fundamental right, guaranteeing health coverage both to regular, legal, documented migrants and irregular, illegal, and undocumented ones. This implies investment in the services: legal, organizational, and economic resources are needed, linguistic and cultural barriers need to be contested, and training and retraining of staff, aimed at obtaining a crosscultural competence, requires professional planning. In order to maximize the chances of the effectiveness of such programs, a multidisciplinary teamwork and a "transcultural" approach is very important. Protecting the health of ethnic minorities is both a challenge for governments and a test of the quality of their health systems. One of the main international recommendations is to make health systems "migrant sensitive" [35].

As stated by Michael Marmot introducing a series of articles that recently appeared in an issue of the European Journal of Epidemiology:

*"There are some politicians who would argue that to treat migrants well is simply to encourage others to come. Such a view argues, in effect, that individuals be treated as instruments of political policy. This view is immoral. It runs counter to medical ethics that state clearly that all individuals should be treated with dignity. One way to treat people with dignity is to understand and respond to health problems caused by their migrant status"* [4].

## **Acknowledgements**

is *"protected by the [Italian] Constitution as an inviolable aspect of human dignity"* (Sentence No. 252 of 2001), in conformity with the view already expressed by the Court, according to which *"the foreigner is […] entitled to all the fundamental rights that the Constitution recognizes as owned* 

In February 2007, by means of Legislative Decree No. 30 of 2007, Italy implemented the European Resolution 2004/38/CE in relation to the right of European citizens and their families to move and settle freely within the territory of the Member States. The untimeliness of the measure, nearly 3 years after the European Resolution, and the concomitant entrance (1st of January 2007) of Romania and Bulgaria into the EU, created considerable confusion and widespread use of discretion within the health services. Not only were tens of thousands of "neo-communitarian citizens" immediately excluded from health protection, as they were unable to meet the necessary conditions in order to obtain health assistance (possession of the European Health Insurance Card or legal work and/or registered residency), but the directions later on provided by the central government were unclear and in some cases contradictory (Circular issued by the Ministry of Health on 3 August 2007, 19 February 2008, 24 July 2009, and 11 more in less than a year). For these reasons, the different Italian regions had provided very different answers, not only in relation to procedure but also with regard to possible levels of health care, especially with reference to the socially and economically

This "pendulum of competences" generates a high level of risk in terms of creating inequalities, not only in the terms of access to health services but also in terms of the health profile of the immigrant population. As a result of the above considerations, at the end of 2008 an Inter-Regional Committee was established by the Health Commission of the Conference of Regions, in order to create a stable form of collaboration among the regions, as well as a form of negotiation between the regions and the state, on the issues of immigrants' health and healthcare assistance, and to reduce the discretionary interpretation of national laws. After 2 years of work, the Committee produced the document "*Directions for the correct application of legislation for health care assistance to the foreign population by the Italian Regions and the Autonomous Provinces*," which was first approved by the Assembly of the Regional Health Authorities and then ratified at national level [14]. Despite all these efforts, differences in the interpretation and practical application of the rules remain between the different Italian regions, often bureaucratic attitudes threaten to override the right to health care for immigrants. A recent advocacy action successfully exercised, in particular by the Italian Society of Migration Medicine - S.I.M.M. (the only Scientific Society in the world with this mission), is the recognition of the right to have a permanent pediatrician, chosen by the parents, for the

Migration is a complex phenomenon and the determinants of health can help us to analyze the issue. The success of the migration project usually translates into better health and access to healthcare opportunities, which show the positive impact of the social determinants of health such as education, employment, income, and housing. These are not mechanical and

*by the person"* (Sentence No. 148 of 2008) [14].

122 People's Movements in the 21st Century - Risks, Challenges and Benefits

children of immigrants without stay/residence permits.

disadvantaged.

**3. Conclusion**

Special thanks to Dr. Giulia Gonzales and Dr. Junli Song for her kind collaboration in revising the English text of this paper.

## **Author details**

#### Maurizio Marceca

Address all correspondence to: maurizio.marceca@uniroma1.it

Sapienza University of Rome, Department of Public Health and Infectious Diseases, Italian Society of Migration Medicine (S.I.M.M.), Rome, Italy

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**Author details**

Maurizio Marceca

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Sapienza University of Rome, Department of Public Health and Infectious Diseases, Italian

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#### **The Impact of Tuberculosis among Immigrants: Epidemiology and Strategies of Control in High-Income Countries—Current Data and Literature Review** The Impact of Tuberculosis among Immigrants: Epidemiology and Strategies of Control in High-Income Countries—Current Data and

Carlo Contini, Martina Maritati, Marachiara di Nuzzo, Lorenzo Massoli, Sara Lomenzo and Anastasio Grilli Carlo Contini, Martina Maritati, Marachiara di Nuzzo, Lorenzo Massoli, Sara Lomenzo and

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/66823

Literature Review

#### Abstract

Anastasio Grilli

A significant reappearance of tuberculosis (TB) was observed in industrialized countries during the last two decades. This is due to the spread of HIV infection itself and to today's migratory phenomenon as a consequence of wealth disparity, poverty, wars and political persecutions. This proportion is expected to increase and represents an important cause of the overall resurgence of the TB epidemic and drug-resistant TB in Western Europe and the USA. TB is currently one of the leading causes of death worldwide and a health problem in high-income countries. Although WHO global TB report 2015 with its "STOP TB" strategy has the goal to eliminate TB as a public health problem by 2050, TB shows no signs of disappearing despite some decline in high-income countries. In order to intensify the fights against this deadly disease, further efforts should be aimed to improve examination/detection processes to accurately determine all kinds of TB, and how best to enhance TB control through a coordinated medical screening program of migrants for active TB. Migration in itself is not a definitive risk for TB. Stressful living condition, social isolation, poverty, political fear/persecution, and difficulties to access to health care can expose these individuals to the risk of TB infection during and after the migration process. This chapter aims to discuss and highlight all these issues.

Keywords: tuberculosis (TB), latent tuberculosis infection (LTBI), migrants, documented migrants, undocumented migrants, asylum seekers, refugees, Europe (EU)

## 1. Introduction

Tuberculosis (TB) currently represents one of the leading causes of death worldwide and, despite globally the TB incidence fell by an average of 1.5% per year since 2000 and is now

© The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

18% lower than the level of 2000, it has been declared a global health emergency in highincome countries [4]. TB is also the primary killer due to a single infectious disease and, after HIV/AIDS, is the second single disease which causes more deaths in the world [2]. The World Health Organization (WHO) estimates that one-third of the world population harbors latent TB infections (LTBI), 14.1 million people have active cases, 9 million are newly diagnosed per year (9.6 million new TB cases in 2014, of which 58% in the Southeast Asia and Western Pacific regions), and 1.5 million deaths are attributable to TB annually [1–4]. This death toll equals 2% of global mortality, even if it is a disease for which a cure has existed for 70 years.

In relation to HIV infection, more than 48% of TB patients globally had a documented positive HIV test result. In the African region, which has the highest TB/HIV burden, three out of four TB patients knew their HIV status [4].

Although the general decrease [1, 4] of TB cases (globally, the TB mortality rate fell by an estimated 45% between 1990 and 2013 and the TB prevalence rate fell by 41% during the same period) in recent decades has led the medical profession to pay less attention to the presence of high-risk patients, TB continues to be a public health concern in high-income countries, primarily among the foreign-born and migrant population [5]. In fact, a reappearance of this disease was observed since the early 1990s due to other than the spread of HIV infection and the increase in poor living conditions and immunosuppression; it is due to the migratory phenomenon, and an interplay of various push and pull factors are a consequence of wealth disparity, poverty, wars, and political persecutions [6, 7].

There are 244 million migrants worldwide, which is 41% more since 2000. Note that 76 million are in Europe, the continent with the highest number of migrants, followed by Asia (75 million), United States (54 million), Africa (21 million), Latin America and the Caribbean (9 million), and Oceania (8 million), according to the calculations of the latest International Migration Report of the United Nations [8]. Of all the immigrants living in Europe, Germany and Russia have 12 million, the United Kingdom has 9 million, France has 8 million, Spain and Italy have 6 million; while Saudi Arabia has 10 million and Canada and Australia have 7 million, respectively. According to the previous report of the UN [8], the largest number of citizens migrated abroad come mainly from India (16 million), Mexico (12 million), Russia (11 million), China (10 million), Bangladesh (7 million), Pakistan and Ukraine (6,000,000), and the Philippines and Syria with about 5 million migrants.

Immigrants from TB endemic countries account for a significant proportion of TB cases in industrialized countries. It can be anticipated that this proportion will continue to increase, and will represent an important cause of the overall resurgence of the TB epidemic in Western EU and the USA. Most migrants are healthy, but conditions surrounding the migration process can pose health risks such as inequalities in accessing health services, substandard quality of care, marginalization, and discrimination. Thus, the particular condition of "immigrant" predisposes to an increased risk of developing TB, either for increased incidence rates in their countries of origin, or the high rate of LTBI which predisposes to TB for conditions of social fragility and complexity related to the process of migration and multiculturalism found in the host country.

The chapter is structured as follows:

18% lower than the level of 2000, it has been declared a global health emergency in highincome countries [4]. TB is also the primary killer due to a single infectious disease and, after HIV/AIDS, is the second single disease which causes more deaths in the world [2]. The World Health Organization (WHO) estimates that one-third of the world population harbors latent TB infections (LTBI), 14.1 million people have active cases, 9 million are newly diagnosed per year (9.6 million new TB cases in 2014, of which 58% in the Southeast Asia and Western Pacific regions), and 1.5 million deaths are attributable to TB annually [1–4]. This death toll equals 2% of global mortality, even if it is a disease for which a cure has existed for

In relation to HIV infection, more than 48% of TB patients globally had a documented positive HIV test result. In the African region, which has the highest TB/HIV burden, three out of four

Although the general decrease [1, 4] of TB cases (globally, the TB mortality rate fell by an estimated 45% between 1990 and 2013 and the TB prevalence rate fell by 41% during the same period) in recent decades has led the medical profession to pay less attention to the presence of high-risk patients, TB continues to be a public health concern in high-income countries, primarily among the foreign-born and migrant population [5]. In fact, a reappearance of this disease was observed since the early 1990s due to other than the spread of HIV infection and the increase in poor living conditions and immunosuppression; it is due to the migratory phenomenon, and an interplay of various push and pull factors are a consequence of wealth

There are 244 million migrants worldwide, which is 41% more since 2000. Note that 76 million are in Europe, the continent with the highest number of migrants, followed by Asia (75 million), United States (54 million), Africa (21 million), Latin America and the Caribbean (9 million), and Oceania (8 million), according to the calculations of the latest International Migration Report of the United Nations [8]. Of all the immigrants living in Europe, Germany and Russia have 12 million, the United Kingdom has 9 million, France has 8 million, Spain and Italy have 6 million; while Saudi Arabia has 10 million and Canada and Australia have 7 million, respectively. According to the previous report of the UN [8], the largest number of citizens migrated abroad come mainly from India (16 million), Mexico (12 million), Russia (11 million), China (10 million), Bangladesh (7 million), Pakistan and Ukraine (6,000,000), and the Philippines and

Immigrants from TB endemic countries account for a significant proportion of TB cases in industrialized countries. It can be anticipated that this proportion will continue to increase, and will represent an important cause of the overall resurgence of the TB epidemic in Western EU and the USA. Most migrants are healthy, but conditions surrounding the migration process can pose health risks such as inequalities in accessing health services, substandard quality of care, marginalization, and discrimination. Thus, the particular condition of "immigrant" predisposes to an increased risk of developing TB, either for increased incidence rates in their countries of origin, or the high rate of LTBI which predisposes to TB for conditions of social fragility and complexity related to the process of migration and multiculturalism found in the

70 years.

TB patients knew their HIV status [4].

130 People's Movements in the 21st Century - Risks, Challenges and Benefits

Syria with about 5 million migrants.

host country.

disparity, poverty, wars, and political persecutions [6, 7].


## 2. Overview and epidemiological features of TB among immigrants in low-TB burden countries and screening practices

### 2.1. Overview and epidemiological features of TB among immigrants in low-TB burden countries<sup>1</sup>

Many1 migrants originating from countries where TB has a high incidence, including tropical areas [9], have a high risk of acquiring TB before migration. Much of TB burden is concentrated in high-burden settings of Africa and Asia (28 and 58%, respectively) where TB continues to be a cause of morbidity and mortality [5]. Some areas of tropical countries, such as Haiti, Perù, Bolivia, and Suriname, have the highest TB incidence in the Americas (between 100 and 200 per 100,000 inhabitants) [10], whereas Brazil has a high TB burden, but this is not uniformly distributed. In sub-Saharan Africa and in some regions of India, HIV-coinfection and poverty affecting housing conditions, ventilation, nutritional status, education, and access to health care, other than growing urbanization with the consequent overcrowded living conditions, are the most important determinants of TB epidemic in tropical countries [9].

TB remains one of the major public health challenges in North Africa with decreasing gradient incidence from Morocco (the highest) with more than 27,000 new cases per year, to intermediate in Algeria and lowest in Tunisia and Egypt (30 and 17 cases per 100,000, respectively) [11]. In the European Economic Area (EEA), the majority of subjects of foreign origin with TB in 2009 originated from Asia, Africa, and other European countries (34, 28, and 9.5%, respectively) [9, 10, 12]. This proportion continues to increase, and represents an important cause of the overall resurgence of the TB epidemic in the USA and Western Europe (EU) [12]. It can be anticipated that, despite efforts of the industrialized countries to conquer the disease, the incidence of new TB cases in EU varies from very low rates in Scandinavian countries (6– 8 cases/100,000 population) to rates as high as 231 cases/100,000 populations in Tajikistan; the Russian Federation is eleventh among the 22 high-burden TB countries [12]. In Italy, where

<sup>1</sup> Low TB burden or low TB incidence countries are defined as those with a TB notification rate of ≤100 cases (all forms) per million population a year. The high-TB burden or incidence countries are countries with the highest estimated numbers of incident TB cases that account for 80% of the global total.

over the last decade the TB notification has been stable at approximately 7 cases per 100,000 people annually, the immigrant population has a relative risk of suffering from TB, 10–15 times higher than the Italian-born population [4]. In fact, the proportion of TB cases of foreigners increased from 22% in 1999 to 46% in 2008 of the total [13]; at the same time, the proportion of drug-resistant TB cases rose to 83% [14]. Almost two-thirds of the cases of TB in foreigners in 2008 occurred in northern Italy, where immigration is more prominent than in other areas of the country [13]. The most affected age group was of young adults [13]. Concurrently in Italy, while the proportion of African-born persons with TB decreased from 51 to 30%, the proportion of cases with TB born in Eastern EU, including former Soviet Union countries, increased from 16 to 33% [14, 15]. In the Italian population, the two most affected population groups are the elderly and the foreign born. The elderly population, due to progressive weakening of both, their general conditions and their immune system, caused by the aging process itself, is at increased risk of reactivation of LTBI. Foreign-born residents, which are at increased risk of developing TB either because of the high incidence rates of TB in their countries of origin or because of the social fragility deriving from the migration process itself [16], account for the increase of TB in people less than 65 years of age and for the great majority of drug-resistant TB cases.

Summarizing, the European countries share a TB epidemiology which is characterized by a decrease of TB incidence in natives but an increasing incidence in foreign-born persons; occurrence of the majority of TB cases in recent migrants and younger age groups, especially those experiencing inadequate living and health conditions; and high percentage of drugresistant TB among immigrants and previously treated patients [11].

Factors that influence the risk of TB reactivation among immigrants in low TB burden countries include the prevalence of TB in the country of origin, the duration of residence in the host country, and the efficiency and quality of curative and preventive services. As mentioned previously, after the actual migration process, immigrants are exposed to additional risk of acquiring reactivated TB infection because of stressful living in overcrowded conditions, social isolation, poverty, malnutrition, unemployment, and difficulties to access to health care. Generally, TB in immigrants in low-burden countries arises from an active TB infection which occurred overseas. There are also reactivations of remotely acquired LTBI, which occurs months to years after settlement in the host country, or acquired TB as new infection postarrival in the host county through local transmission or during a return travel to the country of origin [17]. Second-generation migrants, who often keep a link with their country of origin, or international travellers including visiting friends and relatives (VFR), especially children, are known to represent high-risk groups for TB [18]. Finally, homeless immigrants and other deprived groups in low-burden countries can have transmission rates as high as some high-burden countries [19].

#### 2.2. Screening practices among adults

Migrants currently play an important role in determining the current epidemiology of TB in low TB burden countries where they are settled. As a consequence, although reports from different high-income countries with well-performing immigration medical screening have demonstrated that foreign-born TB patients do not contribute to the transmission of TB in the native population [20], there is an increasing interest on how best to enhance TB control through coordinated medical screening of documented as well as undocumented migrants such as migrants or refugees that are arriving presently at the Greek and Italian coasts. Undocumented migrants have been shown to be at higher TB risk than other migrants, as their entry and TB infection is often more recent and their migration and living conditions are worse than those of documented migrants [21].

over the last decade the TB notification has been stable at approximately 7 cases per 100,000 people annually, the immigrant population has a relative risk of suffering from TB, 10–15 times higher than the Italian-born population [4]. In fact, the proportion of TB cases of foreigners increased from 22% in 1999 to 46% in 2008 of the total [13]; at the same time, the proportion of drug-resistant TB cases rose to 83% [14]. Almost two-thirds of the cases of TB in foreigners in 2008 occurred in northern Italy, where immigration is more prominent than in other areas of the country [13]. The most affected age group was of young adults [13]. Concurrently in Italy, while the proportion of African-born persons with TB decreased from 51 to 30%, the proportion of cases with TB born in Eastern EU, including former Soviet Union countries, increased from 16 to 33% [14, 15]. In the Italian population, the two most affected population groups are the elderly and the foreign born. The elderly population, due to progressive weakening of both, their general conditions and their immune system, caused by the aging process itself, is at increased risk of reactivation of LTBI. Foreign-born residents, which are at increased risk of developing TB either because of the high incidence rates of TB in their countries of origin or because of the social fragility deriving from the migration process itself [16], account for the increase of TB in people less than 65 years of age and for the great majority of drug-resistant TB

132 People's Movements in the 21st Century - Risks, Challenges and Benefits

Summarizing, the European countries share a TB epidemiology which is characterized by a decrease of TB incidence in natives but an increasing incidence in foreign-born persons; occurrence of the majority of TB cases in recent migrants and younger age groups, especially those experiencing inadequate living and health conditions; and high percentage of drug-

Factors that influence the risk of TB reactivation among immigrants in low TB burden countries include the prevalence of TB in the country of origin, the duration of residence in the host country, and the efficiency and quality of curative and preventive services. As mentioned previously, after the actual migration process, immigrants are exposed to additional risk of acquiring reactivated TB infection because of stressful living in overcrowded conditions, social isolation, poverty, malnutrition, unemployment, and difficulties to access to health care. Generally, TB in immigrants in low-burden countries arises from an active TB infection which occurred overseas. There are also reactivations of remotely acquired LTBI, which occurs months to years after settlement in the host country, or acquired TB as new infection postarrival in the host county through local transmission or during a return travel to the country of origin [17]. Second-generation migrants, who often keep a link with their country of origin, or international travellers including visiting friends and relatives (VFR), especially children, are known to represent high-risk groups for TB [18]. Finally, homeless immigrants and other deprived groups in low-burden countries can have transmission rates as high as

Migrants currently play an important role in determining the current epidemiology of TB in low TB burden countries where they are settled. As a consequence, although reports from different high-income countries with well-performing immigration medical screening have demonstrated that foreign-born TB patients do not contribute to the transmission of TB in the

resistant TB among immigrants and previously treated patients [11].

cases.

some high-burden countries [19].

2.2. Screening practices among adults

Immigration TB screening programs for high immigration and low TB incidence countries vary according to the national legislation, resource availability, and public health risk management practices. Moreover, programs differ by whether screening is done for active TB or LTBI, or both. The programs also differ in relation to arrival in the host country, i.e., the migrants' status, such as refugees or asylum seekers, the countries of origin, and tools used to screen for active TB or LTBI [22, 23]. The rationale of these programs is the early detection and treatment of active and often contagious TB cases in order to prevent Mycobacterium tuberculosis transmission to the host population of a low-burden country and reduce the burden of imported TB in low-incidence countries. Methods of TB control in migrant populations have historically focused on identifying active TB with accompanying contact tracing, but the yields for this remain relatively low. In this setting, screening can occur before entry (pre-entry screening), at entry (sometimes called port of entry screening), or after entry [24].

In most of cases, active TB immigrant medical screening in high-income industrialized countries for both documented migrants, refugees, or asylum seekers is performed on or soon after the entry (borders such as airport, reception centers/holding camps, migrant centers); 36% (9 of 25 countries including Australia, Canada, Israel, Jordan, New Zealand, France, the UK, and the USA) have a pre-entry TB screening in country of origin for people who intend to migrate; 20% (5 of 25 countries including Norway, Sweden, Switzerland, the Netherlands, and the UK) perform screening at entry [24, 25]. Literature shows that 88% of countries use chest X-rays (CXR) alone or in combination with clinical examination or TST [5, 24]. The sensitivity and specificity of CXR vary from 86–97% to 75–89%, respectively, and according to the criteria of imaging interpretation. CXR alone does not detect extrapulmonary TB (EPTB) which is increasing in comparison to pulmonary TB, especially in low-burden and high immigrant receiving countries [26], and in HIV-positive persons that have higher rates of EPTB compared with those who are HIV-negative.

Sputum smear and culture follow CXR only if this is found to be abnormal. The destiny of migrants to enter the host country depends on the outcome of these tests.

An interesting and original active TB finding approach was recently investigated by Schepisi [27] in Italy, a country where there is no TB national screening policy for new entrants [28]. Italy is a country with a TB incidence rate of 5.3/100,000 persons with 3.153 cases in 2013 [29]. TB cases are especially concentrated among high-risk TB groups, including migrants from high-incidence countries, homeless people, and drug and alcohol abusers. The study analyzed TB case finding intervention based on verbal symptoms screening,<sup>2</sup> conducted at primary centers for undocumented migrants, refugees, and asylum seekers in different Italian sites.

<sup>2</sup> Presence of cough, fever, fatigue, hemoptysis and weight loss.

Although only a limited number of TB cases was detected, of those screened and evaluated, the study, based on its feasible cost approach and reduced burden of medical procedures, contributed to the diagnoses and control of TB, especially among subpopulations that have difficulties to access specialized healthcare centers [27].

#### 2.3. TB screening of migrant children

Although many countries have developed and documented immigration TB screening programs to suit the needs of adults, attention to migrant children lacks intensive studies.

Screening migrant children for TB is particularly important, as they have a higher risk of developing active disease due to recent infection. Furthermore, due to its "paucibacillary" nature, which makes it rarely infectious, when they develop the disease, it is more severe, resulting in increased morbidity and mortality compared with adults. Thus, TB screening in high-risk children from high-incidence countries should form part of all immigration TB screening programs. A recent survey compared various screening tools (history, physical examination, TST, interferon-gamma release assays (IGRAs), CXR,3 and MTB (M. tuberculosis) bacteriology) among migrant children [30]. The screening programs varied considerably between the various participating countries. History and physical examination was often normal in children with active TB disease, and TST emerged as a better predictor of TB infection or disease [30]. Sociocultural and behavioral factors have shown to be involved in the acceptance of LTBI treatment in these populations [31]. In pediatrics, although TB may not be of immediate public health concern, individual morbidity and mortality is high. The goal of TB screening is to identify children with LTBI who are at risk for progression to active TB, as early LTBI treatment prevents extended and disseminated disease.

## 3. Definition of LTBI and risk of progression toward TB

Although the word LTBI should be "reconsidered" considering that both "latent" and "infection" terms indicate lack of disease and thus are redundant [32], LTBI is defined as a state of persistent immune response to previously acquired TB antigens without evidence of clinically manifested active TB disease. It is an asymptomatic and nontransmissible condition that is maintained for the lifetime of the infected person. Current tools are insufficient to measure the global prevalence of LTBI, but investigations carried out a decade ago estimated that approximately one-third of the world population (>2 billion people) is latently infected with M. tuberculosis.

A relatively small proportion, 5–15% of screen-test-positive patients of the estimated >2 billion people with LTBI will develop TB disease (TB reactivation) within the first 5 years after initial infection, with the remaining risk distributed over the rest of the life span [33, 34]. The likelihood of progression from LTBI to active clinical TB disease is determined by bacterial,

<sup>3</sup> Mainly employed in children ages from 11 to 16 years.

host, and environmental factors, potentially favoring TB evolution. A schematic diagram showing TB evolution following exposition is illustrated in Figure 1.

Although only a limited number of TB cases was detected, of those screened and evaluated, the study, based on its feasible cost approach and reduced burden of medical procedures, contributed to the diagnoses and control of TB, especially among subpopulations that have difficulties

Although many countries have developed and documented immigration TB screening pro-

Screening migrant children for TB is particularly important, as they have a higher risk of developing active disease due to recent infection. Furthermore, due to its "paucibacillary" nature, which makes it rarely infectious, when they develop the disease, it is more severe, resulting in increased morbidity and mortality compared with adults. Thus, TB screening in high-risk children from high-incidence countries should form part of all immigration TB screening programs. A recent survey compared various screening tools (history, physical examination, TST, interferon-gamma release assays (IGRAs), CXR,3 and MTB (M. tuberculosis) bacteriology) among migrant children [30]. The screening programs varied considerably between the various participating countries. History and physical examination was often normal in children with active TB disease, and TST emerged as a better predictor of TB infection or disease [30]. Sociocultural and behavioral factors have shown to be involved in the acceptance of LTBI treatment in these populations [31]. In pediatrics, although TB may not be of immediate public health concern, individual morbidity and mortality is high. The goal of TB screening is to identify children with LTBI who are at risk for progression to active TB, as

Although the word LTBI should be "reconsidered" considering that both "latent" and "infection" terms indicate lack of disease and thus are redundant [32], LTBI is defined as a state of persistent immune response to previously acquired TB antigens without evidence of clinically manifested active TB disease. It is an asymptomatic and nontransmissible condition that is maintained for the lifetime of the infected person. Current tools are insufficient to measure the global prevalence of LTBI, but investigations carried out a decade ago estimated that approximately one-third of the world population (>2 billion people) is latently infected with

A relatively small proportion, 5–15% of screen-test-positive patients of the estimated >2 billion people with LTBI will develop TB disease (TB reactivation) within the first 5 years after initial infection, with the remaining risk distributed over the rest of the life span [33, 34]. The likelihood of progression from LTBI to active clinical TB disease is determined by bacterial,

grams to suit the needs of adults, attention to migrant children lacks intensive studies.

early LTBI treatment prevents extended and disseminated disease.

3. Definition of LTBI and risk of progression toward TB

to access specialized healthcare centers [27].

134 People's Movements in the 21st Century - Risks, Challenges and Benefits

2.3. TB screening of migrant children

M. tuberculosis.

Mainly employed in children ages from 11 to 16 years.

3

The risk factors for acquiring LTBI infection involve people at increased risk which include infants, children (<5 years), and adolescents who have intimate contact with high-risk adults, as well as persons who have had close contact with someone known or suspected to have active TB, health care workers, high-risk racial and ethnic minorities, prisoners, residents in nursing homes, hospitals, and homeless shelters [34]. LTBI also occurs in the migrant population coming from low-income countries with a high burden of disease, especially from the Indian subcontinent and sub-Saharan Africa (the highest burden in the world), as well as in asylum seekers and refugees, a subgroup of immigrants at particular risk for TB. Persons coming from tropical areas are also at an increased risk for developing TB. The probability of developing TB is much higher among people with cellular immunity impairment due to: human immunodeficiency virus (HIV) infection, tumor necrosis factor α inhibitors, glucocorticoids administration, and organ or hematologic transplantation. Diabetes mellitus and chronic kidney disease are also more common in migrant populations and significantly increase the risk of reactivation from LTBI to active TB [34, 35].

Among all the considered conditions, HIV infection is the most potent risk factor for progression from LTBI to active TB disease [36]. TB in fact is the leading cause of death among people living with HIV, estimated to account for around 33% of all HIV-related deaths globally [4] and individuals with both, LTBI and HIV infection, have a risk of reactivation of 10% per year of life compared with 10% for life for those who do not have an HIV infection [23]. Many HIVpositive people in developing countries develop TB as the first manifestation of AIDS [4]. The major risk factors for progression from latent infection to active disease are wide ranging and are listed in Table 1.

Figure 1. Evolution of TB from latent infection to active disease following exposition.


• Persons infected with M. tuberculosis within the past 2 years; persons who inject illicit drugs or use other locally identified high-risk substances (e.g., crack cocaine), tobacco, or alcohol abuse (risk of infection and active disease)

• Persons with a history of untreated or inadequately treated TB, including those with CXR findings consistent with previous tuberculosis (e.g., apical fibronodular changes on CXR)


• Persons with the following clinical conditions or other conditions compromising immunity: disorders requiring longterm use of corticosteroids or other immunosuppressant medications (including tumor necrosis factor-alpha antagonists), body weight 10% or more below the ideal, chronic renal failure, and end-stage renal disease requiring dialysis, diabetes mellitus\*, gastrectomy or intestinal bypass, malignancy (cancer of the head, neck, or lung), silicosis


\*Diabetes can increase the relative TB risk (range 1.16–7.83) [37].

\*\*These can negatively impact on TB disease inducing immunological weakening throughout Th1 impairment [38]. \*\*\*Black skin individuals are constitutively more susceptible than white skin persons owing to environmental and genetic factors [39].

Table 1. Groups at increased risk of progression from LTBI to active tuberculosis.

#### 4. Management of LTBI among immigrants and screening practices

Given that the majority of active TB in foreign-born persons in low-incidence countries arises from reactivation of LTBI, acquired many years previously in the country of origin, as also demonstrated by epidemiological studies based on M. tuberculosis strain isolates by molecular genotyping that found that 55-90% of TB cases in foreign-born persons are due to LTBI reactivation [40–41]. Screening new entrants for LTBI remains the cornerstone for controlling imported TB. While most developed countries screen for active TB, screening for LTBI is much less commonly performed [24, 42].

Guidelines for LTBI screening among immigrants are not homogenous and vary among regions; moreover, evidence supporting their effectiveness is lacking and identifying models of best practice remains difficult, so that there are no perfect methods for the diagnosis and management of LTBI [43–45] whose identification provides opportunity for early treatment and the prevention of significant health sequelae for the individual. Diagnosis of TB is currently based on a positive result of either a tuberculin skin test (TST) or IGRA test indicating an immune response to M. tuberculosis. The TST is widely used and inexpensive, but requires a repeat visit to the physician and has low performance in persons recently vaccinated with BCG (e.g., immigrants arriving in industrialized countries), or who are infected with HIV. With the TST, an induration of 15 mm or more is considered positive in persons without risk factors, 10 mm or more is positive for those at higher risk, such as immigrants from high TB-endemic countries with no history of TB, and 5 mm or more is positive for certain high-risk persons (e.g., immunocompromised patients, those exposed to active TB). The more expensive IGRAs overcome some of the TST performance issues [46]. IGRAs require a single patient visit to conduct the test and results can be available within 24 hours. IGRAs, however, are not the preferred testing method for use in children younger than 5 years old, persons recently exposed to TB, immunocompromised persons, and those who will be tested repeatedly [47]. To test immigrant and refugee children with LTBI who are probably vaccinated with BCG, IGRAs may limit the number of children targeted for preventive therapy [48]. The use of one-step IGRA has also demonstrated to be the best option for young migrants [9]. Although in the last decade, IGRAs have increasingly replaced the use of TST, these tests have also limitations, both cannot verify the presence/ absence of dormant bacteria still able to reactivate and thus they do not reliably predict who will progress to active TB [2, 3]. Moreover, strong positive tests do not suggest a higher TB risk reactivation, and in children under 5 years of age and immunocompromised patients, including HIV-infected subjects, the test performances are particularly poor, thus needing a better detection test for LTBI [49, 50]. The comparative performance of the TST and IGRAs also varies between high-incidence and low-incidence countries, possibly because of the effects of BCG vaccination and reinfection [51]. In this setting, WHO strongly recommend that either TST or IGRA be used to test for LTBI in special risk populations (i.e., HIV persons, transplant patients, patients initiating anti-TNF treatments, household members or close contacts, including children of pulmonary TB cases). A positive IGRA or TST test is required to diagnose LTBI and to start specific therapy according WHO guidelines [4]. In high TB burden countries a LTBI test is not required prior to LTBI treatment, but it is encouraged for HIV-positive persons.

