European Journal of Public Health, Vol. 17, No. 5, 503507 The Author 2007.

. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckl279 Advance Access published on January 24, 2007

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Health profiles, lifestyles and use of health resources by the immigrant population resident in Spain
ndez Barrera, R. Jime nez-Garc a* P. Carrasco-Garrido, A. Gil De Miguel, V. Herna
Background: Our study aimed at describing the health profiles, life styles and use of health resources by the immigrant population resident in Spain. Methods: Cross-sectional, epidemiological study from the Spanish National Health Survey (NHS) in 2003. We analysed 1506 subjects of both sexes, aged !16 years, resident in Spain. Results: The immigrant population present diseases that are similar to those of the autochthonous population. The autochthonous population had significantly higher values for alcohol consumption and smoking (60.8 and 39.6%) than immigrants (39.6 and 27.5%). The percentage of immigrants hospitalized in the preceding 12 months was observed to be higher than that of the Spanish population (11.4 vs. 8.2%, P < 0.05). The immigrant population consumed fewer medical drugs than the Spanish population (42.6 and 49.9%, respectively). Conclusions: Immigrants in Spain display better lifestyle-related parameters, in that they consume less alcohol and smoke less than the autochthonous population. As for the use of health-care resources, while immigrants register higher percentages of hospitalization compared with the Spanish population, there is no evidence of excessive and inappropriate use of other health-care resources. Keywords: health survey, immigrants, public health

............................................................................................... Introduction
Immigration has reshaped society worldwide and generated new needs and priorities in many areas, particularly in health care. Large-scale immigration commenced decades ago in countries such as the United States, Canada and in many Member States of the European Union (EU). Their consolidated experience has enabled them to ascertain the health-care needs of their immigrant populations,110 and collect data for their respective national health surveys.2,5,7,8 Thus, the US National Health Interview Survey (NHIS) shows that the total immigrant health-care cost per capita is 55% less than that of autochthonous subjects.2 Similarly, the Canadian Community Health Survey (CCHS) reveals that its health system provides its immigrant population with sufficient services,5 whereas other health surveys conducted in countries such as the Netherlands and England reflect inequalities in access to health services.7,8 In Spain, however, it was not until the latter part of the 1990s that immigration witnessed significant growth. Currently, the population of Spain stands at more than 44 million, nearly 9% of which is accounted for by aliens, though this percentage does not reflect the illegal population.11 In the last decade, the number of foreign residents has doubled, with the result that Spain currently ranks fourth in the European Union in terms of the number of immigrants. It should be highlighted here that the segment registering the most important rise is that of economic immigrants, i.e. persons from countries poorer than Spain.12 Thanks to the basic nature of the Spanish National Health System all legal immigrants enjoy access to public health care, yet the truth is that immigrants who lack valid identity documents and remain in the country as illegal aliens are also
* Unit of Preventive Medicine and Public Health, Rey Juan Carlos n, Madrid. University, Alcorco Correspondence: Carrasco-Garrido P, PhD, MPH, Unidad de blica, Universidad Rey Juan Carlos, Medicina Preventiva y Salud Pu n, Madrid, Spain, tel: 34 914888877, Avda. Atenas s/n. Alcorco fax: 34 914888955, e-mail: pilar.carrasco@urjc.es

attended by the health system, so that reliable data which describe their real health needs are called for. Accordingly, the first ever incorporation into the 2003 National Health Survey of data on the immigrant population in Spain provides researchers with a new tool for the study of this group.13 There can be no doubt that the health of the immigrant population has become a relevant topic from a public-health standpoint. Indeed, this is borne out by the various studies that have reported differences, not only in health, but also in the access to and use of health-care services by this group.1419 In Spain, the health of the immigrant population has been analysed by studies using different methodologies, ranging from bibliographic reviews17 to descriptive studies of specific health-related situations.18,19 To date, however, no studies addressing health-related topics have used a nationally representative sample of the immigrant population. Given the new socio-demographic situation in Spain that has come about by the incorporation of immigrants, our study aimed at describing immigrant health profiles, lifestyles and use of health resources, and identify possible differences between the immigrant and the autochthonous population.

Methods
Ours was a descriptive, cross-sectional, epidemiological study analysing the health profiles and lifestyles of the immigrant population in Spain and their use of health resources. We used individual secondary data collected by the Spanish National Health Survey (NHS) in 2003, from the Ministry of Health.13 This survey was carried out on a wide sample of the non-institutionalized Spanish population by direct interview at home. Sampling was in several stages, stratified by conglomerates, with proportional random selection of the primary sampling units (towns) and secondary units (sections), and random route, sex and age quotas in the last units (individuals). These surveys include data from 21 650 adults, and required weighing. The methodology has been described elsewhere.13 Our study population was made up of 1506 subjects of both sexes, aged !16 years, resident in Spain. The immigrant population selected (persons who, when asked What is

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your nationality?, answered foreign) comprised non-EU citizens, namely, those defined as any person not coming from European Union countries, the United States or Canada. For each such person, two Spanish-born subjects were randomly selected, duly matched by age, sex, size of town noma). or city and Autonomous Region (Comunidad Auto As independent variables, we used the populations principal socio-demographic characteristics: co morbidity; self-perception of health; lifestyles e.g. smoking and alcohol consumption (both defined as dichotomous variables) in the 2 weeks immediately preceding the survey; and physical activity during leisure time. In order to assess the use of health-care resources, subjects were asked about the following: medical visits (time elapsed since last visit); dental visits in the previous 3 months; hospitalization (defined as a minimum of one night in the preceding 12 months); and use of emergency services in the preceding 12 months (dichotomous variables). To identify the use of specific resources by women, we asked whether they had consulted a gynaecologist, had a mammography, or undergone a cytology cervical smear test (affirmative or negative answers). They were also asked whether they had consumed any type of medication in the previous two weeks (dichotomous yes/no variable) and whether this had taken the form of self-medication (taken to mean consumption of over-thecounter medication). Finally, subjects were asked whether they had been immunized against influenza in the latest vaccination campaign. Descriptive statistics of the principal variables included in the study were drawn up. In addition, the relevant frequency distributions of the qualitative variables were calculated, and we analysed whether there were significant differences between the two study populations. For bivariate comparison of proportions, Pearsons 2 method or Fishers exact test was applied, with values of P < 0.05 taken as significant. Estimates were made by incorporating the sampling weights, using the svy (survey command) functions of the STATA programme, which enabled us to incorporate the sampling design into all our statistical calculations (descriptive, chi