#### 4.1. Screening practices

4. Management of LTBI among immigrants and screening practices

• Persons infected with M. tuberculosis within the past 2 years; persons who inject illicit drugs or use other locally identified high-risk substances (e.g., crack cocaine), tobacco, or alcohol abuse (risk of infection and active disease) • Persons with a history of untreated or inadequately treated TB, including those with CXR findings consistent with

• Persons with the following clinical conditions or other conditions compromising immunity: disorders requiring longterm use of corticosteroids or other immunosuppressant medications (including tumor necrosis factor-alpha antagonists), body weight 10% or more below the ideal, chronic renal failure, and end-stage renal disease requiring dialysis, diabetes

\*\*These can negatively impact on TB disease inducing immunological weakening throughout Th1 impairment [38]. \*\*\*Black skin individuals are constitutively more susceptible than white skin persons owing to environmental and genetic

less commonly performed [24, 42].

• Children younger than 5 years

• Black race, black skin individuals\*\*\*

factors [39].

• Persons with immunocompromising conditions (HIV, leukemia, lymphoma)

• Persons with recent conversion of a negative tuberculin skin test to a positive test

Table 1. Groups at increased risk of progression from LTBI to active tuberculosis.

mellitus\*, gastrectomy or intestinal bypass, malignancy (cancer of the head, neck, or lung), silicosis

previous tuberculosis (e.g., apical fibronodular changes on CXR) • Homeless adults, elderly, health care workers, and medical students

136 People's Movements in the 21st Century - Risks, Challenges and Benefits

• Tropical parasitic diseases including helminthic infestations\*\*

\*Diabetes can increase the relative TB risk (range 1.16–7.83) [37].

Given that the majority of active TB in foreign-born persons in low-incidence countries arises from reactivation of LTBI, acquired many years previously in the country of origin, as also demonstrated by epidemiological studies based on M. tuberculosis strain isolates by molecular genotyping that found that 55-90% of TB cases in foreign-born persons are due to LTBI reactivation [40–41]. Screening new entrants for LTBI remains the cornerstone for controlling imported TB. While most developed countries screen for active TB, screening for LTBI is much

Guidelines for LTBI screening among immigrants are not homogenous and vary among regions; moreover, evidence supporting their effectiveness is lacking and identifying models of best practice remains difficult, so that there are no perfect methods for the diagnosis and management of LTBI [43–45] whose identification provides opportunity for early treatment and the prevention of significant health sequelae for the individual. Diagnosis of TB is currently based on a positive result of either a tuberculin skin test (TST) or IGRA test indicating an immune response to M. tuberculosis. The TST is widely used and inexpensive, but requires a repeat visit to the physician and has low performance in persons recently vaccinated with BCG (e.g., immigrants arriving in industrialized countries), or who are infected with HIV. With the TST, an induration of 15 mm or more is considered positive in persons without risk factors, 10 mm or more is positive for those at higher risk, such as immigrants from high TB-endemic countries with no history of TB, and 5 mm or more is positive for certain high-risk persons (e.g., immunocompromised patients, those exposed to

Individuals should be asked about symptoms of TB before being tested for LTBI. In this setting, WHO guidelines [4] suggest an algorithm for targeted diagnosis and treatment of LTBI in individuals of risk groups (Figure 2).

A recent survey found that only 55.2%, 16 out of the previously mentioned 29 countries (see p. 6), screen for LTBI most frequently postarrival in their country using TST in 68.8% of cases, TST plus a confirmatory IGRA in 25%, and IGRA alone in 18.8%. In 11 of these countries, the screening is compulsory for documented migrants [5, 24, 25].

The screening may decrease the period of infectiousness by as much as 33% in some situations [5]. LTBI screening is effective in persons at risk of contracting M. tuberculosis or of progressing from LTBI to active TB. It is generally thought that routine screening outside these high-risk groups wastes resources and leads to high false-positive test rates. According to the WHO 2015 Guidelines on the Management of LTBI [4], systematic testing and treatment of LTBI is highly recommended in immigrants from high TB burden countries; prisoners, homeless persons, and illicit drug users should be treated according to TB epidemiology and resource availability. This procedure has shown to lead to early detection of cases, resulting in a shorter duration of symptoms, and fewer hospitalizations.

The decision to screen for TB is a decision to treat. LTBI can be effectively treated in order to prevent progression to active TB, thus resulting in a substantial benefit for both the individual and the community. Currently available treatment options allow to reduce the risk of

Figure 2. Algorithm for the management of LTBI in individuals at risk for TB. Modified and adapted from Guidelines on the Management of Latent Tuberculosis Infection. Available from: www.who.int/tb/areas-of-work/preventive-care/ltbi/en/

developing active TB by at least 60%. However, safety concerns exist, mainly related to the development of drug-related adverse events including hepatotoxicity. The following regimens recommended by the WHO TB Report 2015 [4] for the treatment of LTBI are: daily therapy with INH for 6–9 months; 12 weeks rifapentine plus INH weekly; 3–4 months INH plus rifampicin daily; rifampicin plus pyrazinamide for 2 months or 3–4 months RIF alone. While the safety of 2 months of RIF and PZA has shown to be acceptable in HIV-infected persons and children, in non-HIV-infected adults, this regimen has demonstrated a high rate of severe liver toxicity [52].

Identification of latently infected individuals and their treatment has lowered TB incidence in rich, advanced countries. Similar approaches also hold great promise for countries with low to intermediate rates of TB incidence. Wide variations are observed for the cost of screening of eligible candidates for LTBI treatment and the costs for treatment. For reasons of practicality and cost effectiveness, most high-income countries consider and check as eligible population refugees or asylum seekers or those individuals arriving from high TB burden settings. The available evidence suggests that screening for and treatment of LTBI may be a cost-effective intervention in population groups characterized by high prevalence of LTBI and/or high risk of progression to active TB, such as persons migrating from high TB incidence countries, contacts with active TB cases, and persons living with HIV.

## 5. Essentials of diagnosis of infectious TB among immigrants in low TB burden countries

Owing difficulties in access to health system, TB diagnosis and treatment are lower in migrant populations compared to native subjects. This is in part due the fact that migrants, in general, have a longer patient diagnostic delay for TB (time elapsed from the onset of symptoms and the first medical visit) possibly due to a combination of reasons including language barriers, unemployment, or interruption due to lack of medical insurance that hinder migrants from using the available health TB services, while natives have a longer health care diagnostic delay (defined as the time elapsed between the first medical consultation and the initiation of treatment) [53]. Although the reliability of epidemiological assessments has progressively improved in recent years, no more than 30% of the estimated number of people suffering from TB, including migrants, is actually diagnosed with a method of proven efficacy [54]. Moreover, current diagnostic tests have poor performance on forms of TB which are intrinsically difficult to diagnose, such as childhood TB, smear-negative pulmonary TB and EPTB, TB in HIV/AIDS patients, and drug-resistant TB.

#### 5.1. Conventional diagnostic methods

developing active TB by at least 60%. However, safety concerns exist, mainly related to the development of drug-related adverse events including hepatotoxicity. The following regimens recommended by the WHO TB Report 2015 [4] for the treatment of LTBI are: daily therapy with INH for 6–9 months; 12 weeks rifapentine plus INH weekly; 3–4 months INH plus rifampicin daily; rifampicin plus pyrazinamide for 2 months or 3–4 months RIF alone. While the safety of 2 months of RIF and PZA has shown to be acceptable in HIV-infected persons and children, in non-HIV-infected adults, this regimen has demonstrated a high rate of severe liver

Figure 2. Algorithm for the management of LTBI in individuals at risk for TB. Modified and adapted from Guidelines on the Management of Latent Tuberculosis Infection. Available from: www.who.int/tb/areas-of-work/preventive-care/ltbi/en/

Identification of latently infected individuals and their treatment has lowered TB incidence in rich, advanced countries. Similar approaches also hold great promise for countries with low to intermediate rates of TB incidence. Wide variations are observed for the cost of screening of eligible candidates for LTBI treatment and the costs for treatment. For reasons of practicality and cost effectiveness, most high-income countries consider and check as eligible population refugees or asylum seekers or those individuals arriving from high TB burden settings. The available evidence suggests that screening for and treatment of LTBI may be a cost-effective intervention in population groups characterized by high prevalence of LTBI and/or high risk of progression to active TB, such as persons migrating from high TB incidence countries, contacts

toxicity [52].

with active TB cases, and persons living with HIV.

138 People's Movements in the 21st Century - Risks, Challenges and Benefits

To date, the most common methods for diagnosing TB worldwide which constitute the backbone of TB diagnosis remain the "old" sputum smear microscopy test and bacteriological culture which is also the test necessary for monitoring patients' response to treatment [2, 3]. These methods, however, represent a major constraint even in high-tech, high-resources western countries, when the mycobacterial load is low or the district of infection is not easily accessible. TB diagnosis includes suspicion as first step. All patients with TB, including migrants, can present with almost any symptom including cough, shortness of breath, chest pain, hemoptysis, together with the presence of constitutional symptoms (weight loss, fever, fatigue, and night sweats) which meet the definition of a suspected TB case according to WHO [55]. These symptoms must be considered in differential diagnosis in patients with epidemiologic risk (exposure to infectious patients, travel to or residence in a high prevalence area, previous TB) [2, 54]. The clinical suspicion of TB is then investigated through radiographic imaging, microbiology, and histopathology. Radiology could also have an important role in the diagnosis of TB in low-resource countries, especially as pre-entry TB screening in country of origin for those migrants who intend to migrate and refugees. However, the equipment is expensive and it needs qualified and experienced staff to be able to interpret the radiological signs—they are not always available in these settings [23, 45, 56, 57]. Moreover, CXR cannot provide a conclusive diagnosis on its own and needs to be followed by sputum testing. Although inexpensive and potentially easy to perform, conventional smear microscopy has a number of limitations including the variable (from 20 to 80%) sensitivity which is low, particularly among all persons coinfected with TB and HIV, including migrants and children, due to the reduced pulmonary bacillary load in these subjects [58]; it cannot distinguish between MBT complex and non-TB mycobacteria and it does not provide information on the resistance profile of the bacilli. In this setting, phenotypic drug-susceptibility testing (DST) on cultured specimens is the conventional method used to detect resistance to first- and SLD-TB drugs in MDR-TB and monitoring patients' response to treatment [4]. Finally, the challenge of TB diagnosis in the low-income countries including the tropics, must also take into account the differential diagnosis with a wide spectrum of microbial agents causing respiratory infections of which migrants can be affected and include viruses, bacteria (Actynomicetes), and parasites (paracoccidioidomycosis, paragonimiasis, dirofilariosis), which can mimic TB [2, 3, 9], and other diseases such as sarcoidosis and cancer. In these settings, basic radiography and other analyses are of considerable use but are not available in all centers [9].

#### 5.2. Advanced diagnostic techniques

Current-generation MTB-specific nucleic acid amplification tests (NAATs) can be a valid surrogate to direct observation or isolation of tubercular bacilli and to replace culture [33] and detect new TB cases within few hours. Although NAATs are widely used in Europe [33, 59], their high cost and level of technical support hindered the widespread adoption in TB endemic countries. Improving diagnosis in high-income countries is a strategic goal in TB research, and the pipeline of diagnostic tools is rapidly growing: new ways of performing sputum smear microscopy and innovative technologies for molecular diagnosis have already been endorsed by WHO, or are under investigation [60]. To respond to the urgent need for simple and rapid diagnostic tools at the point of treatment in high-burden countries, a fully automated molecular test for M. tuberculosis detection and resistance to RIF testing was developed (Xpert®MTB/ RIF) and has been endorsed by WHO in December 2010 [56]. Its capability to simultaneously detect mutations conferring resistance to RIF extends its usefulness beyond the diagnosis of TB (sensitivity 98.2 and 72.5% respectively for smear-positive and smear-negative samples; specificity 99.2%), also to first-line assessment of RIF resistance (99.1% sensitivity and 100% specificity) and prediction of multidrug resistance (99% sensitivity) [61]. Xpert®MTB/RIF system has the advantage to provide accurate results in less than 2 hours as it requires minimal biosafety supplies and training, so that patients can receive treatment from the same day on. According to WHO recommendations, Xpert®MTB/RIF, which is less sensitive than culture but more sensitive than microscopy [62], should be especially used as the initial diagnostic test in all individuals including migrants suspected of multidrug-resistant (MDR) TB or HIVassociated TB and in testing cerebrospinal fluid specimens from patients presumed to have TB meningitis; it may be used as a follow-on test to microscopy in settings where MDR and/or HIV is of lesser concern, especially in smear-negative specimens (conditional recommendation, recognizing major resource implications). With the introduction of Xpert®MTB/RIF, there has been an increase of the number of microbiologically confirmed TB in children [63], thus offering in low-income and middle-income countries, an opportunity for investigators to provide access to diagnosis for children beyond smear microscopy, and an increase of the number of pulmonary TB cases detected in HIV-positive patients when compared with microscopy [62]. Although with high specificity, Xpert®MTB/RIF has shown limited sensitivity for the detection of EPTB especially in HIV-positive individuals and among migrants in whom it can mimic cancer, bacterial and fungal infections [4, 64]. Other than Xpert®MTB/RIF test, new TB diagnostic tests may enhance diagnostic algorithms by offering rapid, point-of-care, or near-care detection of TB. One of these is the urine tests for lipoarabinomannan (LAM) and is detectable in the urine of all individuals with active TB [65]. Urine-based testing has advantages over sputum-based testing because urine is easy to collect and store, and lacks the infection control risks associated with sputum collection. The test is easy to perform, rapid (less than 30 minutes), and may be used at the point at which care is provided for TB or HIV. The urinary LAM assays currently available are unsuitable as general diagnostic or screening tests for TB, due to suboptimal sensitivity. The test was found to be cost-effective in sub-Saharan Africa when used for HIV-positive patients with CD4 counts of less than 100 per mm<sup>3</sup> [66], but lacks accuracy if used in patients with CD4 counts over 200 or in children. WHO recommends that LAM assay should be used for the diagnosis of TB in all HIV-positive persons with low CD4 counts or in those who are seriously ill,<sup>4</sup> and to assist in the diagnosis of TB in HIV-positive adult inpatients with signs or symptoms of TB (pulmonary and/or EPTB) who have a CD4 cell count less than or equal to 100 cells/L [4]. Other new generation NAAT kits have been released for research use [67], but further data are needed before their potential to assist TB control can be judged. Independent studies are required in settings representative of the intended use of the device.

## 6. Management and treatment of drug-resistant TB

So far TB treatment in migrant populations represents a challenge as it contributes considerably to illness and death especially in western countries. There are not only the economic but also the social costs. A number of social determinants, such as limited language, sociopsychological barriers, lack of employment, fear of expulsion, and access to health care facilities, often lead to a protracted diagnosis. Thus, TB treatment of these patients can be limited or inadequate and this is fundamental for conferring TB drug resistance.

#### 6.1. MDR and XDR-TB management issues

MDR-TB and monitoring patients' response to treatment [4]. Finally, the challenge of TB diagnosis in the low-income countries including the tropics, must also take into account the differential diagnosis with a wide spectrum of microbial agents causing respiratory infections of which migrants can be affected and include viruses, bacteria (Actynomicetes), and parasites (paracoccidioidomycosis, paragonimiasis, dirofilariosis), which can mimic TB [2, 3, 9], and other diseases such as sarcoidosis and cancer. In these settings, basic radiography and other analyses

Current-generation MTB-specific nucleic acid amplification tests (NAATs) can be a valid surrogate to direct observation or isolation of tubercular bacilli and to replace culture [33] and detect new TB cases within few hours. Although NAATs are widely used in Europe [33, 59], their high cost and level of technical support hindered the widespread adoption in TB endemic countries. Improving diagnosis in high-income countries is a strategic goal in TB research, and the pipeline of diagnostic tools is rapidly growing: new ways of performing sputum smear microscopy and innovative technologies for molecular diagnosis have already been endorsed by WHO, or are under investigation [60]. To respond to the urgent need for simple and rapid diagnostic tools at the point of treatment in high-burden countries, a fully automated molecular test for M. tuberculosis detection and resistance to RIF testing was developed (Xpert®MTB/ RIF) and has been endorsed by WHO in December 2010 [56]. Its capability to simultaneously detect mutations conferring resistance to RIF extends its usefulness beyond the diagnosis of TB (sensitivity 98.2 and 72.5% respectively for smear-positive and smear-negative samples; specificity 99.2%), also to first-line assessment of RIF resistance (99.1% sensitivity and 100% specificity) and prediction of multidrug resistance (99% sensitivity) [61]. Xpert®MTB/RIF system has the advantage to provide accurate results in less than 2 hours as it requires minimal biosafety supplies and training, so that patients can receive treatment from the same day on. According to WHO recommendations, Xpert®MTB/RIF, which is less sensitive than culture but more sensitive than microscopy [62], should be especially used as the initial diagnostic test in all individuals including migrants suspected of multidrug-resistant (MDR) TB or HIVassociated TB and in testing cerebrospinal fluid specimens from patients presumed to have TB meningitis; it may be used as a follow-on test to microscopy in settings where MDR and/or HIV is of lesser concern, especially in smear-negative specimens (conditional recommendation, recognizing major resource implications). With the introduction of Xpert®MTB/RIF, there has been an increase of the number of microbiologically confirmed TB in children [63], thus offering in low-income and middle-income countries, an opportunity for investigators to provide access to diagnosis for children beyond smear microscopy, and an increase of the number of pulmonary TB cases detected in HIV-positive patients when compared with microscopy [62]. Although with high specificity, Xpert®MTB/RIF has shown limited sensitivity for the detection of EPTB especially in HIV-positive individuals and among migrants in whom it can mimic cancer, bacterial and fungal infections [4, 64]. Other than Xpert®MTB/RIF test, new TB diagnostic tests may enhance diagnostic algorithms by offering rapid, point-of-care, or near-care detection of TB. One of these is the urine tests for lipoarabinomannan (LAM) and is detectable in the urine of all individuals with active TB [65]. Urine-based testing has

are of considerable use but are not available in all centers [9].

140 People's Movements in the 21st Century - Risks, Challenges and Benefits

5.2. Advanced diagnostic techniques

The current standard of care of drug-susceptible MTB requires 6–9 months of combination therapy which includes a 2-month "intensive" phase of a four-drug cocktail containing RIF, INH, PZA, and EMB; followed by a longer "continuation" phase of RIF and INH to eradicate the remaining bacilli that have entered a dormant, slowly replicating the latent phase. Currently, standardized regimens require that patients' daily ingest up to four drugs under direct observation of a healthcare worker for a period of 6–9 months. In this setting, directly observed treatment (DOT) of TB reduces TB-related death, disability, and transmission; it is a highly cost-effective intervention, even in the lowest income countries [54]. Treatment of TB represents a therapeutic challenge because of not only the natural level high resistance of M. tuberculosis to antibiotics, but also because of the occurrence of new mutations that confer additional resistance as well as multidrug strains. The drug-resistant TB represents a constant threat to some groups of patients, including migrants, who do not take the medication once they start to feel better. Indeed, an increasing number of MDR-TB strains are isolated because of the poor compliance to treatment that characterizes migrants themselves. Nowadays, the insufficient treatment regimens, nonadherence, and poor availability of drugs are a major

<sup>4</sup> Respiratory rate >30/min, temperature >39°C, heart rate >120/min, severe difficulty to walk unaided.

cause of treatment failure, relapse of disease, and TB drug-resistance especially in migrants. Eastern European countries are among those with the highest rates of MDR-TB and have also the most drug-resistant (XDR) strains in the world5 [15]. By the end of September 2009, at least one case of XDR-TB had been reported by each of the 25 countries in the European continent. The majority of European and other low prevalence countries, excluding some of the high priority countries in the WHO European Region (such as Latvia, Lithuania, Bulgaria, and Estonia), also reported higher prevalence of MDR-TB cases in migrants when compared to the native population [68]. The number of cases of XDR-TB diagnosed globally is rising as expected because of improved laboratory testing and reporting. The diagnosis of XDR-TB is equivalent today to a death sentence. Factors contributing to higher mortality rates in patients with XDR-TB include: resistance to six or more drugs, delayed diagnoses, prescribing ineffective drug therapies due to the lack of DST, and deprivation of programmatic access to effective SLD. During 2015, 105 countries reported cases of XDR-TB to the WHO [4]. However, the highest numbers were registered in 2014 and included India, Ukraine, South Africa, Belarus, and Kazakhstan [4]. In the United States, 15 cases of XDR-TB were reported to the CDC between 2009 and 2014 [4]. In Italy, the proportion of TB cases notified in foreigners increased from 22% in 1999 to 46% in 2008, paralleling the proportion of MDR-TB cases which consistently grew to 83% [13, 69]. A recent retrospective study conducted over the period 2008–2010 aimed to investigate drug-resistance proportions and drug-resistance profiles of M. tuberculosis strains circulating among immigrants and natives. It showed that the five countries mainly contributing to the TB resistance in foreigner groups in Italy were Romania (28.7%), Morocco (9.9%), Peru (5.8%), Pakistan (5.8%), and India (5.6%). Moreover, the MDR-TB prevalence in immigrants was consistent with that of their native countries (e.g., in 2009: Romania, 11.2%; Ukraine, 19%; Moldova, 44.3%). Differences in culture may impact significantly on TB prevention, diagnosis, and treatment in immigrants which, unlike the general population, are also at greater risk of having an infection with MDR-TB [14]. In general, patients who do not respond to previous TB therapy have an up to a 50-fold higher risk of having MDR- and XDR-TB. Other prominent risk factors include close contact to a patient with MDR-TB, migration, HIV infection, and young age. Moreover, as infection control policies are problematic in many developing countries, nosocomial transmission of MDR- and XDR-TB is 3–6 times higher in patients hospitalized for more than 14 days [70]. In particular, the risk increases in open hospital wards where advanced HIV-infected with low CD4 cell counts can facilitate the nosocomial spread of infection. The management of patients with MDR-TB, XDR-TB, or total resistant TB requires an appropriate and rapid diagnosis. After identification of high-risk groups, microbiological confirmation and appropriate treatment should be started [71, 72]. Confirmation of resistant-TB and identification of potentially effective drugs in an optimized combination treatment regimen should be done on the basis of antimicrobial DST. However, only 22% of countries worldwide routinely perform cultures and DST, and only 48% of the 46 countries in the WHO Africa region have ever undertaken a drug-resistance survey [4, 73]. Moreover, DST is often too expensive, especially in high-burden countries, and in many settings it is neglected because

<sup>5</sup> That is, MDR strains resistant to any FC and to at least one of three injectable SLD: KM, CM, AK.

of the lack of SLD [73, 74]. In general, treatment for MDR-TB can extend up to 2 years after microbiologic culture conversion and relies on more toxic, less efficacious second- or third-line agents, many of which are even more scarce than frontline drugs in affected areas [75].

cause of treatment failure, relapse of disease, and TB drug-resistance especially in migrants. Eastern European countries are among those with the highest rates of MDR-TB and have also the most drug-resistant (XDR) strains in the world5 [15]. By the end of September 2009, at least one case of XDR-TB had been reported by each of the 25 countries in the European continent. The majority of European and other low prevalence countries, excluding some of the high priority countries in the WHO European Region (such as Latvia, Lithuania, Bulgaria, and Estonia), also reported higher prevalence of MDR-TB cases in migrants when compared to the native population [68]. The number of cases of XDR-TB diagnosed globally is rising as expected because of improved laboratory testing and reporting. The diagnosis of XDR-TB is equivalent today to a death sentence. Factors contributing to higher mortality rates in patients with XDR-TB include: resistance to six or more drugs, delayed diagnoses, prescribing ineffective drug therapies due to the lack of DST, and deprivation of programmatic access to effective SLD. During 2015, 105 countries reported cases of XDR-TB to the WHO [4]. However, the highest numbers were registered in 2014 and included India, Ukraine, South Africa, Belarus, and Kazakhstan [4]. In the United States, 15 cases of XDR-TB were reported to the CDC between 2009 and 2014 [4]. In Italy, the proportion of TB cases notified in foreigners increased from 22% in 1999 to 46% in 2008, paralleling the proportion of MDR-TB cases which consistently grew to 83% [13, 69]. A recent retrospective study conducted over the period 2008–2010 aimed to investigate drug-resistance proportions and drug-resistance profiles of M. tuberculosis strains circulating among immigrants and natives. It showed that the five countries mainly contributing to the TB resistance in foreigner groups in Italy were Romania (28.7%), Morocco (9.9%), Peru (5.8%), Pakistan (5.8%), and India (5.6%). Moreover, the MDR-TB prevalence in immigrants was consistent with that of their native countries (e.g., in 2009: Romania, 11.2%; Ukraine, 19%; Moldova, 44.3%). Differences in culture may impact significantly on TB prevention, diagnosis, and treatment in immigrants which, unlike the general population, are also at greater risk of having an infection with MDR-TB [14]. In general, patients who do not respond to previous TB therapy have an up to a 50-fold higher risk of having MDR- and XDR-TB. Other prominent risk factors include close contact to a patient with MDR-TB, migration, HIV infection, and young age. Moreover, as infection control policies are problematic in many developing countries, nosocomial transmission of MDR- and XDR-TB is 3–6 times higher in patients hospitalized for more than 14 days [70]. In particular, the risk increases in open hospital wards where advanced HIV-infected with low CD4 cell counts can facilitate the nosocomial spread of infection. The management of patients with MDR-TB, XDR-TB, or total resistant TB requires an appropriate and rapid diagnosis. After identification of high-risk groups, microbiological confirmation and appropriate treatment should be started [71, 72]. Confirmation of resistant-TB and identification of potentially effective drugs in an optimized combination treatment regimen should be done on the basis of antimicrobial DST. However, only 22% of countries worldwide routinely perform cultures and DST, and only 48% of the 46 countries in the WHO Africa region have ever undertaken a drug-resistance survey [4, 73]. Moreover, DST is often too expensive, especially in high-burden countries, and in many settings it is neglected because

142 People's Movements in the 21st Century - Risks, Challenges and Benefits

That is, MDR strains resistant to any FC and to at least one of three injectable SLD: KM, CM, AK.

5

#### 6.2. Therapeutic concerns of MDR and XDR-TB in different population groups including migrants

Patients with MDR-TB strains should receive therapy based on individual DST including residual first-line (SM), EMB, PZA drugs, and SLD such as oxacin, KM, CM, ET, PAS, and CS. As with other antimicrobial agents, the use of SLD can generate resistant mutants. DST often shows poor reproducibility and lack of correlation with clinical response. The initial intensive phase of therapy should last 6–8 months and includes at least 4 months after culture conversion. Compared with the treatment of drug-susceptible TB, the treatment of MDR- and XDR-TB requires more drugs that are less well tolerated for a more prolonged duration. The available TB drugs against MDR/XDR-TB are included among a hierarchy of five groups, with first-line TB drugs listed in Group 1 and second-line drugs in Groups 2 through 5 [76]. Group 1 is composed of first-line TB drugs RIF, INH, PZA, and EMB; Group 2 contains the injectable agents embracing the bactericidal aminoglycosides (SM, AK, and KM) and CM, whereas Group 3 consists of FC including gatifloxacin and moxifloxacin. The remaining SLD ethionamide/prothionamide, CS, and PAS are inside Group 4 and are considered less potent and often less well tolerated by patients. Group 5 contains new antimicrobial agents, those with less clinical experience, and drugs with less proven efficacy in the management of drugresistant TB such as clofazimine, developed in the 1950s to treat leprosy. Bedaquiline, delamanid, linezolid, clofazimine, meropenem, amoxicillin-clavulanate, and clarithromycin are included in this category. Although adherence to therapeutic programs is often impossible for immigrants as they are often lost in follow-up, at least five drugs (including an injectable agent) should be given for an "intensive phase" of up to 8 months. The specific drugs chosen depend on a patient's previous TB drug therapies and individual DST results. Thereafter, a "continuation phase" of least four oral drugs should be continued until a total minimum duration of 20 months. Prolonged therapy presents a range of practical challenges including prolonged hospitalization with conspicuous health care cost, toxicity (i.e., nephro- and ototoxicity with aminoglycoside drugs), and high loss to follow-up during continuation therapy. Finally, drug-resistant TB can represent in Africa a particular risk to individuals with HIV with high transmission of infection and high mortality [77]. Treatment success rates of MDR/XDR-TB vary between 36 and 79% [78, 79]. Surgery can have a positive adjunctive role with combination of antimicrobial drug therapy in the management of drug-resistant TB, but does not allow for shortening the duration of therapy [80].

Three groups of people deserve special attention in MDR/XDR TB management: children, pregnant women, and HIV-positive patients.

There are not enough data regarding optimal duration of MDR/XDR-TB treatment in children which may vary from case to case. Depending on the extent of the disease, the TB DST pattern and the immune status of the child, a total duration of treatment between 12 and 18 months following culture conversion could be acceptable, with the recommendation to continue the treatment only in particular cases to avoid relapse [30]. However, the clinical trials in children so far carried out are not enough to supporting this approach.

Regarding pregnancy, there is consensus that neither LTBI following contact of a patient with MDR/XDR-TB nor active MDR/XDR-TB requires cessation of pregnancy [81]. While safety of many drugs for the unborn child is unknown, treatment of pregnant females who develop MDR/XDR-TB or become pregnant during treatment can be successful without adverse events for the newborn, although aminoglycosides/polypeptides are not recommended for MDR/XDR-TB treatment during pregnancy [82]. Theoretically, breastfeeding should be recommended only in females who are not infectious. However, the known and theoretical benefits of continuing treatment seem to outweigh theoretical risks to the mother and fetus.

Being TB and HIV strictly related, HIV exacerbates TB and the phenomenon of MDR/XDR-TB is somehow increasing in these patients in whom HIV testing is not always evaluated especially in particular countries, thereby delaying the initiation of antiretroviral therapy (ART) which could significantly reduce mortality, relapse rates, and development of resistant strains [83]. This is especially true for immigrants in whom not only it is difficult the access HIV testing, but also ART testing. A large body of research has in fact shown that migrants are more likely to enter into the healthcare system late and are less likely to be retained at successive stages of the HIV treatment cascade.

MDR/XDR-TB has higher mortality rates especially in South Africa [83, 84] among MDR/XDR-TB and HIV coinfected cases with very low CD4 cell counts and limited access to ART. Timely diagnosis based on molecular assays is crucial to reduce the mortality associated with MDR/ XDR-TB patients among HIV-infected persons. Owing to high case detection rates compared to smear microscopy, WHO recommends Xpert®MTB/RIF as a primary diagnostic test for TB in persons living with AIDS [4].

In conclusion, treatment for MDR/XDR-TB is far from optimal at present. In particular, treatment of MDR/XDR-TB in migrants living in high-income countries is associated with increased risk of therapy nonadherence, loss to follow-up, and in general, noncontinuity of anti-TB care that worsens drug-resistant TB. Migrants' slow progression through the TB or HIV treatment cascade can be attributed to feelings of confusion, inability to effectively communicate in the native language, and poor knowledge about administrative or logistical requirements of the healthcare system.

Novel therapeutic interventions with shorter treatment regimens with higher efficacy and better tolerability than those currently available are required. In addition, new drugs need to be developed and existing drugs for anti-TB properties should be reevaluated for their potential efficacy in the treatment of MDR/XDR-TB. In receiving high-income countries, the international community has responded with financial and scientific support, leading to new drugs [85] and regimens in advanced clinical development and an increasingly sophisticated understanding of resistance mechanisms and their application to all aspects of TB control and treatment. In the absence of a preventive vaccine, more effective diagnostic tools, and novel drugs, the control of MDR/XDR-TB will be extremely difficult. Moreover, the increasing rates of drug-resistant TB in Eastern EU, Asia, and sub-Saharan Africa is now threatening the gains made by TB control programs worldwide.

## 7. Conclusions and social issues

treatment only in particular cases to avoid relapse [30]. However, the clinical trials in children

Regarding pregnancy, there is consensus that neither LTBI following contact of a patient with MDR/XDR-TB nor active MDR/XDR-TB requires cessation of pregnancy [81]. While safety of many drugs for the unborn child is unknown, treatment of pregnant females who develop MDR/XDR-TB or become pregnant during treatment can be successful without adverse events for the newborn, although aminoglycosides/polypeptides are not recommended for MDR/XDR-TB treatment during pregnancy [82]. Theoretically, breastfeeding should be recommended only in females who are not infectious. However, the known and theoretical benefits of continuing treatment seem to outweigh theoretical

Being TB and HIV strictly related, HIV exacerbates TB and the phenomenon of MDR/XDR-TB is somehow increasing in these patients in whom HIV testing is not always evaluated especially in particular countries, thereby delaying the initiation of antiretroviral therapy (ART) which could significantly reduce mortality, relapse rates, and development of resistant strains [83]. This is especially true for immigrants in whom not only it is difficult the access HIV testing, but also ART testing. A large body of research has in fact shown that migrants are more likely to enter into the healthcare system late and are less likely to be retained at

MDR/XDR-TB has higher mortality rates especially in South Africa [83, 84] among MDR/XDR-TB and HIV coinfected cases with very low CD4 cell counts and limited access to ART. Timely diagnosis based on molecular assays is crucial to reduce the mortality associated with MDR/ XDR-TB patients among HIV-infected persons. Owing to high case detection rates compared to smear microscopy, WHO recommends Xpert®MTB/RIF as a primary diagnostic test for TB

In conclusion, treatment for MDR/XDR-TB is far from optimal at present. In particular, treatment of MDR/XDR-TB in migrants living in high-income countries is associated with increased risk of therapy nonadherence, loss to follow-up, and in general, noncontinuity of anti-TB care that worsens drug-resistant TB. Migrants' slow progression through the TB or HIV treatment cascade can be attributed to feelings of confusion, inability to effectively communicate in the native language, and poor knowledge about administrative or logistical requirements of the

Novel therapeutic interventions with shorter treatment regimens with higher efficacy and better tolerability than those currently available are required. In addition, new drugs need to be developed and existing drugs for anti-TB properties should be reevaluated for their potential efficacy in the treatment of MDR/XDR-TB. In receiving high-income countries, the international community has responded with financial and scientific support, leading to new drugs [85] and regimens in advanced clinical development and an increasingly sophisticated understanding of resistance mechanisms and their application to all aspects of TB control and treatment. In the absence of a preventive vaccine, more effective diagnostic tools, and novel drugs, the control of MDR/XDR-TB will be extremely difficult. Moreover, the increasing rates

so far carried out are not enough to supporting this approach.

144 People's Movements in the 21st Century - Risks, Challenges and Benefits

risks to the mother and fetus.

in persons living with AIDS [4].

healthcare system.

successive stages of the HIV treatment cascade.

Although the WHO Report 2015 [4] with its "STOP TB" strategy has the goal to eliminate TB as a public health problem (defined as <1 case per 1 million population per year) by 2050, TB shows no signs of disappearing in the near future despite declining incidence in most high-income countries. TB is still one of the top three infectious killing diseases in the world, after HIV/AIDS that kills 3 million people each year, TB kills 2 million, and malaria kills 1 million [4]. In order to intensify the fights against this deadly disease, further efforts aimed to strength surveillance programs to accurately estimate the burden of all kinds of TB are of great significance. Considering the enormous number of migrants around the world [8] with its high rates in the USA and Europe (54 and 76 million, respectively), particularly in Germany, Russia, the UK, France, Spain, and Italy, other than Saudi Arabia, Canada, and Australia, the problem of TB is of foremost importance and deserves great attention in order to act promptly to find solutions.

Although migration in itself is not a definitive risk for TB, several factors can put migrants in vulnerable situations that push factors (desertification, famine/drought, political fear/persecution, poor medical care, loss of wealth, and natural disasters), and pull factors (search of job opportunities, better living conditions, better medical care, political and/or religious freedom and security) migrant people in and out of TB-endemic areas [86]. Social fragility of migrant populations, despite its heterogeneity, shows areas of health suffering in large part due to highly uncertain circumstances and integration policies in receiving countries, especially at the local level, difficulties in access to services, and to relational communicative problems. In fact, the slow or less rapid deterioration of the migrant health in the host country creates serious problems, both to the person who is sick, and to the community which is forced to support the social and economic costs that this entails. Therefore, understanding the changing socioenvironmental situation as well as population movements and their associated risks for TB infection is critical for control, containment, and elimination of this disease which still poses infection-control and public-health challenges in the twenty-first century. Providing services aimed to identify and treat TB in migrants, refugees, or asylum seekers who are at high TB risk is challenging and requires a multidisciplinary approach and a high rate of investment of resources, human, structural, and material [87]. In immigrants living in high-income countries there are crucial factors that play an important role in TB-drug adherence which include length of treatment course, complex regimens, medication side effects, poor access to health care services, poor communication with health care providers, lack of social support, negative perceptions, stigma, and discrimination. The lack of laboratory facilities in their country of origin made the laboratory diagnosis of infectious diseases, including TB, difficult in many parts of the African continent as well as in the majority of other poor and low resource countries, where the diagnosis continues to rely on century-old sputum microscopy. In recent years, a growing number of rapid and more sensitive tests for TB and drug-resistant TB, based on molecular methods, including Xpert®MTB/ RIF, have become available to replace or parallel exist to conventional tests; however, current TB diagnostics are still suboptimal in their performance for childhood TB, smear-negative TB, EPTB, HIV-TB, and drug-resistant TB. Furthermore, there is no standard test for the identification of LTBI, which, if correctly identified in particular risk groups including migrants, could be appropriately treated in order to prevent the onset of TB. So far, neither test can reliably predict future disease among persons with positive tests, and strong positive tests do not suggest a higher risk.

Looking at the movement of people today, at world politics, and at the increasing gap between the rich and the poor, it is expected that the number of immigrants will increase and with it health risks of those on the move and, to a lesser extent, the risk of those in the receiving countries can also be anticipated. It is argued here that a substantial increase in funding for TB research is required. There is no vaccine with adequate effectiveness, and TB treatment regimens are protracted and have a risk of toxic effects. Moreover, fundamental understanding of the pathogenesis of this disease is inadequate. In order to achieve the ambitious targets of the End-TB strategy 2035 (95% reduction in TB deaths, compared with 2015), 90% reduction in TB incidence rate (less than 100 TB cases per million population, no affected families facing catastrophic costs due to TB), greater efforts are needed also regarding migrants interventions, such as support services to receive and treat migrants, improving their access to health facilities, preventing the development of drug resistance through high quality treatment of drugsusceptible TB, improving adherence to anti-TB treatment, and offering vaccination for TB especially to prevent TB meningitis in children in endemic areas. Control strategies need to be adapted to local realities after evaluation of data prevalence/incidence, feasibility, and cost effectiveness. TB transmission among immigrants and natives is still rare, although it could increase in case of limited TB control. Thus, interventions such as expansion of the free service package and education about TB diagnosis among community health personnel are urgently required for early LTBI or case detection among migrants, particularly those born in a country with a high incidence of disease or in those persons exposed to the contact with TB, like close relatives of infectious patients [87]. It is recommended that high-income countries and their institutions cooperate in the near future with high-burden countries [4]. One important goal inside the "Global Action Framework for Research towards TB Elimination," developed by WHO [4] for the period 2016–2025 will be in fact to translate the new technologies and innovative approaches into policies and practices and then adapt to particular country contexts as appropriate. This is only another rational approach that in future will help to reach some of the ambitious targets to control, perhaps stop TB, in the coming decades.

#### Abbreviations


The Impact of Tuberculosis among Immigrants: Epidemiology and Strategies of Control in High-Income Countries... http://dx.doi.org/10.5772/66823 147


#### Author details

diagnostics are still suboptimal in their performance for childhood TB, smear-negative TB, EPTB, HIV-TB, and drug-resistant TB. Furthermore, there is no standard test for the identification of LTBI, which, if correctly identified in particular risk groups including migrants, could be appropriately treated in order to prevent the onset of TB. So far, neither test can reliably predict future disease among persons with positive tests, and strong positive tests do not suggest a higher risk. Looking at the movement of people today, at world politics, and at the increasing gap between the rich and the poor, it is expected that the number of immigrants will increase and with it health risks of those on the move and, to a lesser extent, the risk of those in the receiving countries can also be anticipated. It is argued here that a substantial increase in funding for TB research is required. There is no vaccine with adequate effectiveness, and TB treatment regimens are protracted and have a risk of toxic effects. Moreover, fundamental understanding of the pathogenesis of this disease is inadequate. In order to achieve the ambitious targets of the End-TB strategy 2035 (95% reduction in TB deaths, compared with 2015), 90% reduction in TB incidence rate (less than 100 TB cases per million population, no affected families facing catastrophic costs due to TB), greater efforts are needed also regarding migrants interventions, such as support services to receive and treat migrants, improving their access to health facilities, preventing the development of drug resistance through high quality treatment of drugsusceptible TB, improving adherence to anti-TB treatment, and offering vaccination for TB especially to prevent TB meningitis in children in endemic areas. Control strategies need to be adapted to local realities after evaluation of data prevalence/incidence, feasibility, and cost effectiveness. TB transmission among immigrants and natives is still rare, although it could increase in case of limited TB control. Thus, interventions such as expansion of the free service package and education about TB diagnosis among community health personnel are urgently required for early LTBI or case detection among migrants, particularly those born in a country with a high incidence of disease or in those persons exposed to the contact with TB, like close relatives of infectious patients [87]. It is recommended that high-income countries and their institutions cooperate in the near future with high-burden countries [4]. One important goal inside the "Global Action Framework for Research towards TB Elimination," developed by WHO [4] for the period 2016–2025 will be in fact to translate the new technologies and innovative approaches into policies and practices and then adapt to particular country contexts as appropriate. This is only another rational approach that in future will help to reach

146 People's Movements in the 21st Century - Risks, Challenges and Benefits

some of the ambitious targets to control, perhaps stop TB, in the coming decades.

Abbreviations

RIF Rifampicin INH Isoniazid PZA Pyrazinamide EMB Ethambutol KM Kanamycin CM Capreomycin

Carlo Contini\*, Martina Maritati, Marachiara di Nuzzo, Lorenzo Massoli, Sara Lomenzo and Anastasio Grilli

\*Address all correspondence to: cnc@unife.it

Department of Medical Sciences, Section of Infectious Diseases and Dermatology, University of Ferrara, Ferrara, Italy

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**Settlement of Immigrants – Some Cultural Aspects**

**Provisional chapter**

## **Sociocultural Models of Second-Language Learning of Young Immigrants in Canada Sociocultural Models of Second-Language Learning of Young Immigrants in Canada**

Fanli Jia, Alexandra Gottardo and Aline Ferreira Fanli Jia, Alexandra Gottardo and Aline Ferreira

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/66952

"People in America don't realized how funny I can be. When I was in China, I was known as quick-witted. I was always the first to make a funny joke about an ironic situation. Now, when these situations arise, I am trying to translate from Chinese to English what might be funny, but by the time, I do this, someone else has already made the witty joke. People around me here don't think I have a sense of humor. I feel I have lost a part of me when I moved here."


#### **Abstract**

The most significant challenge for the minority immigrant is learning a new language. They arrive in a new culture and community hoping to master English quickly in order to achieve their academic and career goals. However, many immigrants have mentioned general barriers resulting from being unable to communicate with peers outside their cultural and linguistic group. Recent research has identified several cognitive variables such as vocabulary, reading aloud, and grammatical judgment related to second-language learning in immigrants; however, little attention was given to sociocultural factors such as acculturation, motivation, and cultural learning because learning a language is a necessary aspect of being socialized into a particular culture. This chapter reviews research of sociocultural models in relation to second-language learning of immigrant youth in Canada. We address this paradigm for research by incorporating both acculturation and sociolinguistic approaches, as well as more traditional cognitive-linguistic approaches, to models of second-language learning in immigrants.

**Keywords:** Canada, language learning, acculturation, sociolinguistics, immigrants

and reproduction in any medium, provided the original work is properly cited.

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

## **1. Introduction**

Many individuals who migrate have little or no exposure to the majority language(s) of the country to which they immigrate. This is especially true of people from developing countries, who migrate to developed countries, such as Canada and United States. In addition, many individuals, who learn English in their country of origin before they emigrate, learn the language from non-native speakers. Therefore, how can a person succeed when that person cannot communicate effectively with other people on a daily basis? Most research has focused on the fact that language proficiencies in the mainstream language play a key role in most accounts of acculturation [1, 2, 6, 9, 10]. However, there has been surprisingly little research conducted that examines how cultural orientation and participation have an impact on language learning in the mainstream society. For example, learning the mainstream language varies among individuals with different levels of acculturation [3, 4]. Key questions include the following: do sociocultural factors such as acculturation, cultural learning in, and cultural orientation to the values of the mainstream culture of the host country have an impact on immigrants' secondlanguage proficiency beyond cognitive-linguistic variables traditionally used in the literature?

In an attempt to investigate this question, this chapter reviews theories of and research about sociocultural factors in relation to immigrants' second-language (L2) learning. There are many similarities between learning a language and learning a culture. A very appropriate proxy for how familiar a person is with a culture is his or her skill with the language (e.g., how he or she communicates verbally and in writing). Hence, one possible explanation for the relationship between language learning and acculturation is that it is easier for the immigrant to adapt the mainstream culture once they have a good grasp of the society's majority language. Understanding the patterns of language learning and cultural engagement in immigrants will lead to the development of improved programs to assist recent immigrants in becoming more successful learners.

## **2. Definition of acculturation**

Acculturation (as indicated in other chapters) refers to the change in the pattern of affiliation to one or both cultures that results from intergroup contact [5] including psychological and sociocultural adjustments [6]. Psychological adjustments refer to the person's general satisfaction with the society of settlement and are influenced by changes in cultural values, attitudes, and behaviors. Sociocultural adaption includes the ability to successfully interact with and fit into the mainstream culture.

John Berry laid the foundations for research on acculturation within psychology [6]. He has proposed that two issues are critical to the outcome of one's acculturation. The first issue involves how well people attempt to participate in the larger society of their new culture. Do people have positive attitudes toward the mainstream culture, and are they actively seeking to fit in? The second issue involves how well people are striving to maintain their own heritage culture and identity as members of that culture. Do people have positive attitudes toward their heritage culture and are they actively seeking ways to preserve the traditions of the heritage culture?

**Figure 1.** Four different types of acculturation.

**1. Introduction**

158 People's Movements in the 21st Century - Risks, Challenges and Benefits

**2. Definition of acculturation**

into the mainstream culture.

Many individuals who migrate have little or no exposure to the majority language(s) of the country to which they immigrate. This is especially true of people from developing countries, who migrate to developed countries, such as Canada and United States. In addition, many individuals, who learn English in their country of origin before they emigrate, learn the language from non-native speakers. Therefore, how can a person succeed when that person cannot communicate effectively with other people on a daily basis? Most research has focused on the fact that language proficiencies in the mainstream language play a key role in most accounts of acculturation [1, 2, 6, 9, 10]. However, there has been surprisingly little research conducted that examines how cultural orientation and participation have an impact on language learning in the mainstream society. For example, learning the mainstream language varies among individuals with different levels of acculturation [3, 4]. Key questions include the following: do sociocultural factors such as acculturation, cultural learning in, and cultural orientation to the values of the mainstream culture of the host country have an impact on immigrants' secondlanguage proficiency beyond cognitive-linguistic variables traditionally used in the literature? In an attempt to investigate this question, this chapter reviews theories of and research about sociocultural factors in relation to immigrants' second-language (L2) learning. There are many similarities between learning a language and learning a culture. A very appropriate proxy for how familiar a person is with a culture is his or her skill with the language (e.g., how he or she communicates verbally and in writing). Hence, one possible explanation for the relationship between language learning and acculturation is that it is easier for the immigrant to adapt the mainstream culture once they have a good grasp of the society's majority language. Understanding the patterns of language learning and cultural engagement in immigrants will lead to the development

of improved programs to assist recent immigrants in becoming more successful learners.

Acculturation (as indicated in other chapters) refers to the change in the pattern of affiliation to one or both cultures that results from intergroup contact [5] including psychological and sociocultural adjustments [6]. Psychological adjustments refer to the person's general satisfaction with the society of settlement and are influenced by changes in cultural values, attitudes, and behaviors. Sociocultural adaption includes the ability to successfully interact with and fit

John Berry laid the foundations for research on acculturation within psychology [6]. He has proposed that two issues are critical to the outcome of one's acculturation. The first issue involves how well people attempt to participate in the larger society of their new culture. Do people have positive attitudes toward the mainstream culture, and are they actively seeking to fit in? The second issue involves how well people are striving to maintain their own heritage culture and identity as members of that culture. Do people have positive attitudes toward their heritage culture and are they actively seeking ways to preserve the traditions of the heritage culture?

**Figure 1** illustrates different acculturation styles. The style that involves attempts to fit in and fully participate in the mainstream culture while at the same time striving to maintain the heritage culture is known as *integration*. People attempt to fully participate in the mainstream culture while making little or no effort to maintain the heritage culture is known as the *assimilation*. *Separation* involves efforts to maintain the heritage culture while establishing little contact with the host culture. Lastly, *marginalization* involves no effort to participate in the host culture or maintain the heritage culture.

## **3. Major models of acculturation and second-language learning in immigrant**

In Schumann's model, the main contributor to second-language learning is social distance from the mainstream culture [7]. He argued that the assimilation strategy is one of the most important social factors affecting L2 learning. If immigrants fully assimilate and adopt the mainstream lifestyles and values, social distances between the immigrant and mainstream culture are likely to be reduced. This strategy decreases social and psychological distances between the two groups and improves acquisition of the target L2 proficiency. Attitudes toward the mainstream culture are other important factors in acculturation that are related to L2 learning. If immigrant groups have positive attitudes toward the mainstream cultural groups, L2 learning is more likely to be enhanced than if the groups view each other negatively. Schumann also argued that the length of residence in a specific culture needs to be considered in relation to L2 learning. If the immigrants have been in the country for a long period of time, they are likely to develop more extensive contacts with mainstream groups [7].

Gardner's socio-educational model [4] postulates that achievement in L2 is related to a variety of social psychological outcomes such as "integrativeness," which refers to individuals' attitudes toward the mainstream cultural community, an acceptance of other culture, and an interest in participating in social interactions with members of the mainstream community. Immigrants who are eager to make contact with members of the mainstream community would be more interested in learning the language than individuals who do not. A few studies have indicated that "integrativeness" is positively related to L2 motivation and proficiency [4, 8]. For example, Masgoret and Gardner studied 248 Spanish-speaking newcomers to Canada [8]. Their results showed that the newcomers who adopted an assimilation mode of acculturation (a combination of high levels of English contact and low levels of Spanish contact) had higher levels of L2 English proficiency than the newcomers who demonstrated other acculturation strategies.

Clément and Bourhis [9] expanded the socio-educational model to include the construct of language confidence, which refers to confidence in being able to communicate in a well-organized and well-articulated way when using the L2. Studies have demonstrated that individual confidence in communicating in L2, along with subsequent language achievement, is a function of the frequency and quality of contact one has with the host culture [10]. However, it should be noted that the frequency and quality of contact require not only the willingness of the newcomer to communicate with members of the mainstream community but also the willingness of the mainstream community to interact with newcomers [11].

Cultural learning theory also offered an insight into the importance of acculturation and language learning through the concept of intercultural contact [12]. Ward and Searle [13] indicated that positive interactions with members of the mainstream cultural group are an essential factor for sociocultural adaptation, which enhances L2 proficiency. Despite this finding, studies conducted in Canada and USA have consistently shown that although newcomers expect and desire contact with members of the mainstream culture, the level of contact tends to be relatively low, and intercultural friendships are infrequent [2]. Lybeck [14] examined the social contact networks of English-Norwegian speakers. She found that building network connections with native Norwegian L2 speakers was positively related to more native-like pronunciation of Norwegian in L2 learners when compared with L2 learners who had greater difficulty establishing these connections. However, Harwood [15] argued that different types of social interaction had not been examined extensively. He proposed two dimensions with which to examine interactions: (1) being extensively involved in the interaction versus observing the social interaction and (2) interacting via social media versus face-to-face interactions.

In addition to intercultural contact, cultural learning researchers have examined mass media exposure and usage [16]. Immigrants make use of various types of mass media, such as TV, radio, newspapers, and magazines, which not only provide L2 exposure and practical day-today information but also provide knowledge about cultural norms and values for interpreting the cultural environment [16].

## **4. Other important factors that need to be considered in the research**

#### **4.1. Distance from mother tongue to English**

The ease with which people learn English is influenced by how distant their mother tongue is from English. One source for assessing how easily people learn the language of the mainstream culture is the average score for each country of origin on the International English Language Testing System (IELTS). People who wish to immigrate to Canada typically need to


**Table 1.** Average scores on the International English Language Testing System (IELTS).

pass the general training test on IELTS. Although average country scores on the language tests are influenced by many factors, these scores also vary considerably based on the participants' own mother language (**Table 1**). Individuals who grew up speaking languages that are similar to English or have the same roots (e.g., Spanish, French, or German) perform better than those who grew up speaking other European languages. Moreover, speakers of Indo-European languages tend to perform better on the IELTS than those who grew up speaking languages, which have linguistic roots that are distant from English such as Japanese and Korean [17]. Written languages can also vary markedly in terms of writing systems and scripts that determine ways in which sound-symbol relations are represented, with alphabetic scripts differing from morpho-syllabic scripts [18, 19]. For example, Chinese orthography codes language at the syllabic and morphemic level [19]; however, English is written using an alphabetic system. Other differences in written language include types of scripts, and the direction in which the langue is written.

#### **4.2. Previous experience with other cultures**

studies have indicated that "integrativeness" is positively related to L2 motivation and proficiency [4, 8]. For example, Masgoret and Gardner studied 248 Spanish-speaking newcomers to Canada [8]. Their results showed that the newcomers who adopted an assimilation mode of acculturation (a combination of high levels of English contact and low levels of Spanish contact) had higher levels of L2 English proficiency than the newcomers who demonstrated

Clément and Bourhis [9] expanded the socio-educational model to include the construct of language confidence, which refers to confidence in being able to communicate in a well-organized and well-articulated way when using the L2. Studies have demonstrated that individual confidence in communicating in L2, along with subsequent language achievement, is a function of the frequency and quality of contact one has with the host culture [10]. However, it should be noted that the frequency and quality of contact require not only the willingness of the newcomer to communicate with members of the mainstream community but also the

Cultural learning theory also offered an insight into the importance of acculturation and language learning through the concept of intercultural contact [12]. Ward and Searle [13] indicated that positive interactions with members of the mainstream cultural group are an essential factor for sociocultural adaptation, which enhances L2 proficiency. Despite this finding, studies conducted in Canada and USA have consistently shown that although newcomers expect and desire contact with members of the mainstream culture, the level of contact tends to be relatively low, and intercultural friendships are infrequent [2]. Lybeck [14] examined the social contact networks of English-Norwegian speakers. She found that building network connections with native Norwegian L2 speakers was positively related to more native-like pronunciation of Norwegian in L2 learners when compared with L2 learners who had greater difficulty establishing these connections. However, Harwood [15] argued that different types of social interaction had not been examined extensively. He proposed two dimensions with which to examine interactions: (1) being extensively involved in the interaction versus observing the social inter-

In addition to intercultural contact, cultural learning researchers have examined mass media exposure and usage [16]. Immigrants make use of various types of mass media, such as TV, radio, newspapers, and magazines, which not only provide L2 exposure and practical day-today information but also provide knowledge about cultural norms and values for interpreting

**4. Other important factors that need to be considered in the research**

The ease with which people learn English is influenced by how distant their mother tongue is from English. One source for assessing how easily people learn the language of the mainstream culture is the average score for each country of origin on the International English Language Testing System (IELTS). People who wish to immigrate to Canada typically need to

willingness of the mainstream community to interact with newcomers [11].

action and (2) interacting via social media versus face-to-face interactions.

other acculturation strategies.

160 People's Movements in the 21st Century - Risks, Challenges and Benefits

the cultural environment [16].

**4.1. Distance from mother tongue to English**

General knowledge about the mainstream culture and previous experience abroad [13] plays a role in relation to social adjustment and L2 learning. For example, Bernaus et al. [20] found that background experiences with the language and culture of the host countries were significantly related to the degree of acculturation of British teachers in Spain. It is suggested that generic skills learned in oversees settings might be applied to new cultural contexts. In line with this finding, research has found that immigrants' adjustments tend to increase with the length of residence [20]. Sociocultural adaptation was found to increase markedly between 1 and 6 months of residence in the specific country. However, language learners require 6–8 years to acquire high levels of L2 literacy [21].

#### **4.3. Age of L2 acquisition**

Related to the age of L2 acquisition is the argument for the critical period hypothesis of L2 learning, with later L2 learners being less malleable to input than early L2 learners [22]. Traditionally, it was believed that early language learners who acquire their L2 in early childhood (ages 5–6) become more fluent than late learners who acquire their L2 later in childhood (ages 10–12), in adolescence or in adulthood, after the developmental window of the language acquisition. The concept of this "critical period" was based on the idea of loss of neocortical plasticity with maturation of the brain by 10–12 years of age, after which implicit language acquisition can no longer occur [22]. In addition, Krashen [22] argued that the process of first-language acquisition is complete by the age of 5 years and that a second language learnt after that time is not adversely affected. However, researchers examining bilingualism argue that the optimal age for learning L2 really hinges on the acquisition of different linguistic structures such as grammar, vocabulary, and pronunciation, which are differentially related to the age of the learner [23]. For example, Bialystok and colleagues illustrated that phonological acquisition is more sensitive to age than grammar and vocabulary. They found that new sounds are easier to pronounce with native-like accuracy than sounds that are similar but not identical to those found in one's first language [22]. Thus, people who learn their L2 after puberty often maintain a permanent accent related to their mother tongue, despite gaining proficiency in other aspects of language.

#### **4.4. Age of exposure to the mainstream culture and mainstream acculturation**

Because learning a language and being socialized in a culture are closely intertwined, age of cultural acquisition should also be expected. Heinz and colleagues [24] argued that immigrants who moved into a new culture after the sensitive window of language acquisition (i.e., after puberty) would have a difficult time to adjusting to their new culture [24]. They studied different generations of Hong Kong immigrants in Vancouver, Canada. Questions about their identification with Hong Kong and questions about how much they identified with Canada were asked. The results indicated that immigrants who arrived in Canada before the age of 15 identified more strongly with the Canadian culture and that this was related to how long they lived in Canada. However, those immigrants who arrived in Canada after early adulthood did not identify more closely with the Canadian culture over time. It is possible that because a critical window for cultural acquisition was largely closed for this latter group, repeated exposure to a culture that they had difficulty relating to became increasingly frustrating over time [24].

## **5. Three methodological challenges**

The first methodological challenge is to strive for a cohesive definition of acculturation. Some researchers have argued that the acculturation is a linear, unidimensional process, in which individuals inevitably lose their own heritage culture and language as they adopt the culture and language of the mainstream society [7]. However, recent research has indicated that the acculturation process is a bidimensional or even multidimensional process [6, 16, 25]. For example, acculturation is described as "the process of adapting to the norms of the dominant group," and enculturation is described as "the process of retaining the norms of the heritage group" [26]. Acculturation and enculturation occur at different rates across various life domains such as language acquisition, social interaction, and the learning of values and norms. Involvement in mainstream culture does not necessitate a decrease in involvement with the heritage culture. Researchers found that successful L2 learners created a mixed identity that embraced both their heritage culture and mainstream culture suggesting that the successful adaptation might be tied to the adoption of both cultures [3].

A common outcome of this unidimensional definition of acculturation is the phenomenon of heritage language loss. The immigrants who are newcomers to a country are trying to learn the L2. In this process, some immigrants avoid speaking their native tongue and subsequently the next generation, their children, become monolingual speakers of the majority language [26]. Even though some immigration countries such as Canada and the United States are multicultural/multilingual societies [1, 3], the use of English is reinforced through government, education, social media, and business. Especially, the United States has a history of suppressing the active use of non-English languages for the purpose of promoting the assimilation of the immigrants [26].

The second challenge to conducting research on acculturation and language learning is that most studies used self-report methodology to measure language proficiency. Even though self-report is one of the most broadly used approaches to measure language proficiency, using self-report has been criticized by recent researchers [1, 3, 28, 29]. For example, language learners might underestimate or overestimate their language ability in self-report [1]. Simple self-rating scales are not sensitive enough to place language learners on a scale of greater or lesser language fluency [1, 3, 28]. Language proficiencies for both academic language and conversation are complex constructs that require better measurement strategies [1]. Only a few studies have used standardized tests rather than self-report data to measure language proficiency [3, 27, 28, 29].

The third challenge is in determining the directionality of the link between acculturation and language learning [3]. In the literature on immigration, language proficiency has been identified as an important indicator of sociocultural and psychological adjustment [1, 3, 16, 7, 16, 25]. In sociolinguistic literature, acculturation has been recently incorporated into models of reading literacy [29]. However, the two bodies of research have rarely overlapped with each other. It is reasonable to assume bidirectional processes between acculturation and language learning. During immigrants' settlement process, more confidence in speaking the L2, the language of the mainstream society, gives rise to more positive interactions which in turn lead to a reinforcement of the immigrants to acculturate in the mainstream cultural group [1, 29]. This reinforcement keeps motivating and facilitating the immigrants' L2 learning.

## **6. Our projects**

**4.3. Age of L2 acquisition**

162 People's Movements in the 21st Century - Risks, Challenges and Benefits

proficiency in other aspects of language.

**5. Three methodological challenges**

Related to the age of L2 acquisition is the argument for the critical period hypothesis of L2 learning, with later L2 learners being less malleable to input than early L2 learners [22]. Traditionally, it was believed that early language learners who acquire their L2 in early childhood (ages 5–6) become more fluent than late learners who acquire their L2 later in childhood (ages 10–12), in adolescence or in adulthood, after the developmental window of the language acquisition. The concept of this "critical period" was based on the idea of loss of neocortical plasticity with maturation of the brain by 10–12 years of age, after which implicit language acquisition can no longer occur [22]. In addition, Krashen [22] argued that the process of first-language acquisition is complete by the age of 5 years and that a second language learnt after that time is not adversely affected. However, researchers examining bilingualism argue that the optimal age for learning L2 really hinges on the acquisition of different linguistic structures such as grammar, vocabulary, and pronunciation, which are differentially related to the age of the learner [23]. For example, Bialystok and colleagues illustrated that phonological acquisition is more sensitive to age than grammar and vocabulary. They found that new sounds are easier to pronounce with native-like accuracy than sounds that are similar but not identical to those found in one's first language [22]. Thus, people who learn their L2 after puberty often maintain a permanent accent related to their mother tongue, despite gaining

**4.4. Age of exposure to the mainstream culture and mainstream acculturation**

Because learning a language and being socialized in a culture are closely intertwined, age of cultural acquisition should also be expected. Heinz and colleagues [24] argued that immigrants who moved into a new culture after the sensitive window of language acquisition (i.e., after puberty) would have a difficult time to adjusting to their new culture [24]. They studied different generations of Hong Kong immigrants in Vancouver, Canada. Questions about their identification with Hong Kong and questions about how much they identified with Canada were asked. The results indicated that immigrants who arrived in Canada before the age of 15 identified more strongly with the Canadian culture and that this was related to how long they lived in Canada. However, those immigrants who arrived in Canada after early adulthood did not identify more closely with the Canadian culture over time. It is possible that because a critical window for cultural acquisition was largely closed for this latter group, repeated exposure to a culture that they had difficulty relating to became increasingly frustrating over time [24].

The first methodological challenge is to strive for a cohesive definition of acculturation. Some researchers have argued that the acculturation is a linear, unidimensional process, in which individuals inevitably lose their own heritage culture and language as they adopt the culture and language of the mainstream society [7]. However, recent research has indicated that the acculturation process is a bidimensional or even multidimensional process [6, 16, 25]. For example, acculturation is described as "the process of adapting to the norms of the domi-

Our research has been instrumental in demonstrating a link between language proficiency and acculturation among immigrants in Canada. Our research program builds on past research and extends it in several ways. In 2014, we recruited a group of 94 Chinese-born immigrant adolescents (60 females and 34 males) who were learning English as a second language in Canada. This group differs from adult immigrants who have passed the critical period of language and cultural acquisition as we discussed above. These immigrant adolescents were enrolled in grades 7–12 (average age was 16) and lived in medium-sized to large urban areas in southern Ontario. In addition to the large range of ages, a wide range of lengths of residence in Canada were included (6 months to 17 years) to capture variability in the acculturation and language-learning processes. We divided our sample into recent immigrants/L2 learners with a length of residency in Canada of less than 6 years and long-term immigrants/ L2 learners, with a length of residency in Canada of more than 7 years. All participants completed a number of self-assessment measures of acculturation and individually administrated standardized language tests of Chinese (Mandarin) and English. For the standardized tests, we asked participants to read a list of words and pseudowords of increasing length and difficulty to assess their reading accuracy. Participants were also asked to read short passages and answer multiple-choice questions. For vocabulary knowledge, participants were asked to choose a picture in an array of four that best described the orally present word. For morphological awareness, we presented with a target word and then presented an incomplete sentence in both oral and written forms. Participants were asked to complete the sentence with the correct derivation of the target word.

First, comparisons were made between the two Chinese immigrant groups who completed the standardized language proficiency tests. In both groups, participants were born outside of Canada, but could speak, read, and write both Mandarin and English. Mainstream acculturation and heritage enculturation on the Vancouver Inventory of Acculturation [30] were highly correlated after controlling various individual variables such as age, gender, and length of residence in Canada. Participants' English proficiency was highly correlated with the length of residency in Canada in years. Despite their similarities, these two bicultural groups provided systematically divergent responses. For the recent immigrant adolescents, there was significant correlation between mainstream acculturation and their vocabulary knowledge, reading accuracy, and reading comprehension. For the long-term immigrant adolescents, the correlation between mainstream acculturation and English proficiency was not significant (see **Table 2**). The results suggested that the link between acculturation and L2 learning might have a time limit depending on the student's length of residency and immigration status.

We also tested the link using similar measures in Spanish immigrant children living in Canada *N* = 51, average age was 11 years old [31]. They had lived in a large metropolitan area


**Table 2.** Correlations between acculturation and English proficiency.

in Canada for an average of 6 years, but showed high variability in terms of their time living in Canada (standard deviation *SD* = 3.3 years). Half of the participants were classified as Spanish dominant (Spanish was predominantly used at home and they had higher scores in Spanish than in English), while the other half of the participants were classified as English dominant (English was predominantly used at home and they had higher scores in English than in Spanish). Although mainstream acculturation was related to English-reading comprehension, acculturation was no longer significantly related to the English-reading comprehension when vocabulary and reading accuracy were statistically controlled. This finding that acculturation is not uniquely related to reading comprehension suggests that younger children might not necessarily need to be acculturated in order to learn their L2 because they still have the ability to acquire their L2 relatively easily. Cognitive variables such as building vocabulary and reading words accurately and quickly were more important in determining L2-reading comprehension. Thus, mainstream acculturation may play a less important role in the L2 acquisition of elementary school-aged children than cognitive variables. The finding that acculturation had such a minor impact on L2 learning among long-term Chinese immigrant adolescents and young Spanish children supports the hypothesis of sensitive period for both language and cultural acquisition.

One major limitation of studies examining the relationship between sociocultural and cognitive-linguistic literatures is the correlational nature of the data that prevented us from establishing causal relations between acculturation and language learning. We proposed a longitudinal study to investigate this link. Two developmental paths should be observed: (1) a higher level of early-onset acculturation would lead to immigrants' growth in English proficiency and (2) developing higher levels of acculturation through cultural engagement would provide another pathway for growth in English proficiency. Growth and changes across time in English proficiency and acculturation will be followed up over 2 years. Standardized tests of language proficiency will be administered at each wave of data collection.

Moreover, qualitative methods (life-narrative interviews) to assess acculturation will be implemented into the research in addition to questionnaires. McAdams states that the stories that people tell about their lives reflect a synthesis of how they make sense of life events and the sociocultural environments in which the stories are embedded [32]. As a result, narrative methods could provide insight into nuances and multiple facets of complex multicultural adaptation. In our proposed study, immigrants will be asked several questions about their engagement with the mainstream culture, and will be asked to tell a cultural immersion story. For example, "please describe an episode through which you underwent substantial change in your approach to adapt into Canadian culture."

## **7. Conclusion**

adolescents (60 females and 34 males) who were learning English as a second language in Canada. This group differs from adult immigrants who have passed the critical period of language and cultural acquisition as we discussed above. These immigrant adolescents were enrolled in grades 7–12 (average age was 16) and lived in medium-sized to large urban areas in southern Ontario. In addition to the large range of ages, a wide range of lengths of residence in Canada were included (6 months to 17 years) to capture variability in the acculturation and language-learning processes. We divided our sample into recent immigrants/L2 learners with a length of residency in Canada of less than 6 years and long-term immigrants/ L2 learners, with a length of residency in Canada of more than 7 years. All participants completed a number of self-assessment measures of acculturation and individually administrated standardized language tests of Chinese (Mandarin) and English. For the standardized tests, we asked participants to read a list of words and pseudowords of increasing length and difficulty to assess their reading accuracy. Participants were also asked to read short passages and answer multiple-choice questions. For vocabulary knowledge, participants were asked to choose a picture in an array of four that best described the orally present word. For morphological awareness, we presented with a target word and then presented an incomplete sentence in both oral and written forms. Participants were asked to complete the sentence

First, comparisons were made between the two Chinese immigrant groups who completed the standardized language proficiency tests. In both groups, participants were born outside of Canada, but could speak, read, and write both Mandarin and English. Mainstream acculturation and heritage enculturation on the Vancouver Inventory of Acculturation [30] were highly correlated after controlling various individual variables such as age, gender, and length of residence in Canada. Participants' English proficiency was highly correlated with the length of residency in Canada in years. Despite their similarities, these two bicultural groups provided systematically divergent responses. For the recent immigrant adolescents, there was significant correlation between mainstream acculturation and their vocabulary knowledge, reading accuracy, and reading comprehension. For the long-term immigrant adolescents, the correlation between mainstream acculturation and English proficiency was not significant (see **Table 2**). The results suggested that the link between acculturation and L2 learning might have a time limit depending on the student's length of residency and immigration status.

We also tested the link using similar measures in Spanish immigrant children living in Canada *N* = 51, average age was 11 years old [31]. They had lived in a large metropolitan area

Reading comprehension 0.49\*\* 0.19 Word reading 0.38\* 0.21 Vocabulary 0.36\* 0.03

**Table 2.** Correlations between acculturation and English proficiency.

\* p < 0.05. \*\*p < 0.01. **Recent immigrants ≤6 years Long-term immigrants ≥7 years**

with the correct derivation of the target word.

164 People's Movements in the 21st Century - Risks, Challenges and Benefits

When immigrants arrive in a new country, they face many challenges including language barriers. Specifically, a lack of English language skills may lead to low levels of confidence in interacting with members of their new culture, which will influence cultural immersion. In this chapter, we reviewed sociocultural factors in relation to immigrants' second-language learning with a focus on immigrants to Canada. We addressed this research paradigm by incorporating both the sociolinguistic approach such as acculturation, distance between the mother tongue and English, previous experience in host countries, age of L2, and acquisition of the mainstream culture as well as including key variables related to the cognitive-linguistic approach when examining models of second-language learning in young immigrants. However, we propose that the social context of the language learner affects the level of proficiency attained. In contexts where it is necessary to speak as native, the speaker will continue to progress in their L2 skills rather than fossilizing at the level of adequate communication, albeit with a non-native accent.

We are currently addressing this paradigm of research by incorporating both acculturation and sociolinguistic approaches in models of second-language learning in young immigrants. With regard to assessing language learning and proficiency, we suggest the use of standardized language tests rather than self-report data. This procedure will allow us to disentangle the impact of psychological and social factors of acculturation on language-learning processes, and vice versa, and to determine whether the causal relationship can be advanced. This reciprocal link can be tested for its general applicability across different cultural backgrounds and levels of immigration status. We have suggested that relations within the construct of acculturation and between acculturation and second-language acquisition are complex and merit further examination. Future studies should involve longitudinal measures of acculturation variables such as life stories, attitude, and engagement, and motivation toward learning the mainstream culture, along with demographic variables such as age of arrival, length of residency, cultural differences between the country of origin and the country of immigration, and linguistic differences between the first and second languages. Even though additional research must be conducted before we can make this causal association, we hope that we raised issues that must be resolved when examining relations between acculturation and second-language acquisition.

## **Author details**

Fanli Jia1 \*, Alexandra Gottardo<sup>2</sup> and Aline Ferreira3


3 Department of Spanish and Portuguese, University of California, Santa Barbara, Santa Barbara, CA, USA

### **References**

[1] Noels, K. A. Acculturation in Canada. The Cambridge Handbook of Acculturation Psychology; Sam, D. L. and Berry, J. W., Eds.; Cambridge University Press: Cambridge, UK. **2006**, pp. 274–293.

[2] Ward, C., Masgoret, A. M. An integrative model of attitudes toward immigrants. International Journal of Intercultural Relations. **2006**, 30, 671–682.

focus on immigrants to Canada. We addressed this research paradigm by incorporating both the sociolinguistic approach such as acculturation, distance between the mother tongue and English, previous experience in host countries, age of L2, and acquisition of the mainstream culture as well as including key variables related to the cognitive-linguistic approach when examining models of second-language learning in young immigrants. However, we propose that the social context of the language learner affects the level of proficiency attained. In contexts where it is necessary to speak as native, the speaker will continue to progress in their L2 skills rather than

We are currently addressing this paradigm of research by incorporating both acculturation and sociolinguistic approaches in models of second-language learning in young immigrants. With regard to assessing language learning and proficiency, we suggest the use of standardized language tests rather than self-report data. This procedure will allow us to disentangle the impact of psychological and social factors of acculturation on language-learning processes, and vice versa, and to determine whether the causal relationship can be advanced. This reciprocal link can be tested for its general applicability across different cultural backgrounds and levels of immigration status. We have suggested that relations within the construct of acculturation and between acculturation and second-language acquisition are complex and merit further examination. Future studies should involve longitudinal measures of acculturation variables such as life stories, attitude, and engagement, and motivation toward learning the mainstream culture, along with demographic variables such as age of arrival, length of residency, cultural differences between the country of origin and the country of immigration, and linguistic differences between the first and second languages. Even though additional research must be conducted before we can make this causal association, we hope that we raised issues that must be resolved when

fossilizing at the level of adequate communication, albeit with a non-native accent.

166 People's Movements in the 21st Century - Risks, Challenges and Benefits

examining relations between acculturation and second-language acquisition.

and Aline Ferreira3

1 Department of Psychology, Seton Hall University, South Orange, NJ, USA

2 Department of Psychology, Wilfrid Laurier University, Waterloo, ON, Canada

3 Department of Spanish and Portuguese, University of California, Santa Barbara, Santa

[1] Noels, K. A. Acculturation in Canada. The Cambridge Handbook of Acculturation Psychology; Sam, D. L. and Berry, J. W., Eds.; Cambridge University Press: Cambridge,

**Author details**

Barbara, CA, USA

UK. **2006**, pp. 274–293.

**References**

\*, Alexandra Gottardo<sup>2</sup>

\*Address all correspondence to: fanli.jia@shu.edu

Fanli Jia1


#### **Acculturation, Adaptation and Loneliness among Brazilian Migrants Living in Portugal Acculturation, Adaptation and Loneliness among Brazilian Migrants Living in Portugal**

Joana Neto, Eliany Nazaré Oliveira and Félix Neto Joana Neto, Eliany Nazaré Oliveira and Félix Neto

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/64611

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*The whole conviction of my life now rests upon the belief that loneliness far from being a rare and curi‐ ous phenomenon, peculiar to myself and to a few other solitary men, is the central and inevitable fact of human existence.*

Thomas Wolfe

#### **Abstract**

Acculturation refers to the changes that individuals undergo following intercultural contact. Adaptation is the long‐term outcome of the process of acculturation, and lone‐ liness represents one indicator of negative psychological adaptation. This study, using acculturation strategies, looks to answer to four questions: (1) what is the relationship between intercultural strategies and loneliness? (2) What influence does cultural identity have on the loneliness of migrants? (3) What influence does perceived discrimination have on the loneliness of migrants? and (4) what influences do self‐worth and percep‐ tions of others have on the loneliness? Answering these questions is important for reduc‐ ing migrants' loneliness. This study, carried out in 2012, is constituted by 258 Brazilian migrants in Portugal (53% females and 47% males) with a mean age of 36 years. The mean length of residence in Portugal was 14 years. In order to measure loneliness, we used the ULS‐6 scale. Other scales were used to measure intercultural strategies, cul‐ tural identity, perceived discrimination, self‐esteem and attitudes towards ethnocultural groups. As predicted, in what concerns intercultural strategies, loneliness was negatively associated with the strategy of integration, and positively associated with assimilation, separation and marginalization. Ethnic identity was negatively associated with loneli‐ ness, but, contrary to expectations, national identity was positively associated with lone‐ liness. Perceived discrimination predicted positively loneliness. Finally, as expected, self‐esteem and perceptions of the in‐group predicted negatively loneliness. Implications of the study are discussed.

**Keywords:** acculturation, adaptation, Brazilian migrants, loneliness, Portugal

and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

## **1. Introduction**

Social scientists have conceptualized the phenomena arising from intercultural contacts under the field of acculturation [1]. Acculturation represents one of the main topics of research in cross‐cultural psychology [2]. Adaptation is the long‐term outcome of the process of accul‐ turation, and it is highly variable, ranging from well‐ to poorly‐adapted. Adaptation can assume two forms: psychological adaptation and sociocultural adaptation [2]. The former is sometimes referred as 'feeling well'; the latter refers to 'doing well' in activities of daily intercultural living. Loneliness can be considered as an indicator of negative psychological adaptation [3].

Aristotle's remark about the significance of positive interpersonal relations holds in the era of globalization as well as in the ancient Greece. Loneliness is experienced in every culture, as displayed by researchers with various cultural samples including Canadians and Portuguese [4], Chinese Canadians [5], Angolans [6], British [7] and Turks [8]. Loneliness is experienced in every stage of the lifespan, even in 5‐year‐old children [9]. Loneliness affects both young people (e.g., [8, 10, 11]) and older migrants (e.g., [12, 13]). For individuals in Western societies, loneliness seems to follow a U‐shaped distribution, whereby adolescents/young adults (<25 years old) and older adults (>65 years old) have higher rates of loneliness than adults in the middle‐age spectrum [7].

Extant literature calls our attention to the diffuse and adverse outcomes of loneliness [14]. In particular, immigration provides a unique opportunity to study loneliness. According to Ponizovski and Ritsner [15] 'newly immigrated persons find themselves in a drastically dif‐ ferent network of social relationships and experience multiple stressors, including losses' (p. 408). However, contrary to what might be expected, the research of loneliness among migrants is scarce [3]. The main purpose of this research is to provide some insights into the experiences of loneliness among Brazilian migrants living in Portugal.

#### **1.1. Brazilians living in Portugal**

Currently, migration from Brazil is one of the largest immigration flows to Portugal. In 2014, this flow represented 22% of the foreign population resident in the country [16]. Although relations between these two countries are not a new phenomenon, the patterns of migration have changed over time. Despite the fact that Portugal used to be traditionally an emigration country, from the last quarter of the twentieth century, Portugal has become a mixed migra‐ tory pattern country. Presently, there are numerous Portuguese‐speaking migrants, who are mostly from Brazil and Cape Verde, but other population groups became also numerous, such as Eastern European and China migrants [16].

The immigration from Brazil to Portugal started to rise in mid‐1990. According to foreign registration statistics, only 7470 Brazilian immigrants resided in Portugal in 1989. However, in 2008, this foreign population exceeded 100,000 migrants and augmented to 119,363 in 2010. This period of time was clearly characterized by the labour migration caused by the pro‐ gressive opening of the economy and the perception of imbalances in the structure of the Portuguese labour market. Many Brazilian immigrants work in low‐skilled jobs, in sectors such as industry, construction, agriculture, services and tourism. When the financial and eco‐ nomic recession struck Portugal, many Brazilian workers, who had been employed in these sectors, lost their jobs. The precarious work has made Brazilian migrants extremely vulner‐ able to economic fluctuations and susceptible to unemployment. Despite the economic crisis creating a decrease of the foreign‐resident population comparatively to previous years, in 2014, 87,493 Brazilians lived in Portugal [16].

According to official statistics [16], concerning the gender, there is a female predominance, with a percentage difference of 22.4%. Regarding the age, there is a concentration in the eco‐ nomically active age groups. And, concerning the geographic distribution, most of the immi‐ grants are located above all along the coast line.

In order to deal with this new Portuguese migratory reality, the government's policies on immigration have undergone serious changes in terms of integration's policies, access to citizenship and regulation of flows. The pro‐assimilationist discourse remains in the past and the new migration's political agenda is based on multiculturalism. According to the Migrant Integration Policy Index (MIPEX IV), Portugal has the second‐most favourable integration policies in the developed world.

#### **1.2. Loneliness and the migratory process**

**1. Introduction**

170 People's Movements in the 21st Century - Risks, Challenges and Benefits

adaptation [3].

the middle‐age spectrum [7].

**1.1. Brazilians living in Portugal**

such as Eastern European and China migrants [16].

Social scientists have conceptualized the phenomena arising from intercultural contacts under the field of acculturation [1]. Acculturation represents one of the main topics of research in cross‐cultural psychology [2]. Adaptation is the long‐term outcome of the process of accul‐ turation, and it is highly variable, ranging from well‐ to poorly‐adapted. Adaptation can assume two forms: psychological adaptation and sociocultural adaptation [2]. The former is sometimes referred as 'feeling well'; the latter refers to 'doing well' in activities of daily intercultural living. Loneliness can be considered as an indicator of negative psychological

Aristotle's remark about the significance of positive interpersonal relations holds in the era of globalization as well as in the ancient Greece. Loneliness is experienced in every culture, as displayed by researchers with various cultural samples including Canadians and Portuguese [4], Chinese Canadians [5], Angolans [6], British [7] and Turks [8]. Loneliness is experienced in every stage of the lifespan, even in 5‐year‐old children [9]. Loneliness affects both young people (e.g., [8, 10, 11]) and older migrants (e.g., [12, 13]). For individuals in Western societies, loneliness seems to follow a U‐shaped distribution, whereby adolescents/young adults (<25 years old) and older adults (>65 years old) have higher rates of loneliness than adults in

Extant literature calls our attention to the diffuse and adverse outcomes of loneliness [14]. In particular, immigration provides a unique opportunity to study loneliness. According to Ponizovski and Ritsner [15] 'newly immigrated persons find themselves in a drastically dif‐ ferent network of social relationships and experience multiple stressors, including losses' (p. 408). However, contrary to what might be expected, the research of loneliness among migrants is scarce [3]. The main purpose of this research is to provide some insights into the

Currently, migration from Brazil is one of the largest immigration flows to Portugal. In 2014, this flow represented 22% of the foreign population resident in the country [16]. Although relations between these two countries are not a new phenomenon, the patterns of migration have changed over time. Despite the fact that Portugal used to be traditionally an emigration country, from the last quarter of the twentieth century, Portugal has become a mixed migra‐ tory pattern country. Presently, there are numerous Portuguese‐speaking migrants, who are mostly from Brazil and Cape Verde, but other population groups became also numerous,

The immigration from Brazil to Portugal started to rise in mid‐1990. According to foreign registration statistics, only 7470 Brazilian immigrants resided in Portugal in 1989. However, in 2008, this foreign population exceeded 100,000 migrants and augmented to 119,363 in 2010. This period of time was clearly characterized by the labour migration caused by the pro‐ gressive opening of the economy and the perception of imbalances in the structure of the Portuguese labour market. Many Brazilian immigrants work in low‐skilled jobs, in sectors

experiences of loneliness among Brazilian migrants living in Portugal.

'Social transitions are a basic fact of modern life, and so is loneliness' ([17], p. 1). Diverse defi‐ nitions of this phenomenon have been advanced and most definitions of loneliness emphasize perceived deficits in relationships. For instance, Ascher and Paquette [18] define loneliness as 'the cognitive awareness of a deficiency in one's social and personal relationships, and ensur‐ ing affective reactions of sadness, emptiness, or longing' (p. 75).

Loneliness is a psychological state, constituted by a set of cognitions and discomfort emo‐ tions which appear in reaction to the threatened loss of a person's social and affective bonds [19]. In fact, the scientific literature identifies two components related to loneliness: (a) a cognitive component, which compares the desired and the real social and affective rela‐ tions quantitatively and qualitatively, and (b) an affective component involving negative emotional experiences such as sadness, emptiness, longing, disorientation or feeling lost among others.

Loneliness is not synonymous with being alone [20]. Loneliness is a state of mind rather than an objective condition. As observed by Peplau and Perlman [17] 'Loneliness is a subjective experience, it is not synonymous with objective social isolation. People can be alone without being lonely or lonely in the crowd' (p. 3). For example, it is possible to have many friends or an amorous relationship, and still feel lonely. Therefore, research on loneliness has mainly been evaluated through self‐report measures that approach people's perceptions of their feel‐ ings [21].

The identification of the factors, which contribute to loneliness, is relevant for diverse motives, such as its relationship with low physical activity [22], poor academic competence and perfor‐ mance [23], unmet intimacy needs [24], health outcomes such as increment in hypertension [25], sleep disturbance [26] and mental health problems [26]. For instance, a relation between loneliness, depressive symptoms, anxiety and suicidal ideation was found [27, 28]. Literature indicates that loneliness provides an increased risk of not only morbidity but also mortality later in life [29].

Many changes may occur as a result of migration [1] and these changes may impact on experi‐ enced loneliness by migrants. Some literature points out that migrants may be prone to loneli‐ ness as they are a target of discrimination [30]. However, there are studies that do not report differences in loneliness between migrants and native people from the societies of origin and of residence. For example, Portuguese youths living in France and Portuguese youths without migratory experience revealed no differences in loneliness [31]. Similar findings were shown among Portuguese migrants living in Switzerland [32], and among Angolan, Cape Verdean and Indian youths of immigrant backgrounds residing in Portugal [33]. A recent study even found that Portuguese youths returned with their migrant families from France displayed lower loneliness than native Portuguese who have never migrated [3]. In this vein, Fuligni [34] has reported: 'Some immigrant children show similar or better development outcomes than their American‐born counterparts than would be expected because of their socioeco‐ nomic background and status as newcomers in American society' (pp. 299–300). Thus, several researches showed that not all migrants do evidence psychological disadvantages due to the intercultural contact.

#### **1.3. The present study**

The purpose of this study is to examine the relationship between loneliness and acculturation strategies, cultural identity, perceived discrimination, self‐worth and social perceptions.

In the course of acculturation, migrants face new styles of living. Cultural identity and perceived discrimination are generally seen as core aspects of acculturation [33, 35, 36]. To examine the relationship between acculturation and loneliness, we used Berry's model [1] of acculturation strategies. Acculturation strategies indicate how the migrants wish to live inter‐ culturally in the settlement country after immigration [1] and these strategies are grounded in two basic intercultural dimensions: maintenance of one's cultural heritage ('culture main‐ tenance') and contact with others outside one's group ('cultural contact'). The intersection of these two dimensions, 'cultural maintenance' and 'culture contact', results in four accultura‐ tion strategies, that is, assimilation, integration, separation and marginalization.

According to Berry et al. [1, 33, 35], assimilation refers to a migrant's low interest in maintain‐ ing his/her own cultural identity and being interested in having daily interaction with other cultures. Separation refers to an individual's interest in maintaining his/her own cultural iden‐ tity and a low interest in having interaction with other cultures. Marginalization refers to little interest in one's own cultural maintenance and in establishing interaction with others. Finally, most of the research suggests that integration is the most adaptive, whereas marginaliza‐ tion is associated with poor psychological adaptation; the two other acculturation strategies, assimilation and separation, are intermediate [33, 35, 37]. In Portugal, Neto [38] found that the integration strategy had a significant and positive link to psychological adaptation and sociocultural adaptation among young immigrants from Angola, Cape Verde, Guinea‐Bissau, India, Mozambique, São‐Tomé and East Timor. Nguyen and Benet‐Martinez [39] performed a meta‐analytic study. They reported that integration ('biculturalism' in their terms) was sig‐ nificantly related to both psychological adaptation and sociocultural adaptation.

loneliness, depressive symptoms, anxiety and suicidal ideation was found [27, 28]. Literature indicates that loneliness provides an increased risk of not only morbidity but also mortality

Many changes may occur as a result of migration [1] and these changes may impact on experi‐ enced loneliness by migrants. Some literature points out that migrants may be prone to loneli‐ ness as they are a target of discrimination [30]. However, there are studies that do not report differences in loneliness between migrants and native people from the societies of origin and of residence. For example, Portuguese youths living in France and Portuguese youths without migratory experience revealed no differences in loneliness [31]. Similar findings were shown among Portuguese migrants living in Switzerland [32], and among Angolan, Cape Verdean and Indian youths of immigrant backgrounds residing in Portugal [33]. A recent study even found that Portuguese youths returned with their migrant families from France displayed lower loneliness than native Portuguese who have never migrated [3]. In this vein, Fuligni [34] has reported: 'Some immigrant children show similar or better development outcomes than their American‐born counterparts than would be expected because of their socioeco‐ nomic background and status as newcomers in American society' (pp. 299–300). Thus, several researches showed that not all migrants do evidence psychological disadvantages due to the

The purpose of this study is to examine the relationship between loneliness and acculturation strategies, cultural identity, perceived discrimination, self‐worth and social perceptions.

In the course of acculturation, migrants face new styles of living. Cultural identity and perceived discrimination are generally seen as core aspects of acculturation [33, 35, 36]. To examine the relationship between acculturation and loneliness, we used Berry's model [1] of acculturation strategies. Acculturation strategies indicate how the migrants wish to live inter‐ culturally in the settlement country after immigration [1] and these strategies are grounded in two basic intercultural dimensions: maintenance of one's cultural heritage ('culture main‐ tenance') and contact with others outside one's group ('cultural contact'). The intersection of these two dimensions, 'cultural maintenance' and 'culture contact', results in four accultura‐

According to Berry et al. [1, 33, 35], assimilation refers to a migrant's low interest in maintain‐ ing his/her own cultural identity and being interested in having daily interaction with other cultures. Separation refers to an individual's interest in maintaining his/her own cultural iden‐ tity and a low interest in having interaction with other cultures. Marginalization refers to little interest in one's own cultural maintenance and in establishing interaction with others. Finally, most of the research suggests that integration is the most adaptive, whereas marginaliza‐ tion is associated with poor psychological adaptation; the two other acculturation strategies, assimilation and separation, are intermediate [33, 35, 37]. In Portugal, Neto [38] found that the integration strategy had a significant and positive link to psychological adaptation and sociocultural adaptation among young immigrants from Angola, Cape Verde, Guinea‐Bissau, India, Mozambique, São‐Tomé and East Timor. Nguyen and Benet‐Martinez [39] performed

tion strategies, that is, assimilation, integration, separation and marginalization.

later in life [29].

172 People's Movements in the 21st Century - Risks, Challenges and Benefits

intercultural contact.

**1.3. The present study**

In the current research, we explore whether the preference of the integration strategy by Brazilian migrants has greater benefits for their adaptation than their preferences for other acculturation strategies.

Cultural identity represents one domain of acculturation that focus on migrants' sense of self, including both ethnic identity and national identity. Ethnic identity concerns their sense of belonging to the migrant ethnic group and national identity refers to their sense of belong‐ ing to the new society of settlement [35]. The great majority of studies about migration have approached only the ethnic identity; however, for migrants both ethnic identity and national identity are relevant [36]. A strong ethnic identity and national identity provides a sense of emotional stability, personal security and a good self‐concept for migrants [36].

Cultural identity may have an important impact on loneliness. Investigation has evidenced a positive relation between cultural identity and adaptation. For example, both ethnic iden‐ tity and national identity were positively associated with psychological adaptation in a large international study from 13 countries, including Portugal [35].

Besides acculturation strategies and cultural identity, we also analyse whether perceived dis‐ crimination exerts an influence on loneliness. Past research has examined whether perceived discrimination was related to psychological ill health [40]. The subjective interpretation of events as discriminatory may be positively related to loneliness [33, 39, 41].

Literature shows a consistent relation between loneliness and negative self‐regard [42, 43]. Feeling lonely and experiencing low self‐esteem are a common problem [44], especially in migrants [38]. Self‐esteem includes feelings of personal worth [45]. Several theories (e.g., evo‐ lutionary theory and the cognitive discrepancy model) have acknowledged a relationship with self‐esteem [44].

The feelings of loneliness tend to be linked not only to poor self‐regard but also to negative social perceptions. For instance, lonely persons assessed interaction partners more negatively than non‐lonely persons [46]. Similar findings for lonely persons' negative views of others have also be en shown outside the laboratory setting. For example, loneliness was related to negative views of others in classrooms [47], and in college students' judgements of their roommates [48].

In the current research, we analyse the relation between loneliness and self‐esteem, and how the migrants rate members of their own national group (in‐group evaluation), members of other national groups, that is, individuals of the host society (Portuguese), and individuals of other national groups of migrants (out‐group evaluations).

In summary, we tested five hypotheses derived from the aforementioned research:

*Hypothesis 1*: It is predicted that the integration strategy will be negatively associated with loneliness, and the assimilation, separation and marginalization strategies will be positively associated with loneliness.

*Hypothesis 2*: It is hypothesized that loneliness will be negatively predicted by ethnic identity and majority identity.

*Hypothesis 3*: It is expected that perceived discrimination will predict higher levels of loneliness.

*Hypothesis 4*: It is expected that self‐esteem will predict negatively loneliness.

*Hypothesis 5*: It is hypothesized that perceptions of others will predict loneliness negatively, beyond self‐esteem.

## **2. Method**

#### **2.1. Participants**

The participants were 258 Brazilian migrants (121 men and 137 women). The migrants ranged in age from 18 to 60 years (*M* = 35.92; standard deviation (SD) = 10.51). The mean length of residence was 14.33 years (SD = 9.59). Participants married constituted 48.8% of the sample, not married 50.0% and 1.2% of participants had not answered. Concerning employment, the main category was unskilled work (42%). Relative to the level of education, 41.8% had no secondary education, 39.9% had completed secondary education, 8.9% had attended tertiary education and 3.1% had not answered. Most of the migrants declared to be Roman Catholics (58.1%), and about a quarter declared that they have no religion.

#### **2.2. Measures**

For this study, we used the following measures:

*Acculturation strategies.* This scale consists of 16 items, grounded on the model of Berry [49, 50]. It evaluated four acculturation strategies (assimilation, integration, separation and mar‐ ginalization), each one with four items. An example of an item assessing each of the accultura‐ tion strategies is as follows:

Assimilation: 'I feel Brazilian should adapt to mainstream Portuguese society and not main‐ tain their own traditions';

Separation: 'I prefer to have only Brazilian friends';

Integration: 'Brazilians should have both Brazilian and Portuguese friends';

Marginalization: 'I don't want to attend either Portuguese or Brazilian social activities'.

Each item was assessed on a five‐point scale from 1 (*strongly disagree*) to 5 (*strongly agree*). Cronbach's alpha of assimilation, integration, separation and marginalization for the present research was 0.63, 0.66, 0.66 and 0.75, respectively. The internal consistencies were moderate; however, factor analyses on data from the 13 countries participating in the International Comparative Study of Ethnocultural Youth (ICSEY), including Portugal, showed that the scales were unifactorial and comparable across countries and across eth‐ nocultural groups [35].

*Cultural identity*. Cultural identity was measured with a scale originally developed by Phinney et al. [36]. The scale assessed Brazilian identity with four items (Cronbach's alpha, 0.94). A sample item is 'I feel that I am part of Brazilian culture'. The other scale (four items) assessed Portuguese identity (Cronbach's alpha, 0.94). A sample item is 'I am happy that I am Portuguese'. Each item was rated on a five‐point scale from 1 (*strongly disagree*) to 5 (*strongly agree*).

*Perceived discrimination*. This scale includes five items [35, 51] evaluating the direct experi‐ ence of discrimination—negative or unfair treatment from others (e.g., 'I have been teased or insulted because of my Brazilian background'). Each item was rated on a five‐point scale from 1 (*strongly disagree*) to 5 (*strongly agree*). Cronbach's alpha for the present study was 0.90.

*Self‐esteem.* Self‐esteem was assessed using the [52] 10‐item inventory. Sample items are 'On the whole I am satisfied with myself' and 'I have a positive attitude toward myself'. Each item was rated on a five‐point scale from 1 (*totally disagree*) to 5 (*totally agree*). The scale was previously adapted into Portuguese [53]. Cronbach's alpha for the current research was 0.72.

*Attitudes towards ethnocultural groups*. This measure was a version of the 'feeling thermom‐ eter', in which participants are presented with a scale of 1–100 and asked to indicate how favourable their attitude is towards immigrants coming from various countries (1 = *extremely unfavourable*, 100 = *extremely favourable*). Participants were asked to rate besides Brazilians and Portuguese, other 16 groups, including Angolans, Chinese and Cape Verdeans. Cronbach's alpha showed that the scale to assess attitudes towards the other 16 groups had good reliabil‐ ity in this study (Cronbach's alpha = 0.96).

*Loneliness*. The brief Portuguese version of the revised University of California, Los Angeles (UCLA) Loneliness Scale [54] was used [21, 55]. This is a six‐item scale ULS‐6. One sample item reads: 'People are around me but not with me'. Migrants were asked to indicate how often they felt for each statement on a five‐point scale ranging from 1 (*never*) to 4 (*often*). Cronbach's alpha for the current research was 0.82.

*Demographic information*. The demographic questionnaire included the following: age, gender, place of birth, age at arrival in Portugal, marital status, level of education, occupation and religion.

#### **2.3. Procedure**

*Hypothesis 2*: It is hypothesized that loneliness will be negatively predicted by ethnic identity

*Hypothesis 3*: It is expected that perceived discrimination will predict higher levels of loneliness.

*Hypothesis 5*: It is hypothesized that perceptions of others will predict loneliness negatively,

The participants were 258 Brazilian migrants (121 men and 137 women). The migrants ranged in age from 18 to 60 years (*M* = 35.92; standard deviation (SD) = 10.51). The mean length of residence was 14.33 years (SD = 9.59). Participants married constituted 48.8% of the sample, not married 50.0% and 1.2% of participants had not answered. Concerning employment, the main category was unskilled work (42%). Relative to the level of education, 41.8% had no secondary education, 39.9% had completed secondary education, 8.9% had attended tertiary education and 3.1% had not answered. Most of the migrants declared to be Roman Catholics

*Acculturation strategies.* This scale consists of 16 items, grounded on the model of Berry [49, 50]. It evaluated four acculturation strategies (assimilation, integration, separation and mar‐ ginalization), each one with four items. An example of an item assessing each of the accultura‐

Assimilation: 'I feel Brazilian should adapt to mainstream Portuguese society and not main‐

Marginalization: 'I don't want to attend either Portuguese or Brazilian social activities'.

Each item was assessed on a five‐point scale from 1 (*strongly disagree*) to 5 (*strongly agree*). Cronbach's alpha of assimilation, integration, separation and marginalization for the present research was 0.63, 0.66, 0.66 and 0.75, respectively. The internal consistencies were moderate; however, factor analyses on data from the 13 countries participating in the International Comparative Study of Ethnocultural Youth (ICSEY), including Portugal, showed that the scales were unifactorial and comparable across countries and across eth‐

Integration: 'Brazilians should have both Brazilian and Portuguese friends';

*Hypothesis 4*: It is expected that self‐esteem will predict negatively loneliness.

174 People's Movements in the 21st Century - Risks, Challenges and Benefits

(58.1%), and about a quarter declared that they have no religion.

For this study, we used the following measures:

Separation: 'I prefer to have only Brazilian friends';

and majority identity.

beyond self‐esteem.

**2. Method**

**2.1. Participants**

**2.2. Measures**

tion strategies is as follows:

tain their own traditions';

nocultural groups [35].

The recruitment of the participants was carried out in Lisbon Metropolitan area. The ques‐ tionnaire was administered by two trained research assistants. The participation rate was high (about 75%). The respondents were informed about the goals and procedures of the study and they gave informed consent. The participants' responses were anonymous. All questionnaires were administered in Portuguese. The questionnaire took approximately 25 min to complete. There were no rewards given for completing the questionnaire. All aspects of the research were in line with American Psychological Association (APA) ethical guidelines [56].

## **3. Results**

Before testing our hypotheses, descriptive statistics for the study variables are presented (see **Table 1**), and a series of analyses were performed to explore potential relations between socio‐demographic variables and loneliness. One‐sample *t*‐test showed that the mean score of migrants on loneliness (*M* = 2.03; SD = 0.74) was significantly below the scale midpoint of 2.50 (*p* < 0.001). Overall, this result suggests that migrants experienced a relatively slight level of loneliness. Also, one‐sample *t*‐tests showed that the average score of integration (*M* = 3.68; SD = 0.73) was significantly higher than the midpoint (3) of the scale (*p* < 0.001), while aver‐ age scores on assimilation (*M* = 2.61; SD = 0.71), separation (*M* = 2.68; SD = 0.76) and mar‐ ginalization (*M* = 2.40, SD = 0.79) were significantly lower than the midpoint of the scale (all *p*s < 0.001). These mean scores pointed to two clusters: integration was unequivocally on the preferred side, while assimilation, separation and marginalization were not preferred. Regarding cultural identity, the mean score of ethnic identity (*M* = 4.47; SD = 0.93) was signifi‐ cantly higher than the midpoint of the scale (3), while national identity (*M* = 2.27; SD = 1.28) was significantly lower than the midpoint. Overall, these results suggest that ethnic identity is more valuated than national identity.

Now, we are going to present the relationships of loneliness in relation to socio‐demographic variables such as age, gender, level of education and length of residence.

*Age*. Respondents were divided into two age groups: the young adults ranged in age from 18 to 34, and the middle‐age adults (35–60 year olds). There were significant age differ‐ ences across the adult lifespan, [*F*(1, 255) = 4.75, *p* < 0.05, *η*<sup>2</sup> = 0.018] on loneliness. The young adults (*M* = 1.93, SD = 0.73) felt less loneliness than the middle‐age adults (*M* = 2.13, SD = 0.75).


**Table 1.** Means, standard deviations and reliability coefficients of the measures for the Brazilian migrants (*N* = 258).

*Gender*. There were no differences between men (*M* = 2.00, SD = 0.76) and women (*M* = 2.06, SD = 0.73), [*F*(1, 255) = 1.35, *p* > 0.05, *η*<sup>2</sup> = 0.001] on loneliness.

**3. Results**

SD = 0.75).

is more valuated than national identity.

176 People's Movements in the 21st Century - Risks, Challenges and Benefits

Before testing our hypotheses, descriptive statistics for the study variables are presented (see **Table 1**), and a series of analyses were performed to explore potential relations between socio‐demographic variables and loneliness. One‐sample *t*‐test showed that the mean score of migrants on loneliness (*M* = 2.03; SD = 0.74) was significantly below the scale midpoint of 2.50 (*p* < 0.001). Overall, this result suggests that migrants experienced a relatively slight level of loneliness. Also, one‐sample *t*‐tests showed that the average score of integration (*M* = 3.68; SD = 0.73) was significantly higher than the midpoint (3) of the scale (*p* < 0.001), while aver‐ age scores on assimilation (*M* = 2.61; SD = 0.71), separation (*M* = 2.68; SD = 0.76) and mar‐ ginalization (*M* = 2.40, SD = 0.79) were significantly lower than the midpoint of the scale (all *p*s < 0.001). These mean scores pointed to two clusters: integration was unequivocally on the preferred side, while assimilation, separation and marginalization were not preferred. Regarding cultural identity, the mean score of ethnic identity (*M* = 4.47; SD = 0.93) was signifi‐ cantly higher than the midpoint of the scale (3), while national identity (*M* = 2.27; SD = 1.28) was significantly lower than the midpoint. Overall, these results suggest that ethnic identity

Now, we are going to present the relationships of loneliness in relation to socio‐demographic

*Age*. Respondents were divided into two age groups: the young adults ranged in age from 18 to 34, and the middle‐age adults (35–60 year olds). There were significant age differ‐

young adults (*M* = 1.93, SD = 0.73) felt less loneliness than the middle‐age adults (*M* = 2.13,

Assimilation 2.61 0.71 4 0.63 Integration 3.68 0.73 4 0.66 Separation 2.68 0.76 4 0.66 Marginalization 2.40 0.79 4 0.75 Ethnic identity 4.47 0.93 4 0.94 National identity 2.27 1.28 4 0.94 Perceived discrimination 2.15 1.09 5 0.90 Self‐esteem 3.83 0.72 10 0.72 Attitudes towards Brazilians 9.71 1.06 1 – Attitudes towards Portuguese 7.69 3.03 1 – Attitudes towards other migrants 3.91 2.34 16 0.96 Loneliness 2.03 0.74 6 0.82

**Table 1.** Means, standard deviations and reliability coefficients of the measures for the Brazilian migrants (*N* = 258).

*M* **SD Number of items Cronbach's** *α*

= 0.018] on loneliness. The

variables such as age, gender, level of education and length of residence.

ences across the adult lifespan, [*F*(1, 255) = 4.75, *p* < 0.05, *η*<sup>2</sup>

*Education*. There were no differences in the level of education for participants who have not completed secondary schooling (*M* = 2.12, SD = 0.72) and those who completed secondary schooling or tertiary education (*M* = 1.94, SD = 0.77), [*F*(1, 247)= 0.3.80, *p* > 0.05, *η*<sup>2</sup> **=** 0.016] on loneliness.

Concerning the *length of residence*, participants were divided into two groups: those with 10 years or less of length of residence in Portugal and those with more than 10 years. In relation to loneliness, there were no differences between participants with a shorter length of resi‐ dence (*M* = 1.94, SD = 0.74) and those with a longer length of residence (*M* = 2.09; SD = 0.74), [*F*(1, 255) = 0.2.57, *p* > 0.05, *η*<sup>2</sup> **=** 0.010].

Pearson product‐moment correlations between loneliness and intercultural strategies were performed in order to test hypothesis 1 (see **Table 2**). As expected, integration was negatively correlated with loneliness (*r* = ‐0.16, *p* < 0.05), while assimilation (*r* = 0.42, *p* < 0.001), separa‐ tion (*r* = 0.22, *p* < 0.01) and marginalization (*r* = 0.48, *p* < 0.001), were positively correlated with loneliness. These findings confirm our first hypothesis.

In order to test whether cultural identity predicts loneliness, we performed a hierarchical multiple regression. Prior to performing the regression analysis, collinearity diagnostics were analysed to ensure that variance inflation factor did not exceed 10. To control for the pos‐ sible confounding effects of gender, age, level of education and length of residence, they were entered in the first block. Ethnic identity and national identity were entered in the second block. In the first block, no significant socio‐demographic predictor emerged. In the second block, the regression showed that 36% of the total variance in loneliness could be explained by the independent variables, *F*(6, 244) = 22.25, *p* < 0.001 (see **Table 3**). Loneliness was predicted by lower level of education (*β* = ‐0.11, *p* < 0.05), lower ethnic identity (*β* = ‐0.11, *p* < 0.05) and higher national identity (*β* = 0.56, *p* < 0.001). These findings support partially our second hypothesis.

To analyse the relationship between perceived discrimination and loneliness, we performed also a hierarchical multiple regression. Prior to performing the regression analysis, collinear‐ ity diagnostics were analysed to ensure that variance inflation factor did not exceed 10. To


**Table 2.** Correlations between intercultural strategies of Brazilian migrants and loneliness.

control for the possible confounding effects of gender, age, level of education and length of residence, they were entered in the first block. Perceived discrimination was entered in the second block. In the first block, no significant socio‐demographic predictor emerged. In the second block, the regression showed that 41% of the total variance in loneliness could be explained by the independent variables, *F*(5, 245) = 33.49, *p* < 0.001 (see **Table 4**). Loneliness was predicted by higher perceived discrimination (*β* = 0.62, *p* < 0.001). These results support hypothesis 3.

Finally, to test the relationships between loneliness and self‐worth and social perceptions, hierarchical multiple regression was used. Prior to performing the regression analysis, collinearity diagnostics were analysed to ensure that variance inflation factor did not


**Table 3.** Hierarchical regression models of socio‐demographic variables and cultural identity predicting loneliness among migrants.


**Table 4.** Hierarchical regression models of socio‐demographic variables and perceived discrimination predicting loneliness among migrants.


**Table 5.** Hierarchical regression models of socio‐demographic variables, self‐esteem and social perceptions predicting loneliness among migrants.

exceed 10. To control for the possible confounding effects of gender, age, level of education and length of residence, they were entered in the first block. Self‐esteem was entered in the second block. The final block included attitudes towards Brazilians, attitudes towards Portuguese and attitudes towards other ethnocultural groups. No significant predictors emerged in the first block. In the second block, self‐esteem (*β* = ‐0.46, *p* < 0.001) emerged as a significant predictor of loneliness. Independent variables explained 22% of the total variance in loneliness. In the third block, the explained variance increased to 27%, *F*(8, 239) = 10.62, *p* < 0.001. Self‐esteem (*β* = ‐0.43, *p* < 0.001) remained in this model as a sig‐ nificant predictor, and lower attitude towards Brazilians (*β* = ‐0.22, *p* < 0.001) and higher attitudes towards other ethnocultural groups (*β* = 0.14, *p* < 0.001) emerged also as signifi‐ cant predictors. These results support hypothesis 4, while hypothesis 5 was only partially supported(see **Table 5**).

## **4. Discussion**

control for the possible confounding effects of gender, age, level of education and length of residence, they were entered in the first block. Perceived discrimination was entered in the second block. In the first block, no significant socio‐demographic predictor emerged. In the second block, the regression showed that 41% of the total variance in loneliness could be explained by the independent variables, *F*(5, 245) = 33.49, *p* < 0.001 (see **Table 4**). Loneliness was predicted by higher perceived discrimination (*β* = 0.62, *p* < 0.001). These results support

Finally, to test the relationships between loneliness and self‐worth and social perceptions, hierarchical multiple regression was used. Prior to performing the regression analysis, collinearity diagnostics were analysed to ensure that variance inflation factor did not

**Table 3.** Hierarchical regression models of socio‐demographic variables and cultural identity predicting loneliness

**Table 4.** Hierarchical regression models of socio‐demographic variables and perceived discrimination predicting

**Variables Block 1,** *β* **Block 2,** *β* Age 0.13 0.02 Gender 0.03 ‐0.01 Level of education 0.02 ‐0.11\* Length of residence 0.10 ‐0.02 Ethnic identity ‐0.11\* National identity 0.56\*\*\* *R*<sup>2</sup> 0.04 0.36 Adjusted *R*<sup>2</sup> 0.04 0.34 *F*‐change 2.57\* 60.29\*\*\*

178 People's Movements in the 21st Century - Risks, Challenges and Benefits

**Variables Block 1,** *β* **Block 2,** *β* Age 0.13 0.06 Gender 0.03 ‐0.02 Level of education 0.02 0.04 Length of residence 0.10 0.10 Perceived discrimination 0.62\*\*\* *R*<sup>2</sup> 0.04 0.41 Adjusted *R*<sup>2</sup> 0.04 0.40 *F*‐change 2.57\* 152.46\*\*\*

hypothesis 3.

\* *p* < 0.05. \*\*\* *p* < 0.001.

\*\*\* *p* < 0.001.

loneliness among migrants.

among migrants.

This study tested five hypotheses among Brazilian migrants living in Portugal. The data sup‐ ported three hypotheses; however, two hypotheses were only partially supported. The results showed that Brazilians prefer integration, that is, the maintenance of their own cultural heri‐ tage and also the development of close ties with the host society. The first hypothesis was sup‐ ported as integration was associated negatively with loneliness and positively with the other three acculturation strategies. Thus, the present results match with those reporting a positive correlation between a favourable attitude towards integration and migrants' psychological adaptation [39]. The more opportunities to both, maintaining the heritage culture and identity and seeking relationships among groups in the society of settlement, the more migrants tend to display lower loneliness.

The second hypothesis was partially supported. As expected, ethnic identity predicted nega‐ tively loneliness in agreement with past research that supports the view that a strong ethnic identity contributes positively to psychological well‐being [35, 36]. However, contrary to our expectation national identity predicted positively loneliness. This finding does not support the view that positive psychological outcomes for migrants tend to be related to a strong identification with the society of settlement.

Perceived discrimination predicted loneliness in accordance with previous research [41]. The relationship between perceived discrimination and loneliness was also in agreement with past research that showed links between experiences of ethnic discrimination and poor psy‐ chological well‐being [38, 40, 57]. When a migrant recognizes unequal treatment because of his/her membership in a group, he or she will tend to experience loneliness. This result sup‐ ports hypothesis 3.

A strong relationship between self‐esteem and loneliness was found, denoting that lonely migrants had less favourable views of themselves than non‐lonely migrants, which is in con‐ sonance with previous research on adolescents [26, 44] and among adults [41]. This finding supports our fourth hypothesis. This cross‐sectional study does not allow us to explore the direction of the effect between self‐esteem and loneliness. However, previous research indi‐ cates that self‐esteem and loneliness reciprocally affect one another [17, 44]. According to this view, both constructs exacerbate one another over time.

In this study, we have tested the negativity of social perceptions, in particular, how migrants rate members of three national groups. Findings showed that the negativity of the perceiver effect cannot be generalized to all national groups. So hypothesis 5 was only partially sup‐ ported. A negative evaluation of the Brazilians was related to higher loneliness, a finding in agreement with our fifth hypothesis. However, no relationship was found between loneli‐ ness and the evaluation of members of the host society, but a positive association was found between loneliness and attitudes towards other migrant groups. How can this lack of gener‐ alizability of the negative perceiver effect be explained?

The negativity of lonely persons' social perceptions has been consistently documented [39, 43, 58]. However, Christensen and Kashy [59] found the opposite using unacquainted persons as participants. Lonely people showed a positivity bias in perceiving others. This result suggests that lonely persons' negativity might target close friends more than new contacts. However, [43] have observed that 'Christensen and Kashy's study left ambigu‐ ity to the use of participants who were previously unacquainted with each other or to the sophisticated SRM analyses' (p. 224). Tsai and Reis [43] shed light on this aspect. They showed that 'rather than being universally negative about others, lonely people appear to be negative primarily in their ratings of close acquaintances' (p. 236). If it would be possible to translate those findings at the level of close acquaintances to the level of close nationalities, our findings make sense. Lonely migrants target more negatively members of their national group (Brazilians) than members of the society of settlement or of other migrant groups. To lonely migrants, novel contacts with members of other nationalities may constitute new opportunities for meeting intimacy needs. It is worthwhile to research if the pattern of results found in the present study is also present in other migrants groups or in other cultural contexts.

In conclusion, this study followed Berry's [1] strategies of acculturation to determine differ‐ ent degrees of loneliness among Brazilian migrants in Portugal and to recommend ways of counteracting the consequences of this condition. Our research displayed that lonely migrants tended to have negative views towards themselves, but in terms of perceiving others, these pessimistic views cannot be generalized to all national groups. They were more salient in rela‐ tion to their own national group than towards other national groups.

This study has several limitations that should be noted. Firstly, participants were recruited through the snowball technique which limits their representativeness. Secondly, all the data were self‐reported. Thirdly, the findings of this research are cross‐sectional and correlational and therefore the causal relations between variables cannot be determined. Finally, given the uniqueness of the immigrant population studied we are uncertain whether current findings can be generalized to other immigrant groups and worldwide.

Despite these limitations, the current study suggests implications for interventions aimed at alleviating loneliness. The consistent relationship between loneliness and a large array of relevant health problems (e.g., depression, anxiety, suicidal ideation and substance abuse) highlights the need to develop interventions in order to alleviate loneliness. For example, findings from the current work stress the relevance of enhancing self‐esteem, positive atti‐ tudes towards the Brazilians and ethnic identity. A meta‐analysis on loneliness interven‐ tions showed that social skills training was less effective comparatively with interventions addressing maladaptive social cognitions [14]. Thus, our results are in agreement with ([44], p. 1078) suggesting that 'clinical work could significantly benefit from extending cur‐ rent social skills trainings with interventions aimed at improving social cognitions and self‐perceptions'.

As psychologists, we have emphasized individuals and individual differences. Experts using other approaches might reach different explanations. For example, anthropologists might have found a larger role for culture; sociologists, a larger role for power relations and estab‐ lished institutions; and political scientists, a higher relevance for national policies. We argue that using the psychological strategies of acculturation, as developed by Berry [1], provided this study with some important findings which could be integrated into the education of health‐care professionals to combat loneliness among migrants.

## **Author details**

and seeking relationships among groups in the society of settlement, the more migrants tend

The second hypothesis was partially supported. As expected, ethnic identity predicted nega‐ tively loneliness in agreement with past research that supports the view that a strong ethnic identity contributes positively to psychological well‐being [35, 36]. However, contrary to our expectation national identity predicted positively loneliness. This finding does not support the view that positive psychological outcomes for migrants tend to be related to a strong

Perceived discrimination predicted loneliness in accordance with previous research [41]. The relationship between perceived discrimination and loneliness was also in agreement with past research that showed links between experiences of ethnic discrimination and poor psy‐ chological well‐being [38, 40, 57]. When a migrant recognizes unequal treatment because of his/her membership in a group, he or she will tend to experience loneliness. This result sup‐

A strong relationship between self‐esteem and loneliness was found, denoting that lonely migrants had less favourable views of themselves than non‐lonely migrants, which is in con‐ sonance with previous research on adolescents [26, 44] and among adults [41]. This finding supports our fourth hypothesis. This cross‐sectional study does not allow us to explore the direction of the effect between self‐esteem and loneliness. However, previous research indi‐ cates that self‐esteem and loneliness reciprocally affect one another [17, 44]. According to this

In this study, we have tested the negativity of social perceptions, in particular, how migrants rate members of three national groups. Findings showed that the negativity of the perceiver effect cannot be generalized to all national groups. So hypothesis 5 was only partially sup‐ ported. A negative evaluation of the Brazilians was related to higher loneliness, a finding in agreement with our fifth hypothesis. However, no relationship was found between loneli‐ ness and the evaluation of members of the host society, but a positive association was found between loneliness and attitudes towards other migrant groups. How can this lack of gener‐

The negativity of lonely persons' social perceptions has been consistently documented [39, 43, 58]. However, Christensen and Kashy [59] found the opposite using unacquainted persons as participants. Lonely people showed a positivity bias in perceiving others. This result suggests that lonely persons' negativity might target close friends more than new contacts. However, [43] have observed that 'Christensen and Kashy's study left ambigu‐ ity to the use of participants who were previously unacquainted with each other or to the sophisticated SRM analyses' (p. 224). Tsai and Reis [43] shed light on this aspect. They showed that 'rather than being universally negative about others, lonely people appear to be negative primarily in their ratings of close acquaintances' (p. 236). If it would be possible to translate those findings at the level of close acquaintances to the level of close nationalities, our findings make sense. Lonely migrants target more negatively members of their national group (Brazilians) than members of the society of settlement or of other

to display lower loneliness.

ports hypothesis 3.

identification with the society of settlement.

180 People's Movements in the 21st Century - Risks, Challenges and Benefits

view, both constructs exacerbate one another over time.

alizability of the negative perceiver effect be explained?

Joana Neto, Eliany Nazaré Oliveira and Félix Neto\*

\*Address all correspondence to: fneto@fpce.up.pt

Faculty of Psychology and Educational Sciences, University of Porto, Porto, Portugal

#### **References**


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## **Asians as Model Minorities: A Myth or Reality among Scientists and Engineers in Academia Asians as Model Minorities: A Myth or Reality among Scientists and Engineers in Academia**

Meghna Sabharwal Meghna Sabharwal

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/66827

#### **Abstract**

Asians from China, India, South Korea, and Taiwan constitute the largest non‐White group in academic science and engineering (S&E). Most of the studies in relation to race/ ethnicity combine Asians into one category whether they are immigrants (foreign born) or US citizens. Research has suggested that job satisfaction differs with the type of cit‐ izenship status held by faculty members. However, what studies fail to notice is that Asian faculty members who are either born in the United States or are naturalized might experience very different levels of attitudes and satisfaction toward their job when com‐ pared with Asian faculty members who are foreign born and on temporary visa status, impacting retention. Do institutions recognize the differences between these two groups, or are Asian faculty members considered a "model minority" group and "problem‐free?" This is the question that this study aims to examine. Given the growing competition in S&E globally, matters pertaining to faculty members' satisfaction, retention, and persis‐ tence will take a front seat among policy makers and university administrators. Data for this study come from the National Science Foundation's Survey of Doctorate Recipients (SDR).

**Keywords:** Asian‐non‐US citizens, other non‐US citizens, Asian‐US citizens, other‐US citizens, immigrant scientists, academic science and engineering, job satisfaction, job productivity, "model minority"

## **1. Introduction**

Asians constitute the largest non‐White group in academic Science and Engineering (S&E) in the United States (USA). According to recent S&E indicators report, in 2014, Asian faculty members, being born in the United States or foreign born, occupied close to 16% of full‐time positions in US academic institutions, up from 4% in 1973. These people come from countries

and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

such as Far East, Southeast Asia, or the Indian subcontinent, for example, Cambodia, China, India, Indonesia, Japan, Korea, Malaysia, Pakistan, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. Note that the use of faculty does not imply an academic depart‐ ment or organizational unit rather refers to academic personnel (tenured and nontenured academic staff members) working at a university. These numbers are much higher in disci‐ plines like computer sciences where over one‐third (35%) of faculty members are of Asian origin [1]. According to the 2014 S&E Indicators report, "of the 46,000 US‐trained Asian or Pacific Islander S&E doctorate holders employed in academia in 2010, 10% were native‐born US citizens, 39% were naturalized US citizens, and 51% were noncitizens. In 2010, Asians or Pacific Islanders represented 52% of the foreign‐born S&E faculty employed full‐time in the United States [2].

Of the foreign‐born faculty members, scholars of Chinese (22%) and Indian (15%) origin occupy more than a third of the full‐time positions at 4‐year colleges and universities in the United States [3]. Despite these statistics, there are no systematic studies examining the job satisfaction of Asian faculty members working in science and engineering departments in the United States. Most of the studies by race/ethnicity combine individuals of Asian descent into one category irrespective of their citizenship status Faculty members born in the United States or naturalized through the immigration process experience very different levels of satisfac‐ tion toward their job when compared with foreign‐born faculty members on temporary status [3]. This study thus separates Asians by their citizenship status (i.e., Asian‐non‐US citizens and US citizens) and compares their satisfaction to other‐noncitizens and other‐US citizens. Data for this study comes from the 2003 Survey of Doctorate Recipients conducted by the National Science Foundation (NSF).

The academic sector in the United States is to a large extent dependent on the scientific con‐ tributions made by foreign‐born scientists and engineers [4–6]. However, there is seldom a study exclusively focused on citizenship status and race. Even though many parallels can be drawn between the experiences of US‐born Asians and foreign‐born Asians, their achieve‐ ments/barriers in the US labor market are likely to differ, mostly because immigrants from Asian countries arrive with different cultural, educational, and English language abilities. Retaining this group of scientists is important not only because they contribute to the scien‐ tific and technological growth of this country but also are a source of diversity [6]. The tempo‐ rary nature of the citizenship among Asian scientists is concerning.

The governments of nations such as China, India, South Korea, and Taiwan who are the top exporters of talent to the United States are devising policies to attract thousands of their grad‐ uates back from the United States, creating newer economic opportunities for their returnees and the nation [7]. Traditionally, the United States has witnessed close to 85–95% stay rates among foreign‐born scientists and engineers of Chinese and Indian origin; this number is on the decline, however. The percentage of India‐born US‐trained PhDs in science and engineer‐ ing on temporary visa who continued to stay in the United States dropped from 85% in 2005 to 79% in 2009 [8]. The stay rates among Chinese born with identical visa status and educa‐ tional training have dropped 4 percentage points during the 4‐year period (93% in 2005 and 89% in 2009) [8]. There is evidence that between 1992 and 2003, more than eight thousand foreign‐trained scholars returned to mainland China on short visits funded by the Chinese government to lecture and engage in research collaborations [9]. Taiwan reported an 11% point decrease of stay rates from 2005 to 2009, while the highest drop is witnessed among South Korean scientists during the same time period (57% to 42%) [8]. Further, in 2008 of the 39,000 Asian/Pacific Islander PhDs employed in academia, 9% were native‐born US citizens, 44% were naturalized US citizens, and 47% were non‐US citizens [10]. Thus, Asian scien‐ tists on temporary visas (noncitizens) are the largest contributors to academic science and engineering.

The temporary nature of Asian scientists in S&E is thus an important aspect of the scien‐ tific enterprise of the United States. A recent article indicated that the Chinese government is providing research money and setting up labs for the returnees to continue their research. China recently launched the "Thousand Talents Programme" that aims at offering top scien‐ tists grants of 1 million yuan (about \$146,000) along with generous lab funding [11]. India, on the other hand, has not moved as quickly as China, but the Department of Science and Technology recognizes that creating an environment that will facilitate the return of scientists and engineers of Indian origin is crucial in building and fostering collaborative ties with the international scientific world and meeting the human capital demands in higher education. Given the competition in science and technology with other nations and the efforts made by countries, such as South Korea, China, and, to some extent, India, to reclaim their highly skilled faculty members, matters of faculty satisfaction, retention, and persistence will take a front seat among policy makers and university administrators. Thus the purpose of this study is to analyze how Asian‐non‐US citizens and Asian‐US citizens compare with other groups of members of S&E faculties in their satisfaction levels.

## **2. Asians as model minorities**

such as Far East, Southeast Asia, or the Indian subcontinent, for example, Cambodia, China, India, Indonesia, Japan, Korea, Malaysia, Pakistan, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. Note that the use of faculty does not imply an academic depart‐ ment or organizational unit rather refers to academic personnel (tenured and nontenured academic staff members) working at a university. These numbers are much higher in disci‐ plines like computer sciences where over one‐third (35%) of faculty members are of Asian origin [1]. According to the 2014 S&E Indicators report, "of the 46,000 US‐trained Asian or Pacific Islander S&E doctorate holders employed in academia in 2010, 10% were native‐born US citizens, 39% were naturalized US citizens, and 51% were noncitizens. In 2010, Asians or Pacific Islanders represented 52% of the foreign‐born S&E faculty employed full‐time in the

188 People's Movements in the 21st Century - Risks, Challenges and Benefits

Of the foreign‐born faculty members, scholars of Chinese (22%) and Indian (15%) origin occupy more than a third of the full‐time positions at 4‐year colleges and universities in the United States [3]. Despite these statistics, there are no systematic studies examining the job satisfaction of Asian faculty members working in science and engineering departments in the United States. Most of the studies by race/ethnicity combine individuals of Asian descent into one category irrespective of their citizenship status Faculty members born in the United States or naturalized through the immigration process experience very different levels of satisfac‐ tion toward their job when compared with foreign‐born faculty members on temporary status [3]. This study thus separates Asians by their citizenship status (i.e., Asian‐non‐US citizens and US citizens) and compares their satisfaction to other‐noncitizens and other‐US citizens. Data for this study comes from the 2003 Survey of Doctorate Recipients conducted by the

The academic sector in the United States is to a large extent dependent on the scientific con‐ tributions made by foreign‐born scientists and engineers [4–6]. However, there is seldom a study exclusively focused on citizenship status and race. Even though many parallels can be drawn between the experiences of US‐born Asians and foreign‐born Asians, their achieve‐ ments/barriers in the US labor market are likely to differ, mostly because immigrants from Asian countries arrive with different cultural, educational, and English language abilities. Retaining this group of scientists is important not only because they contribute to the scien‐ tific and technological growth of this country but also are a source of diversity [6]. The tempo‐

The governments of nations such as China, India, South Korea, and Taiwan who are the top exporters of talent to the United States are devising policies to attract thousands of their grad‐ uates back from the United States, creating newer economic opportunities for their returnees and the nation [7]. Traditionally, the United States has witnessed close to 85–95% stay rates among foreign‐born scientists and engineers of Chinese and Indian origin; this number is on the decline, however. The percentage of India‐born US‐trained PhDs in science and engineer‐ ing on temporary visa who continued to stay in the United States dropped from 85% in 2005 to 79% in 2009 [8]. The stay rates among Chinese born with identical visa status and educa‐ tional training have dropped 4 percentage points during the 4‐year period (93% in 2005 and 89% in 2009) [8]. There is evidence that between 1992 and 2003, more than eight thousand

rary nature of the citizenship among Asian scientists is concerning.

United States [2].

National Science Foundation (NSF).

Among the major racial/ethnic groups in the United States, Asian‐Americans have the high‐ est levels of education, income, and socioeconomic status [12]. While US citizens of Asian background have come a long way since the time early migrants came as slave laborers about 150 years ago. Asians are referred to as "model minorities." The term "model minority" was coined by higher academic achievement and socioeconomic status of current‐day Asians when compared with African‐Americans and Hispanics [13–16]. However, critics of this model argue that this group continues to confront inequities in income and upward job mobil‐ ity when compared with their Caucasian counterparts [17–20]. Therefore the question arises: is "model minority" a reality or a myth?

The perception of "model minority" is attributed to factors such as college graduation rates, socioeconomic status, and higher representation in science and engineering disciplines [18]. The author also argues that Asian‐Americans are more likely to graduate from college when compared with other minority groups (African‐Americans and Hispanics). Further, they have family support that keeps them motivated to be successful and thus achieve higher paying jobs that translate into improved socioeconomic status. This group has the highest representation in science and engineering disciplines as demonstrated by the success of the American immigration policy targeting high‐skilled science and engineering profession‐ als [21]. Given the high rates of representation of people of Asian descent in science and engineering, the National Science Foundation no longer includes this group as a minority since 1989. The minority categories in subsequent years include members of the following ethnic groups: Alaskan Native, Native American, African‐American, and Hispanic. Thus, the "model minority" image reduces Asian‐Americans as a racial group free of any challenges or racism—touted as the American success story [22].

Recent research has however criticized the "model minority" status glorified by several schol‐ ars [13–15, 23–25]. Studies show that this group faces challenges of income disparity and upward mobility in their jobs owing to their "outsider" perception [19, 20, 26]. A recent study shows that Asian‐Americans have a 12% higher poverty rate than their white counterparts [27] despite the high median income reports [26].

## **3. Asian scientists and engineers: job satisfaction**

This study will utilize data from the Survey of Doctorate Recipients, a national representative survey conducted by the National Science Foundation that understands the factors that contrib‐ ute toward an individual's satisfaction/dissatisfaction with work. Work satisfaction improves the well‐being of employees [28, 29] but more importantly increases the retention of faculty members [30, 31]. Several factors that impact an individual faculty member's job satisfaction are research productivity, faculty rank, tenure status, supervisory position, Carnegie classifica‐ tion of employer institution, discipline, salary, and sociodemographic factors [3, 32–37]. These will be examined for US citizen and noncitizen groups and compared to Asian‐non‐US citizen and Asian‐US‐citizen groups.

Studying satisfaction rates is important because faculties have high levels of job autonomy and they have the discretion to decide how they spend their time and resources. Dissatisfaction with any aspect of their job can result in lower productivity and quality of work [38]. A well‐ functioning faculty would not only impact the morale and quality of faculty members but also influence future faculty members and students. Past studies have shown various barri‐ ers faced by minority groups, impacting on their job satisfaction rates [39]. Foreign‐borns of a faculty are likely to face challenges due to their citizenship status, cultural differences, the stereotypes they encounter, and varied levels of English language skills.

Lower satisfaction was reported among Asian and Middle Eastern faculty members in rela‐ tion to job autonomy, decision‐making authority, salary and benefits, job security, opportu‐ nities for career advancement, and outside consulting [40]. In another study, Asian‐Indian individuals working in the academic and nonacademic sector in the United States (and a few who had returned to India) faced a glass ceiling at work, albeit they constitute a large propor‐ tion of the S&E workforce. Whites in S&E are ahead of Asian‐Indian immigrants in manage‐ ment positions because of the cultural advantage they hold over Asians [41].

"The result is a promotion sequence that amounts to an uninterrupted, non‐Hispanic White male succession, and a tendency to ignore structural conditions that create obstacles for Asian‐Indian immigrants in the S&E workforce (p. 111)." [41]

One of the biggest reasons for Asian‐American immigrants to be absent from upper manage‐ ment levels is due to the perceived lack of leadership qualities and poor English language skills. As one of the faculty members pointed out:

"Suppose you apply for a dean's position. You have good credentials and excellent English, but you also have an accent. I bet you will not be offered the job. The hiring committee will not see you as having language qualifications suited for the American system, though they will not say this openly (p. 103)." [41]

These factors can cause stress and lower one's level of job satisfaction. Asian‐non‐US‐citizen scientists also experience lower satisfaction when spending greater amounts of time in teach‐ ing‐related activities. A qualitative study of 20 engineering faculty members from China and India employed at a Research I University aimed at measuring their job satisfaction found that these individuals expressed greater frustration because of lack of recognition and con‐ cern with balancing teaching and research [42]. Other studies reported that Asian faculty members reported the least satisfaction among all ethnic groups. Despite the challenges faced by foreign‐born faculty members, higher productivity rates were reported compared with native‐born faculty members [3–6, 43–45].

## **4. Data and methodology**

representation in science and engineering disciplines as demonstrated by the success of the American immigration policy targeting high‐skilled science and engineering profession‐ als [21]. Given the high rates of representation of people of Asian descent in science and engineering, the National Science Foundation no longer includes this group as a minority since 1989. The minority categories in subsequent years include members of the following ethnic groups: Alaskan Native, Native American, African‐American, and Hispanic. Thus, the "model minority" image reduces Asian‐Americans as a racial group free of any challenges or

Recent research has however criticized the "model minority" status glorified by several schol‐ ars [13–15, 23–25]. Studies show that this group faces challenges of income disparity and upward mobility in their jobs owing to their "outsider" perception [19, 20, 26]. A recent study shows that Asian‐Americans have a 12% higher poverty rate than their white counterparts

This study will utilize data from the Survey of Doctorate Recipients, a national representative survey conducted by the National Science Foundation that understands the factors that contrib‐ ute toward an individual's satisfaction/dissatisfaction with work. Work satisfaction improves the well‐being of employees [28, 29] but more importantly increases the retention of faculty members [30, 31]. Several factors that impact an individual faculty member's job satisfaction are research productivity, faculty rank, tenure status, supervisory position, Carnegie classifica‐ tion of employer institution, discipline, salary, and sociodemographic factors [3, 32–37]. These will be examined for US citizen and noncitizen groups and compared to Asian‐non‐US citizen

Studying satisfaction rates is important because faculties have high levels of job autonomy and they have the discretion to decide how they spend their time and resources. Dissatisfaction with any aspect of their job can result in lower productivity and quality of work [38]. A well‐ functioning faculty would not only impact the morale and quality of faculty members but also influence future faculty members and students. Past studies have shown various barri‐ ers faced by minority groups, impacting on their job satisfaction rates [39]. Foreign‐borns of a faculty are likely to face challenges due to their citizenship status, cultural differences, the

Lower satisfaction was reported among Asian and Middle Eastern faculty members in rela‐ tion to job autonomy, decision‐making authority, salary and benefits, job security, opportu‐ nities for career advancement, and outside consulting [40]. In another study, Asian‐Indian individuals working in the academic and nonacademic sector in the United States (and a few who had returned to India) faced a glass ceiling at work, albeit they constitute a large propor‐ tion of the S&E workforce. Whites in S&E are ahead of Asian‐Indian immigrants in manage‐

stereotypes they encounter, and varied levels of English language skills.

ment positions because of the cultural advantage they hold over Asians [41].

racism—touted as the American success story [22].

190 People's Movements in the 21st Century - Risks, Challenges and Benefits

[27] despite the high median income reports [26].

and Asian‐US‐citizen groups.

**3. Asian scientists and engineers: job satisfaction**

Data for this study comes from the 2003 Survey of Doctorate Recipients (SDR)1 conducted by the National Science Foundation. This dataset was chosen because it has a large sam‐ ple size and is highly recommended for data sampling. It has rich information on demo‐ graphics, citizenship, nationality, educational background, employment, wages, scholarly activities, and job satisfaction. Such a large coverage reduces the risk of sampling error. In addition, the 2003 SDR data have information about the visa status of the doctoral recipi‐ ents. This will help further break down the analyses of foreign‐born faculty members based on visa status.

The survey was funded by the National Science Foundation and the National Institutes of Health. The actual survey was conducted by the National Opinion Research Center (NORC) at the University of Chicago. The data were collected from doctorate recipients with a degree from a US institution in the fields of science, engineering, or health sciences in June 2002. All the par‐ ticipants were under 76 years of age as of October 1, 2003, which was taken as the survey refer‐ ence week. A total of 40,000 individuals with doctoral degrees were sampled in the 2003 survey.

<sup>1</sup> The 2003 SDR data were used since this is the only most current data that queries the respondents on various aspects of job satisfaction. Subsequent surveys only have one question on the overall job satisfaction. For more details visit http:// www.nsf.gov/statistics/srvydoctoratework/.

The unit of analysis for this study is the individual academic scientist; hence, respondents with nonacademic jobs are filtered before beginning the analysis. For this filtering process, academics are counted as those faculty members working in a 4‐year college or university during the reference week of October 2003. The data analysis is further limited to (1) full‐time faculty employers and (2) faculty members employed in the real of science and engineer‐ ing disciplines: biological, agricultural, and environmental life sciences; computer and infor‐ mation sciences; mathematics and statistics; physical sciences; and engineering. Individuals reporting psychology, social sciences, and health as the field of their first S&E degree were eliminated since the sample was very small for the Asian group to conduct any meaningful analyses. The original unweighted sample size was 29,915 and the weighted sample size was 685,296. The final sample resulted in 6375 (unweighted) and 141,625 (weighted) after follow‐ ing the various filtering stages outlined in this section. Data analysis is conducted by race/ ethnicity and citizenship status. Information about race/ethnicity of individual's parents is not available. The respondents self‐identify into a specific racial group.

It is important to mention that citizenship data is classified into four categories: US citizens, naturalized citizens, legal permanent residents (LPR), and temporary residents. Naturalized citizens are combined with US‐born faculty members into one category (citizens), and LPR and temporary residents are classified as non‐US citizens.

## **5. Results**

#### **5.1. Differences in job characteristics**

Comparisons are made across four subgroups of faculty members: Asian‐US citizens (10.7%), Asian‐US noncitizens (4.2%), other‐US citizens (80.4%), and other non‐US citizens (4.7%). Other noncitizens are faculty members belonging to African‐American, Hispanic, White, and other racial/ethnic groups born outside the United States. The majority of Asian‐non‐US citizens are from China (39.9%) followed by India (26.1%), Korea (8.2%), and Taiwan (6%). **Table 1** presents the mean differences between Asian‐US citizens, Asian‐non‐US citizens and US citizens, and other‐US‐citizen groups. Across the four major groups, the highest number of female faculty members belongs to Asian‐US citizens (32%), followed closely by other‐non‐ US citizens (30%). Over 75% of all faculty members in all four groups are married. Asian‐non‐ US citizens are the youngest group of faculty members with an average age of 39 years, while other‐US citizens are the oldest with an average age of 49 years.

Majority of the faculty members among Asian‐non‐US citizens were employed at research I/II universities. A majority of Asian‐US citizens received their highest degree in Biology (43.5%), similar to other‐US‐citizen groups (45%). Asian‐non‐US citizens have the highest percentage of faculty members with a degree in computer science (10%) and engineering (23%). These statistics are not surprising given that the majority of Asians come to the United States to get their doctoral degrees in these disciplines [1].

Interestingly, though the same percentage (56%) of faculty members belonging to both non‐US‐citizen groups (Asian and non‐Asian) report working at a Research university,


The unit of analysis for this study is the individual academic scientist; hence, respondents with nonacademic jobs are filtered before beginning the analysis. For this filtering process, academics are counted as those faculty members working in a 4‐year college or university during the reference week of October 2003. The data analysis is further limited to (1) full‐time faculty employers and (2) faculty members employed in the real of science and engineer‐ ing disciplines: biological, agricultural, and environmental life sciences; computer and infor‐ mation sciences; mathematics and statistics; physical sciences; and engineering. Individuals reporting psychology, social sciences, and health as the field of their first S&E degree were eliminated since the sample was very small for the Asian group to conduct any meaningful analyses. The original unweighted sample size was 29,915 and the weighted sample size was 685,296. The final sample resulted in 6375 (unweighted) and 141,625 (weighted) after follow‐ ing the various filtering stages outlined in this section. Data analysis is conducted by race/ ethnicity and citizenship status. Information about race/ethnicity of individual's parents is

It is important to mention that citizenship data is classified into four categories: US citizens, naturalized citizens, legal permanent residents (LPR), and temporary residents. Naturalized citizens are combined with US‐born faculty members into one category (citizens), and LPR

Comparisons are made across four subgroups of faculty members: Asian‐US citizens (10.7%), Asian‐US noncitizens (4.2%), other‐US citizens (80.4%), and other non‐US citizens (4.7%). Other noncitizens are faculty members belonging to African‐American, Hispanic, White, and other racial/ethnic groups born outside the United States. The majority of Asian‐non‐US citizens are from China (39.9%) followed by India (26.1%), Korea (8.2%), and Taiwan (6%). **Table 1** presents the mean differences between Asian‐US citizens, Asian‐non‐US citizens and US citizens, and other‐US‐citizen groups. Across the four major groups, the highest number of female faculty members belongs to Asian‐US citizens (32%), followed closely by other‐non‐ US citizens (30%). Over 75% of all faculty members in all four groups are married. Asian‐non‐ US citizens are the youngest group of faculty members with an average age of 39 years, while

Majority of the faculty members among Asian‐non‐US citizens were employed at research I/II universities. A majority of Asian‐US citizens received their highest degree in Biology (43.5%), similar to other‐US‐citizen groups (45%). Asian‐non‐US citizens have the highest percentage of faculty members with a degree in computer science (10%) and engineering (23%). These statistics are not surprising given that the majority of Asians come to the United States to get

Interestingly, though the same percentage (56%) of faculty members belonging to both non‐US‐citizen groups (Asian and non‐Asian) report working at a Research university,

not available. The respondents self‐identify into a specific racial group.

and temporary residents are classified as non‐US citizens.

192 People's Movements in the 21st Century - Risks, Challenges and Benefits

other‐US citizens are the oldest with an average age of 49 years.

their doctoral degrees in these disciplines [1].

**5.1. Differences in job characteristics**

**5. Results**


+ *p* < 0.1.

**Table 1.** Mean differences in job characteristics.

Asian‐non‐US citizens far surpass the other groups in the time they report spending on research and development (62% vs. 51%), while the reverse is true for time spent teaching (24% vs. 35%).

On analyzing the rank of faculty members by citizenship and race, it is interesting to note that 7% of Asian‐non‐US citizens are full professors, while about 17% are full professors among other‐non‐US‐citizen groups. These differences are statistically significant between the two groups. One possible explanation for this disparity is that other‐non‐US‐citizen faculty mem‐ bers have 2 years more experience than Asian‐non‐US citizens. However, Asian‐US citizen and other‐non‐US‐citizen groups have equal proportions of faculty members employed in associate professor positions (17%). As others have argued, this could also be a result of glass ceiling experienced by Asian faculty members while climbing the academic ladder [20, 46, 47]. The difference in tenure rates between these two groups of faculty members is impor‐ tant (19% Asian‐non‐US citizens and 31% other‐non‐US citizens) and statistically significant. Significant differences in tenure rates are also seen between Asian‐US citizens and other‐US citizens. Further investigation is required to determine whether Asian‐non‐US citizens are faced with barriers while trying to move up or whether they are experiencing lower promo‐ tion rates due to their temporary citizenship status. Similar patterns emerge when comparing Asian and other citizen groups, with fewer Asians‐US citizens in leadership and full‐profes‐ sor positions.

#### **5.2. Job satisfaction in relation to Asian descent and citizenship**

Though Asians have been touted as "model minorities," the results of this study show oth‐ erwise. Despite being faced with career trajectories that are not on par with other‐US‐citizen/ non‐US‐citizen groups, Asian‐US citizens are the most productive. They produced the highest number of annual peer‐reviewed journal articles, books, and conference papers. Asian‐US citizens also are most likely to be named as inventors of a patent and awarded a federal grant when compared with the remaining three groups. Despite higher productivity, the aver‐ age difference in salaries between Asian‐US citizens and other‐US citizens is not statistically significant.

Alongside comparing productivity and career trajectories, the aim of this study is to ana‐ lyze the satisfaction of scientists and engineers by citizenship and race. The data in **Table 2** suggests that on average Asian‐non‐US citizens (3.20) and Asian‐US citizens (3.38) express significantly lower overall satisfaction with their job than other‐non‐US‐citizen (3.41) and US‐citizen (3.46) groups.

Satisfaction is further analyzed as a measure of nine different factors: opportunities for advancement, benefits, intellectual challenge, degree of independence, location, level of responsibility, salary, job security, and contribution to society. On analyzing satisfaction by various factors, Asian‐non‐US citizens express the least average satisfaction on all factors but opportunities for advancement when compared with the three groups, other‐non‐US citizens (3.06), Asian‐US citizens (2.99), and other‐US citizens (3.04). Furthermore, Asian‐non‐US citi‐ zens and Asian‐US citizens experience significantly lower levels of responsibility at work than other‐non‐US‐citizen and US‐citizen groups.

Dissatisfaction with level of responsibility is evident by the lower numbers of Asian‐US citi‐ zens in dean/chair/full‐professor positions when compared with other‐US citizens. The results are in line with past research that focuses on the existence of the glass ceiling to upward career mobility experienced by Asians [20, 46, 47]. These studies question the portrayal of Asians in the US media as a "model minority." Instead, they argue that despite their achieve‐ ments, Asians have not reached a level in which they participate in policy and decision‐mak‐

Asian‐non‐US citizens far surpass the other groups in the time they report spending on research and development (62% vs. 51%), while the reverse is true for time spent teaching (24% vs. 35%). On analyzing the rank of faculty members by citizenship and race, it is interesting to note that 7% of Asian‐non‐US citizens are full professors, while about 17% are full professors among

63.0%\*\* 51.0% 55.0%\*\* 50.0%

**Asian‐non‐US citizens (N = 268,** 

194 People's Movements in the 21st Century - Risks, Challenges and Benefits

**Other‐non‐US citizens (N = 302, 4.7%)**

56.0% 56.0% 55.0%\*\* 50.0%

12.0% 11.0% 10.0% 11.0%

11.0%\* 18.0% 14.0%\*\* 19.0%

2.0% 4.0% 4.0%\*\*\* 8.0%

12.0%\* 18.0% 9.0% 10.0%

10.0% 8.0% 7.0%\*\*\* 3.0%

Teaching 24.0%\*\* 35.0% 29.0%\*\*\* 40.0%

Others 19.0%\* 12.0% 17.0%\*\* 13.0%

Biology 37.7%\*\* 26.0% 43.5% 45.0%

Physical science 18.0%\*\* 27.0% 20.0%\*\* 25.0%

Engineering 23.0% 22.0% 21.0%\*\* 17.0% Salary \$62,922+ \$66,778 \$83,842 \$81,870 Years of experience 7.09\*\* 9.15 15.45\*\*\* 17.73

Female 25.0%\* 30.0% 32.0%\*\*\* 24.0% Married 81.0%+ 74.0% 83.0% 82.0% Age 39.4\*\* 41.4 46.8\*\*\* 48.7

Note: *t*‐Test comparisons across groups are statistically significant at various levels:

**Asian‐US citizens (N = 680, 10.7%)**

**Other‐US citizens (N = 5,125 80.4%)**

**4.2%)**

*Institution type* Research I/II universities

Doctoral I/II university

Comprehensive I/II university

Liberal arts I/II university

*Academic discipline*

Mathematics and statistics

Computer and information sciences

**Demographics**

Children living with

**Table 1.** Mean differences in job characteristics.

parents

+ *p* < 0.1.

\*\*\**p* < 0.001, \*\**p* < 0.01, \*

*p* < 0.05, and

ing responsibilities [41]. Additionally, both groups of Asian faculty members (US citizens and non‐US citizens) express significantly lower satisfaction with salary and benefits when compared with other‐non‐US‐citizen and US‐citizen groups.


a Results are in response to the following statement: "Thinking about your principal job held during the week of October 1, 2003, please rate your satisfaction with that job's ….".

b Possible responses: 1 = very dissatisfied, 2 = somewhat dissatisfied, 3 = somewhat satisfied, and 4 = very satisfied \*\*\**p* < 0.001.

\*\**p* < 0.01.

\* *p* < 0.05.

+ *p* < 0.1.

**Table 2.** Mean differences in job satisfaction by race and citizenship.

Asian‐non‐US citizens also express significantly less satisfaction with location when com‐ pared with other non‐US citizens. The location of faculty members and its impact on their job satisfaction have not been studied in detail. The geographic location of faculty members is especially of importance when foreign‐born faculty members are the subject of the study. The choice of location is generally limited among foreign‐born faculty members, especially faculty members on nonimmigrant visa status. These groups of faculty members have fewer opportunities to find academic employment with visa sponsorship and are thus more likely to take up a tenure‐track position irrespective of the location as compared with US citizens. Additionally, Asian‐non‐US citizens also express lower satisfaction with job security (*p* < 0.1) when compared with other‐non‐US citizens.

Job security is an important issue for non‐US‐citizen faculty members. Citizens of Indian and Chinese origin experience the longest delays in processing their permanent residency. An estimate suggests that there are over half a million skilled individuals waiting to get perma‐ nent residency in the United States [48]. Under the employment‐based immigration category (EB2), as of October 2016, applications filed in the year 2007 and later are being processed for immigrants from India [49]. The massive backlog in acquiring permanent residency is add‐ ing to the frustration faced by these groups of scientists. Challenges with acquiring a legal permanent residence (LPR) can serve as a deterrent for faculty members who would like to stay in the United States. The desire to acquire permanent residency along with existing pressures of being on a tenure‐track position can result in lower satisfaction with job security and opportunities for advancement among Asian‐non‐US citizens. Other‐non‐US citizens do not face similar challenges with acquiring permanent residency and/or citizenship; the pro‐ cessing times are drastically shorter than Indian and Chinese immigrants [50].

ing responsibilities [41]. Additionally, both groups of Asian faculty members (US citizens and non‐US citizens) express significantly lower satisfaction with salary and benefits when

> **Other‐non‐US citizens (N = 302,**

3.01 3.06 2.99 3.04

**Asian‐US citizens (N = 680, 10.7%)**

**Other‐US citizens (N = 5,125, 80.4%)**

**4.7%)**

Overall job satisfaction 3.20\*\*\* 3.41 3.38\*\* 3.46

Benefits 3.08\*\*\* 3.31 3.19\* 3.26 Intellectual challenge 3.38\* 3.53 3.53\* 3.59 Degree of independence 3.54\* 3.64 3.65\* 3.70 Location 3.10\*\*\* 3.34 3.36\* 3.42 Level of responsibility 3.29\*\* 3.45 3.40\*\*\* 3.55 Salary 2.74\*\*\* 2.97 2.88\*\*\* 2.99 Job security 3.10+ 3.22 3.35 3.40 Contribution to society 3.46 3.52 3.58 3.58

Asian‐non‐US citizens also express significantly less satisfaction with location when com‐ pared with other non‐US citizens. The location of faculty members and its impact on their job satisfaction have not been studied in detail. The geographic location of faculty members is especially of importance when foreign‐born faculty members are the subject of the study. The choice of location is generally limited among foreign‐born faculty members, especially faculty members on nonimmigrant visa status. These groups of faculty members have fewer opportunities to find academic employment with visa sponsorship and are thus more likely to take up a tenure‐track position irrespective of the location as compared with US citizens. Additionally, Asian‐non‐US citizens also express lower satisfaction with job security (*p* < 0.1)

Results are in response to the following statement: "Thinking about your principal job held during the week of October

Possible responses: 1 = very dissatisfied, 2 = somewhat dissatisfied, 3 = somewhat satisfied, and 4 = very satisfied

Job security is an important issue for non‐US‐citizen faculty members. Citizens of Indian and Chinese origin experience the longest delays in processing their permanent residency. An estimate suggests that there are over half a million skilled individuals waiting to get perma‐ nent residency in the United States [48]. Under the employment‐based immigration category

when compared with other‐non‐US citizens.

compared with other‐non‐US‐citizen and US‐citizen groups.

**Asian‐non‐US citizens (N = 268,** 

196 People's Movements in the 21st Century - Risks, Challenges and Benefits

**4.2%)**

1, 2003, please rate your satisfaction with that job's ….".

**Table 2.** Mean differences in job satisfaction by race and citizenship.

**Work satisfaction measuresa, b**

Opportunities for advancement

a

b

\*\*\**p* < 0.001. \*\**p* < 0.01. \* *p* < 0.05. + *p* < 0.1.

## **5.3. Regression analysis of job satisfaction and productivity, career trajectory and job characteristics by citizenship status**

To further explore the differences in satisfaction, four OLS regression models were run, and the results of which are presented in **Table 3**. The dependent variable is job satisfaction. Most of the studies use a global variable to measure faculty members' job satisfaction [34, 44, 51]. The questions are generally "yes" or "no" or are on a Likert scale with responses varying from "very satisfied" to "very dissatisfied." Single item measures of job satisfaction overesti‐ mate the percentage of satisfied vs. dissatisfied employees. On the other hand, multiple‐item measures are better for estimating satisfaction levels [29]. This study thus uses nine ques‐ tions that measure different aspects of work satisfaction to create the dependent variable job satisfaction. Participants used a 1‐to‐4 rating scale numbered from 1 (very satisfied) through 4 (very dissatisfied). Scores were subsequently reverse‐coded with lower scores signifying lower levels of satisfaction and higher scores indicating more job satisfaction. The total job satisfaction scores range from 9 through 36 (α = 0.79).



\* *p* < 0.05. + *p* < 0.1.

**Table 3.** Job satisfaction by race and citizenship.

The regression uses several sets of independent variables, which are classified into three major cat‐ egories (a) research productivity, (b) career trajectory, and (c) job characteristics. Demographics are included as controls. Model 1 focused on Asian‐non‐US citizens and explained about 22% of variance in job satisfaction. Model 2, which included the other‐non‐US‐citizen group, explained 25% of the variance, the highest of all groups. Model 3 focused on Asian‐US citizens and explained 21.6% of the variance in job satisfaction. Lastly, model 4 with faculty members belonging to non‐Asian‐US‐citizen group explained the least variation in job satisfaction (16.7%).

#### *5.3.1. Job satisfaction and research productivity*

As seen in **Table 3**, the annual number of articles published has a positive and significant impact on the satisfaction of faculty members belonging to all groups, except other‐non‐US citizens. Interestingly, presentations made at conferences lowered the satisfaction of Asian‐ non‐US citizens, a finding that was different for Asian‐US citizens and other‐US‐citizen groups. Conference presentations, although an important part of scholarly life, can take time away from faculty members' work and time spent on research. Except Asian‐US citizens, all other groups of faculty members experienced positive satisfaction when named as a patent inventor. All groups of scientists and engineers reported higher satisfaction when awarded a federal grant. Grant activity is an integral part of faculty members working in science and engineering disciplines. Being awarded a federal grant not only enhances the visibility of the individual scholar but also the department and ultimately the institution.

#### *5.3.2. Job satisfaction and career trajectory and job characteristics*

The regression uses several sets of independent variables, which are classified into three major cat‐ egories (a) research productivity, (b) career trajectory, and (c) job characteristics. Demographics are included as controls. Model 1 focused on Asian‐non‐US citizens and explained about 22% of variance in job satisfaction. Model 2, which included the other‐non‐US‐citizen group,

**Model 1 Asian‐non‐US citizens (N = 268, 4.2%)**

198 People's Movements in the 21st Century - Risks, Challenges and Benefits

*Tenure status*—*tenured (reference group)*

*Research and development (reference group)*

*Discipline*—*biology (reference group)*

*Institution type*—*research I/II universities (reference group)*

On tenure track but not tenured

*Job characteristics*

Comprehensive I/II university

Mathematics and statistics

Computer and information sciences

**Demographics**

*Married (reference group)*

Children living with

Dependent variable: job satisfaction index

**Table 3.** Job satisfaction by race and citizenship.

parents

\*\*\**p* < 0.001. \*\**p* < 0.01. \* *p* < 0.05. + *p* < 0.1.

**Model 2 other‐non‐US citizens (N = 302, 4.7%)**

1.005\*\*\* ‐0.576\* 1.163\*\*\* 1.127\*\*\*

1.250\*\*\* ‐1.796\*\*\* ‐0.483\*\*\* ‐0.850\*\*\*

‐1.713\*\*\* ‐0.532\*\*\* 0.113 0.017

0.720\*\*\* ‐0.104 0.282+ ‐0.177

‐0.247\* ‐0.629\*\*\* ‐0.352\*\*\* 0.191\*

Assistant professor 0.420\*\* ‐0.373 ‐0.524\*\*\* ‐1.520\*\*\* Instructor/lecturer 0.764\*\* 0.651\*\* ‐1.582\*\*\* ‐0.824\*\*

Not on tenure track ‐0.808\*\*\* ‐2.804\*\*\* ‐2.406\*\*\* ‐1.258\*\*\* Tenure not applicable 0.472\* ‐3.551\*\*\* ‐1.205\*\*\* ‐1.011\*\*\* Years of experience 0.023\* ‐0.087\*\*\* 0.051\*\*\* 0.027\*\*\*

Teaching ‐0.599\*\*\* 0.482\*\*\* ‐0.975\*\*\* ‐0.345\*\*\*

Doctoral I/II university 1.034\*\*\* ‐0.653\*\*\* ‐0.326\*\* 0.622\*\*\*

Liberal arts I/II university ‐1.649\*\*\* ‐3.240\*\*\* ‐0.988\*\*\* 0.925\*\*\* Others ‐0.606\*\*\* ‐0.556\*\*\* ‐0.031 0.057

Physical science ‐0.164 ‐0.49\*\*\* 0.071 0.073

Engineering 0.289\* ‐0.847\*\*\* ‐0.236\* ‐0.881\*\*\* Salary 2.583E‐5\*\*\* 2.751E‐5\*\*\* 6.000E‐6\*\*\* 1.069E‐5\*\*\*

Male ‐0.234\* ‐0.309\* ‐0.088 ‐0.022

Never married 0.906\*\*\* 0.360\* ‐0.407\*\* ‐1.007\*\*\* Divorced and separated 1.005\*\*\* 1.132\*\*\* 0.354\* ‐0.640\*\*\*

Pacific region 0.755\*\*\* 1.450\*\*\* 0.101 0.145 Linguistic distance ‐1.918\*\*\* 0.053 ‐3.190\*\*\* 0.956\*\* Adjusted R square 0.218 0.247 0.216 0.167

**Model 3 Asian‐US citizens (N = 680,** 

**Model 4 other‐US citizens (N = 5,125,** 

**80.4%)**

**10.7%)**

Furthermore, as seen in **Table 3**, Asian‐non‐US citizens in assistant, associate, and instruc‐ tor/lecturer positions express higher levels of satisfaction than full professors. Contrary to popular literature [52], both groups of non‐US‐citizen faculty members in part‐time (instruc‐ tor/lecturer) positions express greater satisfaction with their jobs. Higher satisfaction is reported among part‐time faculty members since these faculty members choose not to be on tenure‐track positions and are content with their decision, possibly engaged in activi‐ ties they enjoy the most—teaching and administration [53]. Full‐professor position results in the greatest satisfaction among Asian‐US citizens and other‐US‐citizen groups. All but other‐non‐US‐citizen groups of scientists reported higher satisfaction with more experience.

For all groups, except other non‐US citizens, greater time spent on teaching‐related activi‐ ties resulted in lower job satisfaction. As faculty members spend more time on teaching, it takes time away from research, thus lowering their job satisfaction. The results confirm past findings [37, 54]. Asian‐non‐US citizens, employed at doctoral and comprehensive<sup>2</sup> univer‐ sities, express greater satisfaction that those at research universities. Faculty members not working in research universities might experience a greater balance between research and teaching, thus leading to higher job satisfaction [55, 56]. However, faculty members across all

<sup>2</sup> For a detailed classification of the new Carnegie codes, refer to the website: http://carnegieclassifications.iu.edu/clas‐ sification\_descriptions/basic.php.

The 2006 classification includes (1) Doctoral Granting Universities that further are classified into RU/VH, Research Uni‐ versities (very high research activity); RU/H, Research Universities (high research activity); and DRU, Doctoral/Research Universities. (2) Master's Colleges and Universities: Master's/L, Master's Colleges and Universities (larger programs); Master's/M, Master's Colleges and Universities (medium programs); and Master's/S, Master's Colleges and Universities (smaller programs). (3) Baccalaureate Colleges: Bac/A&S, Baccalaureate Colleges, Arts and Sciences; Bac/Diverse, Bac‐ calaureate Colleges, Diverse Fields; and Bac/Assoc, Baccalaureate/Associate's Colleges. (4) Associate's Colleges have 14 different subclassifications of all colleges offering two‐year degrees. (5) Special Focus Institutions. (6) Tribal colleges.

four groups employed at liberal arts colleges3 , where teaching is greatly emphasized, reported lower job satisfaction than faculty members in research universities.

Asian‐non‐US citizens employed in engineering and computer science disciplines experience greater satisfaction than faculty members employed in biology. The results are in stark con‐ trast to other‐US‐citizen and non‐US‐citizen groups. The findings are interesting and suggest that satisfaction is in part a measure of similar groups working together. Given that one‐third of Asian‐non‐US citizens are employed in these disciplines (computer science and engineer‐ ing), scientists belonging to this group might experience a sense of belongingness, which serves as an intrinsic motivator, further enhancing satisfaction at work [57].

#### *5.3.3. Job satisfaction and demographics*

Male faculty members are significantly less satisfied than female faculty members in both noncitizen groups (Asian‐non‐US‐citizen and other‐non‐US‐citizen groups) (see **Table 3**). The findings of this study differ from several studies that have indicated female faculty members in S&E intend to quit as a result of lower job satisfaction [32, 33, 37, 38, 58, 59]. Past stud‐ ies also indicate that male faculty members derive greater satisfaction from the amount of financial support they receive for their research in comparison with female faculty members who get satisfaction from peer support. Although this study does not report satisfaction with various aspects of work by gender, the findings in the literature are interesting, suggesting that women seek supportive work environments leading to higher intrinsic satisfaction [28].

Marriage lowered the job satisfaction among Asian and other non‐US‐citizen groups when compared with citizen groups. Although several studies have shown the positive impact of marriage on job satisfaction, a few have suggested that marriage can negatively impact satis‐ faction. This is especially true in the case of female faculty members who are constantly faced by the challenges of balancing career and family. Women married with children are often forced into juggling two separate lives, hence putting them at a disadvantage in their profes‐ sional careers [60, 61]. However, scientists belonging to citizen groups (Asian and non‐Asian), who are unmarried, report lower satisfaction than their married counterparts. One possible explanation for opposite findings for US‐citizen and non‐US‐citizen groups is that marriage is related to the age of faculty members [62]. Asian‐non‐US citizens and other‐noncitizen sci‐ entists are typically younger and on tenure‐track positions but not tenured. The demands to achieve tenure along with family responsibilities might result in lower job satisfaction among married non‐US‐citizen groups of scientists. However, the opposite is true for US‐citizen groups.

Asian‐non‐US‐citizen and other‐non‐US‐citizen faculty members employed in the Pacific region of the United States report higher job satisfaction. Location did not impact the satis‐ faction of Asian‐US‐citizen and other‐US‐citizen groups. The Pacific region, according to the 2000 Census Bureau4 , is the most ethnically diverse region in the country, with less than 60%

<sup>3</sup> Liberal arts: These institutions are primarily undergraduate colleges with major emphasis on baccalaureate programs. For more information, see http://carnegieclassifications.iu.edu/downloads/2000\_edition\_data\_printable.pdf. 4 See US Census for more details: http://www.census.gov/quickfacts/table/PST045215/06,00.

of the population being White alone. This confirms the results from previous studies, which suggest that minorities employed in ethnically diverse regions are likely to express greater job satisfaction as compared with faculty members employed in less diverse parts of the country [44, 51]. Further, Asian‐non‐US citizen and Asian‐US citizens with lower English language skills report negative job satisfaction, a finding that supports previous work by [63].

## **6. Conclusion**

four groups employed at liberal arts colleges3

200 People's Movements in the 21st Century - Risks, Challenges and Benefits

*5.3.3. Job satisfaction and demographics*

groups.

3

4

2000 Census Bureau4

lower job satisfaction than faculty members in research universities.

serves as an intrinsic motivator, further enhancing satisfaction at work [57].

Asian‐non‐US citizens employed in engineering and computer science disciplines experience greater satisfaction than faculty members employed in biology. The results are in stark con‐ trast to other‐US‐citizen and non‐US‐citizen groups. The findings are interesting and suggest that satisfaction is in part a measure of similar groups working together. Given that one‐third of Asian‐non‐US citizens are employed in these disciplines (computer science and engineer‐ ing), scientists belonging to this group might experience a sense of belongingness, which

Male faculty members are significantly less satisfied than female faculty members in both noncitizen groups (Asian‐non‐US‐citizen and other‐non‐US‐citizen groups) (see **Table 3**). The findings of this study differ from several studies that have indicated female faculty members in S&E intend to quit as a result of lower job satisfaction [32, 33, 37, 38, 58, 59]. Past stud‐ ies also indicate that male faculty members derive greater satisfaction from the amount of financial support they receive for their research in comparison with female faculty members who get satisfaction from peer support. Although this study does not report satisfaction with various aspects of work by gender, the findings in the literature are interesting, suggesting that women seek supportive work environments leading to higher intrinsic satisfaction [28]. Marriage lowered the job satisfaction among Asian and other non‐US‐citizen groups when compared with citizen groups. Although several studies have shown the positive impact of marriage on job satisfaction, a few have suggested that marriage can negatively impact satis‐ faction. This is especially true in the case of female faculty members who are constantly faced by the challenges of balancing career and family. Women married with children are often forced into juggling two separate lives, hence putting them at a disadvantage in their profes‐ sional careers [60, 61]. However, scientists belonging to citizen groups (Asian and non‐Asian), who are unmarried, report lower satisfaction than their married counterparts. One possible explanation for opposite findings for US‐citizen and non‐US‐citizen groups is that marriage is related to the age of faculty members [62]. Asian‐non‐US citizens and other‐noncitizen sci‐ entists are typically younger and on tenure‐track positions but not tenured. The demands to achieve tenure along with family responsibilities might result in lower job satisfaction among married non‐US‐citizen groups of scientists. However, the opposite is true for US‐citizen

Asian‐non‐US‐citizen and other‐non‐US‐citizen faculty members employed in the Pacific region of the United States report higher job satisfaction. Location did not impact the satis‐ faction of Asian‐US‐citizen and other‐US‐citizen groups. The Pacific region, according to the

Liberal arts: These institutions are primarily undergraduate colleges with major emphasis on baccalaureate programs.

For more information, see http://carnegieclassifications.iu.edu/downloads/2000\_edition\_data\_printable.pdf.

See US Census for more details: http://www.census.gov/quickfacts/table/PST045215/06,00.

, is the most ethnically diverse region in the country, with less than 60%

, where teaching is greatly emphasized, reported

This study compared the job satisfaction of four groups of scientists employed at research uni‐ versities in the United States. With high proportion of S&E Asian immigrant faculty members (US citizens and non‐US citizens) employed in the American academy, the study focused on comparing the job satisfaction of Asian‐non‐US‐citizens to other non‐US‐citizen groups and Asian‐US citizens to other‐US citizens. Comparing the career trajectories, research productiv‐ ity, and job satisfaction of these groups helped debunk the "model minority" myth. While Asian‐US citizens can be considered a "model minority" when comparing research produc‐ tivity with all groups of scientists, they are far from being problem‐free and without encoun‐ tering challenges. Both Asian groups (US citizens and non‐US citizens) express lower degrees of overall job satisfaction, benefits, level of responsibility, salary, intellectual challenge, and degree of independence than other‐US‐citizen and non‐US‐citizen faculty members. Though Asian‐US citizens are the most productive, they are less likely to be in leadership roles, a finding that requires further investigation. Further, the lower job satisfaction reported among Asian‐non‐US citizens is concerning given that satisfaction impacts retention rates [30, 31, 64]. These faculty members play an important role in the scientific, technological, and economic growth of the United States.

According to [8], the percentage of doctorate recipients from Asian countries such as China, India and South Korea, and Taiwan are on temporary visas but have hopes and plans to stay in the United States. Their numbers have decreased to an average of 9 percentage points between 2005 and 2009 for those with definite plans to stay in the United States [8]. Losing them in the form of reverse migration can add to the challenges faced by the scientific enterprise in the United States. The cost of replacing these faculty members could be enormous considering that institutions at a typical research university invest anywhere from \$300,000 to \$500,000 in start‐up costs for an assistant professor and well over a million dollars to attract and retain senior faculty members [65]. The results of this research might aid university administrators to rethink their diversity programs. In addition to increasing the numbers of Asian prospec‐ tive doctorates, there is a need to understand their behavior, their level of uncertainty and attitudes, as well as the difference of satisfaction when looking at those who are US citizens and are of Asian descent (race). This study is a step in that direction.

We argue that further research between US scientists and Asian‐non‐US‐citizen scientists would be helpful in determining the importance of this group. Current data lacks variables on col‐ laboration, environmental factors such as collegial relationships, work environment, and peer and student interactions, which impact faculty members' job satisfaction [34]. Future studies should include these variables for a better comprehension of the issues. Additionally, official statistics should determine Asian faculty members by their country of origin. This would pro‐ vide a further understanding of the career trajectories and satisfaction of this important group and perhaps clarify the myth of the "model minority," something we attempted to do.

#### **Author details**

Meghna Sabharwal

Address all correspondence to: meghna.sabharwal@utdallas.edu

School of Economic, Political and Policy Sciences, The University of Texas at Dallas, Richardson, TX, USA

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#### **Why Do Immigrants to Norway Leave the Country or Move Domestically? Some Important Facts Why Do Immigrants to Norway Leave the Country or Move Domestically? Some Important Facts**

Tom Kornstad, Terje Skjerpen and Lasse Sigbjørn Stambøl Tom Kornstad, Terje Skjerpen and Lasse Sigbjørn Stambøl

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/66951

#### **Abstract**

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We consider immigrants living in Norway and their behavior with respect to mobility. Using cross-sectional data, we employ a trinomial logit model. An immigrant may (i) move to another centrality level, (ii) emigrate, or (iii) stay at the same centrality level as in the previous period. We carry out separate estimations for eight different groups, brought about combining four centrality levels with two genders. To assess the effect of different explanatory variables related to (i) duration of residence in Norway, (ii) labor market status, (iii) reason for immigration, (iv) the extent of education and (v) family size and composition, we calculate marginal effects. In line with earlier results, we obtain that longer duration of residence tends to decrease the probability of emigration and that immigrants who have stated escape as the reason for immigration to Norway tends to have lower probabilities for emigration than those who have stated work as the reason.

**Keywords:** Norway, immigrants, immigration, internal/domestic migration, emigration, importance of education, labor force participation, duration of residence, family

#### **1. Introduction**

With a demographic development that provides perspectives on future labor shortages in the entire European Economic Area, the ability to retain migrant labor in general and highly qualified migrant labor in particular, could prove to be of key importance for a country. In 2013, about 24,000 former immigrants left Norway. Emigration from Norway has increased over time as more immigrants have entered the country, but there are large fluctuations from year to year. It is therefore natural to ask what drives emigration from Norway and whom do we "loose"?

and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

In this article, we look at different patterns of movements of immigrants and how they vary because of factors such as the degree of rurality (we call it "centrality levels" which are explained in Section 3), duration of residence in Norway, immigrants' education level, immigrants' labor force participation as a measure of the degree of integration, as well as family size and family composition. We try to answer important issues such as: What drives the exodus of immigrants from Norway? Which groups of immigrants emigrate? Are they immigrants that are well integrated into society, as measured by labor force participation and educational enrollment, or are they the least integrated ones? What is the impact of having family in Norway? In addition, we investigate at what extent differences in centrality can explain variation in emigration from different parts of Norway and the likelihood of alternatively remaining in a region or to move to another region in Norway.

As opposed to other studies that analyze emigration among immigrants, we not only focus on emigration but also consider the alternative of moving within the country, to another centrality level (see definition in Section 3). In Norway, refugees are placed across the country in order to obtain a balanced regional settlement pattern. In principle, however, they are free to move to another location and after some time in the country, many immigrants seem to do that. Thus, in this study we estimate multinomial (i.e., trinomial) logit models for the probabilities of (i) internal migration, (ii) emigration and (iii) remaining at the same centrality level using data for immigrants in Norway. Estimation is done separately for eight different groups, brought about by combining four centrality levels with two sexes.

As a basis for the analysis, we use individual-based registry data for population, migration, education and employment for all immigrants. The estimations are concentrated on Immigrants' adjustments from 2012 to 2013. There is one record for each of the observational units. The data are cross-sectional data with all the observed characteristics of individuals taken from the year 2012, while the outcome of the settlement, internal migration and emigration is measured for the year 2013.

We find that the probabilities for emigration and domestic migration decrease when the duration of residence increases. These results are rather robust across centrality levels and sexes.

With respect to labor market status, we find that being employed or combining work and education contributes to a lower probability of emigration and an increased probability of remaining at the same centrality level.

Internal migration among immigrants draws in centralizing direction, especially among refugees, while immigrants from the more central regions are more inclined to emigrate.

This paper is organized as follows: In Section 2, we take a closer look at some of the earlier literature. In Section 3, we define different concepts and variables and elaborate on the institutional setting. Section 4 presents the trinomial logit model and the calculation of the marginal effects. The empirical results are provided in Section 5 and some conclusions are drawn in Section 6.

## **2. Earlier studies on emigration among immigrants**

In this article, we look at different patterns of movements of immigrants and how they vary because of factors such as the degree of rurality (we call it "centrality levels" which are explained in Section 3), duration of residence in Norway, immigrants' education level, immigrants' labor force participation as a measure of the degree of integration, as well as family size and family composition. We try to answer important issues such as: What drives the exodus of immigrants from Norway? Which groups of immigrants emigrate? Are they immigrants that are well integrated into society, as measured by labor force participation and educational enrollment, or are they the least integrated ones? What is the impact of having family in Norway? In addition, we investigate at what extent differences in centrality can explain variation in emigration from different parts of Norway and the likelihood of alterna-

As opposed to other studies that analyze emigration among immigrants, we not only focus on emigration but also consider the alternative of moving within the country, to another centrality level (see definition in Section 3). In Norway, refugees are placed across the country in order to obtain a balanced regional settlement pattern. In principle, however, they are free to move to another location and after some time in the country, many immigrants seem to do that. Thus, in this study we estimate multinomial (i.e., trinomial) logit models for the probabilities of (i) internal migration, (ii) emigration and (iii) remaining at the same centrality level using data for immigrants in Norway. Estimation is done separately for eight different groups, brought about by combining four centrality levels with

As a basis for the analysis, we use individual-based registry data for population, migration, education and employment for all immigrants. The estimations are concentrated on Immigrants' adjustments from 2012 to 2013. There is one record for each of the observational units. The data are cross-sectional data with all the observed characteristics of individuals taken from the year 2012, while the outcome of the settlement, internal migration and emigra-

We find that the probabilities for emigration and domestic migration decrease when the duration of residence increases. These results are rather robust across centrality levels and

With respect to labor market status, we find that being employed or combining work and education contributes to a lower probability of emigration and an increased probability of

Internal migration among immigrants draws in centralizing direction, especially among refu-

This paper is organized as follows: In Section 2, we take a closer look at some of the earlier literature. In Section 3, we define different concepts and variables and elaborate on the institutional setting. Section 4 presents the trinomial logit model and the calculation of the marginal effects. The empirical results are provided in Section 5 and some conclusions are drawn in

gees, while immigrants from the more central regions are more inclined to emigrate.

tively remaining in a region or to move to another region in Norway.

208 People's Movements in the 21st Century - Risks, Challenges and Benefits

two sexes.

sexes.

Section 6.

tion is measured for the year 2013.

remaining at the same centrality level.

A comprehensive study addressing return migration to countries within the OECD area has been carried out by Dumont and Spielvogel [1]. According to the definition of the United Nations Statistics Division, return migrants are "persons returning to their country of citizenship after having been international migrants (whether short-term or long-term) in another country and who are intending to stay in their own country for at least a year." The study finds that the return rate is highest in the years immediately following the immigrants' entry to the host country, between 20 and 50% of the immigrants emigrate within a period of 5 years. This percentage varies with the time periods considered and with the characteristics of the host country. The rate of emigration is higher from some European countries than from countries such as Canada, New Zealand and the USA. The study also emphasizes that sex has small impact on the return migration, but age is of importance. There is a u-shaped relationship between return emigration and age and education. Young immigrants and immigrants who approach the pension age have, in other words, a higher probability to emigrate than immigrants of the middle age. Furthermore, not surprisingly the study also finds that there is higher mobility among countries that are at the same level of economic development. The return rates to OECD countries are usually double as high as to developing countries. Many countries run different programs aiming at promoting voluntarily return, but Dumont and Spielvogel [1] state that these arrangements seem to have limited influence on the total level of return migration. Whether this feature is due to the low impact of the arrangements or whether the arrangements only are directed at a limited number of immigrants is not clear. For most of the immigrants, return migration is only an option if the political, social and economic conditions in the origin country have become more satisfactory than what they were initially, see [1]. Furthermore, the study lists four main reasons for return migration:


Even though Norway possesses very good (registry) data on migration, there have been very few newer studies on emigration among immigrants using Norwegian data. Four studies that go beyond a descriptive study using inter alia two-way tables and graphs are the work by [2–5]. Carling and Pettersen [2] study the relationship between intentions of return migration in the future and what they refer to as the integration-transnationalism (IT) matrix of return migration. According to this approach, return migration depends on both the immigrants' integration in the host country and their attachment to the country of origin and it is the relative strength of these two effects that is decisive for the level of the return migration. If one either scores low or high on both these measures, they tend to cancel each other out.

Longva [5] studies the relationship between labor market attachment and (inter alia) emigration among immigrants in Norway and its implications for labor market assimilation analyses. Attachment to work, as measured by the level of the wage earnings, impacts emigration through two different channels. The first one is that economic success may inspire or be a requirement for emigration. The second is that a certain income is forgone if one leaves Norway.

The analysis by Longva [5] is based on two datasets that vary with respect to information about the duration of residence. In the analysis that accounts for the duration of residence in Norway, Longva [5] finds a strong positive effect on emigration of being in the upper income quartile. This is true for individuals who arrived from an OECD country or from another country. The same conclusion is drawn for OECD citizens in the other dataset with no information on the duration of residence, while the results for other immigrants are not clear cut. These results do not agree with those found for Swedish data by Edin et al. [6], where there is a negative relationship between the probability of emigration and the wage earnings of the individual.

The study by Pedersen et al. [4] differs from those mentioned above in that it is a comparative study in which one compares emigration from Denmark, Norway and Sweden, respectively. The study partly focuses on return migration and partly on emigration among all individuals residing in a country, but in the following we concentrate on its findings for return migration. The main focus in the study is whether it is the resourceful or individuals with few resources that emigrate from the Nordic countries (brain gain or drain) and whether systematic change has taken place over time. The study is based on registry data for 1981, 1989 (1991 for Norway) and 1998 for each of the three Scandinavian countries. The study concludes that there is no clear relationship between return migration and income and educational level in any of the Scandinavian countries.

Ekhaugen [3] focuses on the so-called welfare assimilation among immigrants in Norway, that is, how the probability for being on (economic) welfare varies with the duration of residence in Norway. Thus, this study does not aim at studying emigration of immigrants. However, modeling of emigration is needed for a proper analysis of welfare assimilation, as it captures an important control. According to the model specifications, the immigrant can choose between the three states (i) receiving welfare, (ii) emigration and (iii) none of what is mentioned under (i) or (ii). Utilizing registry data for the years 1992–2000, Ekhaugen [3] estimates the transitions between the three states. By estimating transitions, it is possible to determine the effect of receiving welfare on the probability of emigrating during the next period. The results do not entirely support the hypothesis that receiving welfare reduces the probability rate of emigrating from Norway during the subsequent period as the estimate is not significant at the 5% test level.

## **3. Institutional setting and definition of different concepts**

An immigrant is defined by Statistics Norway as a person who has immigrated to Norway and has been registered as living here and as someone who is born abroad with two foreignborn parents and four foreign-born grandparents. To be registered as a resident in Norway, one must generally have the intention to stay in Norway for at least 6 months and have acquired legal residence permit of the country. This means that seasonal workers and other people staying short term in Norway are not included. The same is the case for asylum seekers waiting to have their cases processed. It is also true that not all who have immigrated to Norway are regarded as immigrants. People who are born in Norway, but who have lived for some time abroad and then moved back, are not counted as immigrants in Norway. The same applies to people born abroad to Norwegian-born parents and/or have Norwegian-born grandparents. In this analysis, we investigate emigration in general (not only return migration) and mobility of first-generation immigrants and thus do not include their Norwegianborn children. Refugees are classified as immigrants and included in the analysis.

Longva [5] studies the relationship between labor market attachment and (inter alia) emigration among immigrants in Norway and its implications for labor market assimilation analyses. Attachment to work, as measured by the level of the wage earnings, impacts emigration through two different channels. The first one is that economic success may inspire or be a requirement

The analysis by Longva [5] is based on two datasets that vary with respect to information about the duration of residence. In the analysis that accounts for the duration of residence in Norway, Longva [5] finds a strong positive effect on emigration of being in the upper income quartile. This is true for individuals who arrived from an OECD country or from another country. The same conclusion is drawn for OECD citizens in the other dataset with no information on the duration of residence, while the results for other immigrants are not clear cut. These results do not agree with those found for Swedish data by Edin et al. [6], where there is a negative relationship between the probability of emigration and the wage

The study by Pedersen et al. [4] differs from those mentioned above in that it is a comparative study in which one compares emigration from Denmark, Norway and Sweden, respectively. The study partly focuses on return migration and partly on emigration among all individuals residing in a country, but in the following we concentrate on its findings for return migration. The main focus in the study is whether it is the resourceful or individuals with few resources that emigrate from the Nordic countries (brain gain or drain) and whether systematic change has taken place over time. The study is based on registry data for 1981, 1989 (1991 for Norway) and 1998 for each of the three Scandinavian countries. The study concludes that there is no clear relationship between return migration and income and educational level in any of the

Ekhaugen [3] focuses on the so-called welfare assimilation among immigrants in Norway, that is, how the probability for being on (economic) welfare varies with the duration of residence in Norway. Thus, this study does not aim at studying emigration of immigrants. However, modeling of emigration is needed for a proper analysis of welfare assimilation, as it captures an important control. According to the model specifications, the immigrant can choose between the three states (i) receiving welfare, (ii) emigration and (iii) none of what is mentioned under (i) or (ii). Utilizing registry data for the years 1992–2000, Ekhaugen [3] estimates the transitions between the three states. By estimating transitions, it is possible to determine the effect of receiving welfare on the probability of emigrating during the next period. The results do not entirely support the hypothesis that receiving welfare reduces the probability rate of emigrating from Norway during the subsequent period as the estimate is

An immigrant is defined by Statistics Norway as a person who has immigrated to Norway and has been registered as living here and as someone who is born abroad with two foreign-

**3. Institutional setting and definition of different concepts**

for emigration. The second is that a certain income is forgone if one leaves Norway.

210 People's Movements in the 21st Century - Risks, Challenges and Benefits

earnings of the individual.

Scandinavian countries.

not significant at the 5% test level.

In the empirical analysis, it is being assumed that immigrants can move to another country or another centrality within Norway. We group municipalities according to centrality levels and distinguish between four different levels, that is, the time of travelling from the main cities/ regional centers. The most central municipalities are allocated to centrality level 4 (until 75 min of travelling time to main cities, or 90 min to the capital of Oslo), the somewhat central municipalities are in centrality level 3 (until 60 min of travelling time to main regional centers), the less central municipalities are in centrality level 2 (until 45 min of travelling time to regional centers) and the remaining least central municipalities are in centrality level 1. The reason we do not only focus on emigration to another country is that the likelihood of moving inside Norway (internal migration) or remaining settled in a region constitutes alternatives to emigration. High tendency to move domestically can be expected to curb the emigration that could otherwise have taken place. Refugees are, for example, placed regionally by the authorities after they have received a residence permit. The allocation of refugees to different regions takes account of the need for maintaining a balanced regional settlement pattern. Moving between centrality levels in Norway may thus emerge as an alternative to emigration. Generally, the settlement pattern of immigrants is more centralized than what is the case for the rest of the population.

In the specification of the empirical model, we apply the following information: We have information on where the immigrants reside at the end of 2012. At the end of the subsequent year, 2013, we consider three possibilities: (i) the individual may still live at the same centrality level, (ii) the individual may have moved to another centrality level and (iii) the individual has emigrated. These will be the three states of choice in our trinomial logit models. An emigration is a registered migration from Norway to another country of a person who has been registered as a resident in Norway. The person can either have notified emigration or have been administratively emigrated by the Norwegian Tax Administration. There is no distinction between temporary versus permanent emigration. Not everyone who moves abroad is to be registered as having emigrated—it may include diplomats, people who still have a place of residence in Norway and have working ties to and/or students from Norway who are studying at foreign universities. These people are not considered as having emigrated in our analysis.

**Table 6** in Appendix provides an overview and definition of the observed variables employed in the analysis. To account for the effect of age, we include a second-order polynomial represented by *AGEi* and (*AGEi* /10)2 . To capture integration effects, we construct four different dummy variables according to the duration of stay in Norway (*DRT02i* , *DRT35i* , *DRT610i* and *DRT1115i* ). To consider the impact of education (*DEDU1i* –*DEDU5i* ), we have used the codes from the Norwegian Standard Classification of Education and aggregated with five levels of education for immigrants plus a group of unspecified education. These are as follows: (i) immigrants with only primary education, (ii) immigrants with some secondary education, (iii) immigrants with completed secondary education, (iv) immigrants with 1–4 years of higher education, (v) immigrants with 5 years and longer higher education and finally (vi)—the reference category—immigrants with no or unspecified education.

Immigrants are also grouped according to their labor market status (*DLMSji* , *j* = 1,…,4). We distinguish between (i) employed immigrants, (ii) immigrants who combine employment with education, (iii) immigrants who are enrolled in full-time education, (iv) unemployed individuals and (v)—the reference category—individuals who are not in the workforce and not in the educational system. Employed immigrants are defined as immigrants in employment in November 2012 with an occupational status codes as wage earner or self-employed in the regional employment statistics. Persons with multiple types of employment are defined on the basis of the most important of the working conditions. Employed immigrants who, to a large extent, have been enrolled in education during the calendar year are classified in category (ii) above. We have defined immigrants involved with full-time education as anyone who has undergone training on 1 October 2012 or have taken an examination during the same year. Immigrants undergoing training who are also registered as unemployed during the year are classified as unemployed if the unemployment has lasted for 7 months or longer during the same year.

An unemployed individual is anyone who is registered in the unemployment registry at the Norwegian Labour and Welfare Administration with at least 1 month unemployment during the calendar year. Unemployed immigrants who have also been employed during the calendar year are classified as unemployed if the circumstance has lasted 7 months or longer during the same calendar year. Similarly, unemployed who have undergone training during the calendar year are classified as unemployed if this circumstance has lasted for 7 months or longer during the same calendar year.

Individuals not in the labor force in general are defined as all persons who cannot be placed into any of the status groups described above. The labor force consists of employed and unemployed persons. Persons involved in education are also to be found outside the labor force, but they are defined as a separate group, that is, persons undergoing training.

The analysis also assumes that immigrants' stated reasons for immigration (*DRWORKi* , *DRESCAPEi* , *DRFAMILYi* , *DREDUCATIONi* and *DRUNKi* ) affects their migration patterns. For immigrants outside the Nordic countries, we distinguish between (i) work, (ii) escape, (iii) family, (iv) education and (v) unspecified reason. Immigrants from the Nordic countries do not report their reason for immigration and are allocated to their own group. The reasons for immigration are registered from 1990 on.

The data also provide information about the number of members in the family of the immigrant (*FAMTOTi* ) and the composition of the family with respect to immigration status (*FAMIMMi* ). For instance, all in a family may be immigrants, or a family may consist partly of immigrants and partly of individuals born in Norway.

## **4. The trinomial logit model of internal migration, emigration and continued stay at the same centrality level**

The individual may choose between three alternatives (relating to their ability to move): (i) internal migration, (ii) emigration and (iii) staying at the same centrality level. Consider the dummy variable *Y1i* (**Table 6** in Appendix). It takes on the value 1 if the individual migrates from one centrality level in Norway to another centrality level in Norway and the value 0 if the immigrant stays at the same centrality level. Next, we have the dummy variable *Y2i*. This variable takes on the value 1 if the individual emigrates and otherwise the value 0. The probability of these two binary variables being equal to 1 is given by

variable takes on the value 1 if the individual eigenstates and otherwise the value 0. The probability of these two binary variables being equal to 1 is given by 
$$P(Y\_{ij} = 1) = \frac{\exp(\mathbf{Z}\_i \boldsymbol{\beta}^j)}{1 + \exp(\mathbf{Z}\_i \boldsymbol{\beta}^1) + \exp(\mathbf{Z}\_i \boldsymbol{\beta}^2)'} \quad j = 1, 2. \tag{1}$$

If we let *Yi0* = 1*−Y1i−Y2i*, it follows that the probability of not moving is given by

$$\text{"If we let } Y\_{\text{ul}} = 1 - Y\_{\text{ul}} - Y\_{\text{ul}} \text{ it follows that the probability of not moving is given by}$$

$$\mathbb{P}(Y\_{\text{ul}} = 1 \mid \text{I} = 1) = \frac{1}{1 + \exp(\mathbb{Z}\_{\text{i}} \mathbb{R}^{\text{i}}) \stackrel{!}{\leftarrow} \exp(\mathbb{Z}\_{\text{i}} \mathbb{R}^{\text{i}})} \tag{2}$$

where *Zi* denotes a row vector with explanatory variables (cf. the variables listed in **Table 6** in Appendix) and *β*<sup>1</sup> and *β*<sup>2</sup> are two column vectors with unknown parameters.

Using these equations, we can specify the log-likelihood function and estimate the unknown parameters by the maximum-likelihood procedure.<sup>1</sup> Having estimated these, one may predict the various probabilities by using Eqs. (1) and (2) where the unknown parameters are substituted by their corresponding estimates. In what follows, let ‹‹^ ›› denote estimated parameters and predicted probabilities.

We are interested in how a change in one of the explanatory variables affects the three predicted probabilities (i.e., marginal effects) of a particular individual and show by an example, related to the duration of residence, how this can be done. The reference group is assumed to be immigrants with very long duration of residence, that is, more than 16 years. They are picked up by the intercept. Let us introduce the notation

$$\mathbf{Z}\_{i}\stackrel{\scriptstyle \phi^{\prime}}{\boldsymbol{\beta}}^{\prime} = \stackrel{\scriptstyle \phi^{\prime}}{\boldsymbol{\beta}}^{\prime} + \mathbf{X}\_{i}\boldsymbol{\hat{\phi}}^{\prime} + \stackrel{\scriptstyle \phi^{\prime}}{\boldsymbol{\beta}}\_{5}^{\prime}\text{DRT}\,\mathbf{0}\mathbf{2}\_{1\prime} \qquad j = 1, 2. \tag{3}$$

Here,

by *AGEi*

the same year.

*DRESCAPEi*

grant (*FAMTOTi*

and (*AGEi*

/10)2

grants with no or unspecified education.

longer during the same calendar year.

, *DRFAMILYi*

immigration are registered from 1990 on.

To consider the impact of education (*DEDU1i*

212 People's Movements in the 21st Century - Risks, Challenges and Benefits

variables according to the duration of stay in Norway (*DRT02i*

. To capture integration effects, we construct four different dummy

–*DEDU5i*

Norwegian Standard Classification of Education and aggregated with five levels of education for immigrants plus a group of unspecified education. These are as follows: (i) immigrants with only primary education, (ii) immigrants with some secondary education, (iii) immigrants with completed secondary education, (iv) immigrants with 1–4 years of higher education, (v) immigrants with 5 years and longer higher education and finally (vi)—the reference category—immi-

distinguish between (i) employed immigrants, (ii) immigrants who combine employment with education, (iii) immigrants who are enrolled in full-time education, (iv) unemployed individuals and (v)—the reference category—individuals who are not in the workforce and not in the educational system. Employed immigrants are defined as immigrants in employment in November 2012 with an occupational status codes as wage earner or self-employed in the regional employment statistics. Persons with multiple types of employment are defined on the basis of the most important of the working conditions. Employed immigrants who, to a large extent, have been enrolled in education during the calendar year are classified in category (ii) above. We have defined immigrants involved with full-time education as anyone who has undergone training on 1 October 2012 or have taken an examination during the same year. Immigrants undergoing training who are also registered as unemployed during the year are classified as unemployed if the unemployment has lasted for 7 months or longer during

An unemployed individual is anyone who is registered in the unemployment registry at the Norwegian Labour and Welfare Administration with at least 1 month unemployment during the calendar year. Unemployed immigrants who have also been employed during the calendar year are classified as unemployed if the circumstance has lasted 7 months or longer during the same calendar year. Similarly, unemployed who have undergone training during the calendar year are classified as unemployed if this circumstance has lasted for 7 months or

Individuals not in the labor force in general are defined as all persons who cannot be placed into any of the status groups described above. The labor force consists of employed and unemployed persons. Persons involved in education are also to be found outside the labor

The analysis also assumes that immigrants' stated reasons for immigration (*DRWORKi*

immigrants outside the Nordic countries, we distinguish between (i) work, (ii) escape, (iii) family, (iv) education and (v) unspecified reason. Immigrants from the Nordic countries do not report their reason for immigration and are allocated to their own group. The reasons for

The data also provide information about the number of members in the family of the immi-

and *DRUNKi*

) and the composition of the family with respect to immigration status

force, but they are defined as a separate group, that is, persons undergoing training.

, *DREDUCATIONi*

Immigrants are also grouped according to their labor market status (*DLMSji*

, *DRT35i*

, *DRT610i* and *DRT1115i*

, *j* = 1,…,4). We

), we have used the codes from the

).

,

) affects their migration patterns. For

$$Z\_{\parallel} = \{ \mathbf{1} \quad X\_{\parallel} \text{ } \text{DRT} \, 0 \mathbf{2}\_{\parallel} \}. \tag{4}$$

and

$$
\hat{\boldsymbol{\beta}}^{\boldsymbol{\beta}} = \boldsymbol{\Gamma} \hat{\boldsymbol{\beta}}\_{1}^{\boldsymbol{\beta}} \; \left( \hat{\boldsymbol{\varphi}}^{\boldsymbol{\beta}} \right)^{\boldsymbol{\beta}} \; \hat{\boldsymbol{\beta}}\_{s}^{\boldsymbol{\beta}} \mathbf{1}.\tag{5}
$$

<sup>1</sup> For the trinomial logit model and its estimation cf. [7].

The variable *DRT02i* is a binary variable that takes on the value 1 if individual *i* has a duration of residence of between 0 and 2 years and 0 otherwise, while the row vector *X*<sup>i</sup> , contains the other explanatory variables. If we insert from Eq. (3) into Eqs. (1) and (2), we obtain

$$\text{other explanatory variables. If we insert from Eq. (3) into Eqs. (1) and (2), we obtain}$$

$$\hat{P}(Y\_{i1} = 1) = \frac{\exp(\not{\partial\_{i}}^{'} + X\_{i}\not{\partial\_{i}^{'}}^{'} + \not{\partial\_{i}^{'}}^{'}DRT\,02\_{,i})}{1 + \exp(\not{\partial\_{i}^{'}}^{'} + X\_{i}\not{\partial\_{i}^{'}}^{'}DRT\,02\_{,i}) + \exp(\not{\partial\_{i}^{'}}^{'} + X\_{i}\not{\partial\_{i}^{'}}^{'} + \not{\partial\_{i}^{'}}^{2}DRT\,02\_{,i})}, \quad j = 1, 2,\tag{6}$$

$$\hat{P}(Y\_{i0} = 1) = \frac{1}{1 + \exp(\not{\partial\_{i}}^{'} + X\_{i}\not{\partial\_{i}^{'}}^{'}DRT\,02\_{,i}) + \exp(\not{\partial\_{i}^{'}}^{2} + X\_{i}\not{\partial\_{i}^{'}}^{2} + \not{\partial\_{i}^{'}}^{2}DRT\,02\_{,i})}.\tag{7}$$

$$\hat{P}(Y\_{i0} = 1) = \frac{1}{1 + \exp(\oint\_{1}^{1} X\_{i} \oint\_{1}^{1} + \oint\_{3}^{1} \text{DRT 02}\_{i}) + \exp(\oint\_{1}^{2} X\_{i} \oint\_{1}^{2} + \oint\_{3}^{2} \text{DRT 02}\_{i})} \,. \tag{7}$$

We compare two individuals who have the same value on all explanatory variables except those related to the duration of residence in Norway. One of the individuals has a residence time in Norway of between 0 and 2 years, whereas the reference immigrant has a time of residence that is 16 years or more. We denote these two individuals, respectively, as *i 2* and *i 1* and obtain \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 1 + exp( *<sup>β</sup>*

$$\begin{aligned} \hat{P}(Y\_{ij} = 1 \mid \cdot) \cdot \hat{P}(Y\_{ij} = 1 \mid \cdot) &= \frac{\exp(\boldsymbol{\hat{\beta}}\_{1}^{i} + \mathbf{X}\_{i} \boldsymbol{\hat{\phi}}\_{1}^{j} + \boldsymbol{\hat{\beta}}\_{3}^{j})}{1 + \exp(\boldsymbol{\hat{\beta}}\_{1}^{i} + \mathbf{X}\_{i} \boldsymbol{\hat{\phi}}\_{1}^{j} + \boldsymbol{\hat{\beta}}\_{3}^{i}) + \exp(\boldsymbol{\hat{\beta}}\_{1}^{2} + \mathbf{X}\_{i} \boldsymbol{\hat{\phi}}\_{1}^{2} + \boldsymbol{\hat{\beta}}\_{3}^{2})} \\ &\quad \frac{\exp(\boldsymbol{\hat{\beta}}\_{1}^{i} + \mathbf{X}\_{i} \boldsymbol{\hat{\phi}}^{j})}{1 + \exp(\boldsymbol{\hat{\beta}}\_{1}^{i} + \mathbf{X}\_{i} \boldsymbol{\hat{\phi}}^{j}) + \exp(\boldsymbol{\hat{\beta}}\_{1}^{2} + \mathbf{X}\_{i} \boldsymbol{\hat{\phi}}^{j})}, \quad j = 1, 2, \end{aligned} \tag{8}$$

$$\begin{array}{c} \frac{\exp(\boldsymbol{\hat{\theta}}\_{1}^{\top} + \mathbf{X}\_{i}\boldsymbol{\hat{\phi}}^{\top})}{1 + \exp(\boldsymbol{\hat{\phi}}\_{1}^{\top} + \mathbf{X}\_{i}\boldsymbol{\hat{\phi}}^{\top}) + \exp(\boldsymbol{\hat{\phi}}\_{1}^{\top} + \mathbf{X}\_{i}\boldsymbol{\hat{\phi}}^{\top})}, \quad j = 1, 2, \\\\ \hat{\mathbf{P}}(\boldsymbol{Y}\_{\boldsymbol{\hat{\phi}}\_{0}^{\top}} = \mathbf{1}) \cdot \hat{\mathbf{P}}(\boldsymbol{Y}\_{\boldsymbol{\phi}^{0}} = \mathbf{1}) \quad = \frac{1}{1 + \exp(\boldsymbol{\hat{\phi}}\_{1}^{\top} + \mathbf{X}\_{i}\boldsymbol{\hat{\phi}}^{\top} + \boldsymbol{\hat{\phi}}\_{s}^{\top}) + \exp(\boldsymbol{\hat{\phi}}\_{1}^{\top} + \mathbf{X}\_{i}\boldsymbol{\hat{\phi}}^{\top} + \boldsymbol{\hat{\phi}}\_{s}^{\top})} \quad \tag{9} \\\\ \frac{1}{1 + \exp(\boldsymbol{\hat{\phi}}\_{1}^{\top} + \mathbf{X}\_{i}\boldsymbol{\hat{\phi}}^{\top}) + \exp(\boldsymbol{\hat{\phi}}\_{1}^{\top} + \mathbf{X}\_{i}\boldsymbol{\hat{\phi}}^{\top})}. \end{array} \tag{9}$$

In Eqs. (8) and (9), we have *Xi* = *Xi* 2 = *Xi* . Furthermore, note that we have

1

$$\sum\_{j=0}^{2} \left[ \hat{\mathbf{P}} (Y\_{\downarrow j} = 1 \ ) - \hat{\mathbf{P}} (Y\_{\downarrow j} = 1 \ ) \right] = 0. \tag{10}$$

Formulae constructed in the same type of line can certainly also be used to calculate the effects of partial changes in other explanatory variables than those related to the duration of residence. In fact, this is what we have done for constructing the different tables. The formulae are slightly modified when we consider changes in counting variables. When looking at formulae (8) and (9), we note that the parameter estimates enter both the nominator and the denominator. Since it is relevant to reveal whether the estimated differences are significant or not, we utilize the delta method to obtain estimated standard errors, cf. [8].

#### **5. Empirical results**

In the following, we report the results for eight groups. To save space, we do this in an asymmetrical way. Women in centrality level 1 constitute Group I, which is the reference group. The estimates of the parameters of the trinomial logit model of group 1 are given in **Table 7** in Appendix. Since the parameters in this model are not suitable to interpret, we instead consider the so-called marginal effects, cf. Eqs. (8) and (9). Altogether, there are five tables with such marginal effects for Group I. **Table 1** relates to the duration of residence time in Norway, **Table 2** relates to labor market status, **Table 3** considers reasons to immigration to Norway, **Table 4** investigates at the duration of education and **Table 5** considers family size and composition. For the other seven groups, we report results in a qualitative manner. Groups II–IV consist of female immigrants living at centrality levels 2–4, respectively. Groups V–VIII consist of male immigrants living at centrality levels 1–4, respectively. The results for these seven groups are presented in **Table 8** in Appendix. For these groups, we focus on whether the same sign of the estimated differences in probabilities as for Group I can be obtained and whether the estimates significant.

### **5.1. Duration of residence: empirical results for Group I**

The variable *DRT02i*

*P*

and obtain

*P* ^ ( *Yi* 2

> *P* ^ ( *Yi* 2

In Eqs. (8) and (9), we have *Xi*

**5. Empirical results**

∑

*<sup>j</sup>* = 1 ) <sup>−</sup>*P*

<sup>0</sup> = 1 ) <sup>−</sup>*P*

^ ( *Yi* 1

> ^ ( *Yi* 1

> > 1 = *Xi* 2 = *Xi*

> > > *j*=0 2 [*P*  ^ ( *Yi* 2

utilize the delta method to obtain estimated standard errors, cf. [8].

*P*

is a binary variable that takes on the value 1 if individual *i* has a duration

*DRT* 02 *<sup>i</sup>* )

*DRT* 02 *<sup>i</sup>* )

,  *j* = 1, 2,

1

*<sup>j</sup>* = 1 ) ] = 0. (10)

, contains the

  ,  *j* = 1, 2, (6)

.   (7)

*2* and *i 1*



(9)

(8)

of residence of between 0 and 2 years and 0 otherwise, while the row vector *X*<sup>i</sup>

^ 1 *j* + *Xi ϕ*^ *j* + *β* ^ 5 *j DRT* 02 *<sup>i</sup>* )

^ ( *Yi*<sup>1</sup> <sup>=</sup> <sup>1</sup> ) <sup>=</sup>exp( *<sup>β</sup>*

214 People's Movements in the 21st Century - Risks, Challenges and Benefits

^ 1 1 + *Xi ϕ*^ 1 + *β* ^ 5 1

^ ( *Yi*<sup>0</sup> <sup>=</sup> <sup>1</sup> ) <sup>=</sup><sup>1</sup>

^ 1 1 + *Xi ϕ*^ 1 + *β* ^ 5 1

other explanatory variables. If we insert from Eq. (3) into Eqs. (1) and (2), we obtain

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 1 + exp( *<sup>β</sup>*

^ 1 2 + *Xi ϕ*^ 2 + *β* ^ 5 2

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 1 + exp( *<sup>β</sup>*

^ 1 *j* + *Xi ϕ*^ *j* + *β* ^ 5 *j* )

) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 1 + exp( *<sup>β</sup>*

^ 1 2 + *Xi ϕ*^ 2 + *β* ^ 5 2

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 1 + exp( *<sup>β</sup>*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 1 + exp( *<sup>β</sup>*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 1 + exp( *<sup>β</sup>*

*DRT* 02 *<sup>i</sup>* ) +exp( *β*

*DRT* 02 *<sup>i</sup>* ) +exp( *β*

We compare two individuals who have the same value on all explanatory variables except those related to the duration of residence in Norway. One of the individuals has a residence time in Norway of between 0 and 2 years, whereas the reference immigrant has a time of

> ^ 1 1 + *Xi ϕ*^ 1 + *β* ^ 5 1 ) +exp( *β* ^ 1 2 + *Xi ϕ*^ 2 + *β* ^ 5 2 )

^ 1 1 + *Xi ϕ*^ 1 ) +exp( *β* ^ 1 2 + *Xi ϕ*^ 2 )

<sup>0</sup> <sup>=</sup> <sup>1</sup> ) <sup>=</sup><sup>1</sup>

*<sup>j</sup>* = 1 ) − *P* 

exp( *β* ^ 1 *j* + *Xi ϕ*^ *j*

> ^ 1 1 + *Xi ϕ*^ 1 + *β* ^ 5 1 ) +exp( *β* ^ 1 2 + *Xi ϕ*^ 2 + *β* ^ 5 2 )

^ ( *Yi* 1

Formulae constructed in the same type of line can certainly also be used to calculate the effects of partial changes in other explanatory variables than those related to the duration of residence. In fact, this is what we have done for constructing the different tables. The formulae are slightly modified when we consider changes in counting variables. When looking at formulae (8) and (9), we note that the parameter estimates enter both the nominator and the denominator. Since it is relevant to reveal whether the estimated differences are significant or not, we

In the following, we report the results for eight groups. To save space, we do this in an asymmetrical way. Women in centrality level 1 constitute Group I, which is the reference group. The estimates of the parameters of the trinomial logit model of group 1 are given in **Table 7** in Appendix. Since the parameters in this model are not suitable to interpret, we instead consider the so-called marginal effects, cf. Eqs. (8) and (9). Altogether, there are five tables with

^ 1 1 + *Xi ϕ*^ 1 ) +exp( *β* ^ 1 2 + *Xi ϕ*^ 2 ) .

. Furthermore, note that we have

residence that is 16 years or more. We denote these two individuals, respectively, as *i*

*<sup>j</sup>* <sup>=</sup> <sup>1</sup> ) <sup>=</sup>exp( *<sup>β</sup>*

We start with the duration of residence. Looking at **Table 1**, first line: If one compares a woman with the shortest time of residence, that is 0–2 years, with a woman with a duration of residence that is 16 years or more, the former woman has a significantly lower estimated probability for staying at the same centrality level and a higher estimated probability for emigration. The estimate of the difference in the probability of internal migration is positive, but not statistically significant at the 5% level.

The results for individuals with time of residence of 3–5 years, 6–10 years and 11–15 years resemble those of the group with the shortest time of residence, but the differences are somewhat smaller in absolute terms. Only the estimated difference in probability of emigration remains significant for these three groups.

#### **5.2. Duration of residence: empirical results for Groups II–VIII**

Recall that Groups II–IV (**Table 8** in Appendix) consist of female immigrants living at centrality levels 2–4, respectively, while Groups V–VIII consist of male immigrants living at


Note: *T*-values obtained by using the delta method. Assumptions with respect to other variables than the duration of residence: The individual is a woman aged 30 years who resides at centrality level 1. She is at work and has some secondary education. Her stated reason for immigration is work. She is a member of a family consisting of five persons, whereof four are immigrants.

**Table 1.** Estimated differences in probability of the three alternatives of mobility for different groups of women according to the duration of residence in Norway relative to the group with at least 16 years of residence.

centrality levels 1–4, respectively. Recall also that we in **Table 8** in Appendix only focus on whether the same sign of the estimated differences in probabilities as for Group I can be obtained and whether the estimates are significant, as indicated by the capital letters A, B and C, cf. the notes to the table. From the first block of cells in **Table 8** in Appendix, we note that many of the results obtained for Group I are also found for the other groups, indicated by the As and Bs. As can be seen from the second line in the first block of results, the estimated difference in probability of domestic migration for female immigrants at centrality level 3 is opposite compared to what was found for female immigrants living at centrality level 1. However, both for female immigrants in the benchmark group and for female immigrants living at centrality level 3, the estimate of the difference in probability is not statistically significant different from zero. For those with the next longest time of residence, there are somewhat different results compared to the benchmark group, that is, Group I. For female immigrants living at the centrality levels 2–4, an estimate of the difference in probability of domestic migration that goes in the opposite direction could be obtained. However, only at centrality level 4 a significant result is obtained.

#### **5.3. Labor market status: empirical results for Group I**

Considering the effect of changes in the labor market status, the reference group is made up by female immigrants who are neither working nor being enrolled in education. We find that women who are working have a significantly higher probability rate of staying in the same centrality level and significantly lower probability rate of internal migration and emigration than individuals who are neither in the work force nor enrolled in education. Women who combine work and education display a higher probability rate for staying at the same centrality level and a lower probability of emigration than the group of individuals not in the work force and not enrolled in education. With respect to the probability of internal migration, an insignificant estimate of the difference in probability is obtained.

The next group we consider is the one who contains immigrants who are enrolled in full-time education. This group has no significant estimates of the differences. Finally, we find that


Note: *T*-values obtained by using the delta method. Assumptions with respect to other variables than labor market status: The individual is a woman aged 30 years who resides at centrality level 1. She has some secondary education and a duration of residence between 3 and 5 years. Her stated reason for immigration is work. She belongs to a family with five persons, whereof four are immigrants.

**Table 2.** Estimated differences in probability of the three alternatives of mobility for different groups of women according to labor market status relative to the group that is neither in the workforce nor being occupied with education.

unemployed female immigrants have generally a significant lower estimated probability of emigration and a significant higher probability rate of staying at the same centrality level than women not in the workforce and/or not in the educational system. The estimated probability of internal migration does not differ significantly between unemployed female immigrants and female immigrants outside the work force and the educational system.

#### **5.4. Labor market status: empirical results for Groups II–VIII**

For all the groups, the results are very similar for those that are at work (**Table 8** in Appendix). For the other labor market statuses, the variation is evident. For immigrants who combine work and education, the conclusion with respect to internal migration differs somewhat across the different groups. In two of the groups, that is, for female immigrants at centrality level 3 and male immigrants at centrality level 1, the results are opposite to what was found for female immigrants at centrality level 1. For female immigrants at centrality level 1, a negative estimate of the difference is obtained. For Groups II and IV, the probability rate of domestic migration is significantly higher than for immigrant women who neither are at work nor are enrolled in education. Female immigrants who are occupied with education on a full-time basis demonstrate a notable difference. It is particularly related to the probability of remaining at the same centrality level. Immigrant women in the benchmark group demonstrated a significant lower estimated probability of remaining at the same centrality level than female immigrants who are neither in the workforce nor in the educational system. Female immigrants occupied with education at centrality levels 3 and 4 revealed that the estimate of the probability of remaining at the same centrality level is significantly higher than for female immigrants outside the workforce and outside the educational system. Lastly, for immigrants who are unemployed, some discrepancies between the results for Group I and the others in relation to the probability of domestic migration could be established. For female immigrants in Group I, a negative but insignificant estimate of the difference in probability of domestic migration was found. For immigrants that are living at centrality level 4, the estimated probability of domestic migration is significantly higher for the unemployed immigrants than for immigrants in the reference group. In some of the groups, the estimate of the difference in probability is positive but insignificant.

#### **5.5. Reasons for immigration: empirical results for Group I**

#### *5.5.1. Work*

centrality levels 1–4, respectively. Recall also that we in **Table 8** in Appendix only focus on whether the same sign of the estimated differences in probabilities as for Group I can be obtained and whether the estimates are significant, as indicated by the capital letters A, B and C, cf. the notes to the table. From the first block of cells in **Table 8** in Appendix, we note that many of the results obtained for Group I are also found for the other groups, indicated by the As and Bs. As can be seen from the second line in the first block of results, the estimated difference in probability of domestic migration for female immigrants at centrality level 3 is opposite compared to what was found for female immigrants living at centrality level 1. However, both for female immigrants in the benchmark group and for female immigrants living at centrality level 3, the estimate of the difference in probability is not statistically significant different from zero. For those with the next longest time of residence, there are somewhat different results compared to the benchmark group, that is, Group I. For female immigrants living at the centrality levels 2–4, an estimate of the difference in probability of domestic migration that goes in the opposite direction could be obtained. However, only at centrality level 4 a significant result is obtained.

Considering the effect of changes in the labor market status, the reference group is made up by female immigrants who are neither working nor being enrolled in education. We find that women who are working have a significantly higher probability rate of staying in the same centrality level and significantly lower probability rate of internal migration and emigration than individuals who are neither in the work force nor enrolled in education. Women who combine work and education display a higher probability rate for staying at the same centrality level and a lower probability of emigration than the group of individuals not in the work force and not enrolled in education. With respect to the probability of internal migration, an

The next group we consider is the one who contains immigrants who are enrolled in full-time education. This group has no significant estimates of the differences. Finally, we find that

For woman at work 0.034 4.009 −0.015 −2.701 −0.019 −2.838

For woman enrolled in education −0.003 −0.357 0.009 1.559 −0.006 −1.188 For woman who is unemployed 0.016 2.131 −0.002 −0.495 −0.014 −2.367 Note: *T*-values obtained by using the delta method. Assumptions with respect to other variables than labor market status: The individual is a woman aged 30 years who resides at centrality level 1. She has some secondary education and a duration of residence between 3 and 5 years. Her stated reason for immigration is work. She belongs to a family with

**Table 2.** Estimated differences in probability of the three alternatives of mobility for different groups of women according to labor market status relative to the group that is neither in the workforce nor being occupied with education.

**No migration Internal migration Emigration**

**Estimate** *t***-Value Estimate** *t***-Value Estimate** *t***-Value**

0.018 2.256 −0.000 −0.048 −0.018 −2.713

**5.3. Labor market status: empirical results for Group I**

216 People's Movements in the 21st Century - Risks, Challenges and Benefits

insignificant estimate of the difference in probability is obtained.

**Difference in probability**

and education

For woman who combines work

five persons, whereof four are immigrants.

In **Table 3**, we report results relating to how reasons to immigrate impact the probability of making any of the three choices. Immigrants from the Nordic countries are the reference group. The first line of figures in **Table 3** relates to women that provide work as their reason for immigration. With respect to estimated probabilities of internal migration, there is no significant difference between this group of women and female immigrants from the Nordic countries. Women with work as the stated reason for immigration have significantly lower estimated probability for emigration and significantly higher estimated probability of staying at the same centrality level than women from the Nordic countries.

#### *5.5.2. Escape*

The next group we consider contains those that have stated escape as the reason for immigration. According to the results reported in **Table 3**, line 2, women who provided escape as the reason for immigration have significantly lower estimated probability for emigration than female immigrants from the Nordic countries. Furthermore, these women have a higher estimated probability for internal migration than female immigrants from the Nordic countries. With respect to the probability of staying at the same centrality level, an insignificant estimate of the difference of probability is obtained.

#### *5.5.3. Family*

We proceed with the group that has stated family as the reason for immigration. The relevant results are reported in line 3, **Table 3**. We find that women, who specified family as reason for immigration, have a significant lower estimated probability of emigration than female immigrants from the Nordic countries. With respect to the probability of staying at the same centrality level, these women have a significant higher estimated probability than female immigrants born in the Nordic countries. With respect to internal migration, no significant difference of probability is obtained.

#### *5.5.4. Education*

The next group we consider consists of individuals who have stated education as reason for immigration. For none of the three choices we are able to find any significant differences in


Note: *T*-values obtained by using the delta method. Assumptions with respect to other variables than the reason for immigration: The individual is a woman aged 30 years who resides at centrality level 1. She has some secondary education, a duration of residence between 3 and 5 years and is at work. She belongs to a family consisting of five persons, whereof four are immigrants.

**Table 3.** Estimated differences in probability of the three alternatives of mobility for different groups of women according to reason for immigration relative to female immigrants from the Nordic countries.

estimated probability between female immigrants with education as reason for immigration and female immigrants from the Nordic countries.

#### *5.5.5. No reason stated*

*5.5.2. Escape*

*5.5.3. Family*

*5.5.4. Education*

Difference in probability

for immigration

for immigration

for immigration

for immigration

For woman with work as reason

For woman with escape as reason

For woman with family as reason

For woman with education as reason for immigration

For woman outside the Nordic countries with unspecified reason

persons, whereof four are immigrants.

of the difference of probability is obtained.

218 People's Movements in the 21st Century - Risks, Challenges and Benefits

difference of probability is obtained.

The next group we consider contains those that have stated escape as the reason for immigration. According to the results reported in **Table 3**, line 2, women who provided escape as the reason for immigration have significantly lower estimated probability for emigration than female immigrants from the Nordic countries. Furthermore, these women have a higher estimated probability for internal migration than female immigrants from the Nordic countries. With respect to the probability of staying at the same centrality level, an insignificant estimate

We proceed with the group that has stated family as the reason for immigration. The relevant results are reported in line 3, **Table 3**. We find that women, who specified family as reason for immigration, have a significant lower estimated probability of emigration than female immigrants from the Nordic countries. With respect to the probability of staying at the same centrality level, these women have a significant higher estimated probability than female immigrants born in the Nordic countries. With respect to internal migration, no significant

The next group we consider consists of individuals who have stated education as reason for immigration. For none of the three choices we are able to find any significant differences in

Note: *T*-values obtained by using the delta method. Assumptions with respect to other variables than the reason for immigration: The individual is a woman aged 30 years who resides at centrality level 1. She has some secondary education, a duration of residence between 3 and 5 years and is at work. She belongs to a family consisting of five

**Table 3.** Estimated differences in probability of the three alternatives of mobility for different groups of women according

to reason for immigration relative to female immigrants from the Nordic countries.

No migration Internal migration Emigration

Estimate *t*-Value Estimate *t*-Value Estimate *t*-Value

0.036 3.204 −0.001 −0.454 −0.035 −3.146

−0.004 −0.200 0.043 3.274 −0.040 −3.138

0.032 2.736 0.003 1.071 −0.035 −3.099

0.004 0.434 0.008 1.341 −0.012 −1.754

0.013 1.112 0.012 1.612 −0.024 −2.686

The last group we look at consists of female immigrants from outside the Nordic area who have not stated any reason for immigration. This group of women has a lower estimated probability of emigration than female immigrants from the Nordic countries. For the two other states, there are no significant estimated differences.

#### **5.6. Reasons for immigration: empirical results for Groups II–VIII**

When it comes to reasons to immigrate, the results are different for different groups. For female immigrants with work as reason for immigration to Norway, the results are rather equal to those obtained for females at centrality level 1 who constitute Group I. The results for male immigrants living at centrality level 2 (cf. Group VI) differ slightly from those obtained for female immigrants living at centrality level 1. For internal migration, the estimated difference in probability for male immigrants living at this centrality level and men from the Nordic countries is positive and significant. Also, when escape is the reason for immigration to Norway there are some noticeable differences. For immigrant women at centrality level 1 with escape as reason to immigrate, we found no significant difference in the estimated probability of staying at the same centrality level compared to female immigrants from the Nordic countries. For both sexes living at centrality level 4, we find that the estimated probability of staying at the same centrality level is significantly higher for those with escape as reason for immigration than for immigrants from the Nordic countries. For immigrants stating family as reason for immigration, there are some instances of switches of sign, but in none of these cases the estimates are significant. For female immigrants living at centrality levels 2 and 3, the difference in probability of domestic migration is negative, whereas it was positive for female immigrants living at centrality level 1. In all three cases, the estimates are insignificant. There are some differences for those with education as reason for immigration, in particular for men. Male immigrants living at centrality levels 3 and 4 have significantly lower estimated probability of staying at the same centrality than male immigrants from the Nordic countries living at the same centrality levels. At last, we consider immigrants outside the Nordic countries who have not stated any reason for immigration to Norway. For female immigrants in Group I, we found that the only significant result was related to the estimated difference in the probability of emigration. This estimate was positive. For Groups II–VIII, we did not find any results where the estimated differences in probabilities switch sign and at the same time are significant.

#### **5.7. Duration of education: empirical results for Group I**

We now turn to the importance of educational achievement for the probability of making any of the three choices. Comparison is made with a group of women with either no or unspecified education. Estimates of differences in probabilities are reported in **Table 4**. The figures in line 1 in **Table 4** are for female immigrants with primary school as their highest education. These women have a significant higher estimated probability of staying at the same centrality level and significant lower estimated probability of emigration than women with no or unspecified education. With respect to the probability of internal migration, no significant difference is found.

For women with some secondary education, we do not find any significant differences in probability of making any of the three choices. The third line with figures in **Table 4** is for female immigrants having completed secondary education. Female immigrants with this educational background have a significant lower estimated probability of emigration than female immigrants with no or unspecified education. For the two other states of choice, we do not find that the differences in estimated probabilities are statistically significant.

The results for women with university and/or college education (lower degree) are reported in the fourth line with figures in **Table 4**. We do not find any significant estimated differences in probability for any of the three states. Finally, we consider female immigrants with education from university and/or college education (higher degree), cf. the last line in **Table 4**. These females have a significant lower estimated probability of staying at the same centrality level and a significant higher estimated probability of internal migration than female immigrants with no or unspecified education. The estimated difference in the probability of emigration is insignificant.
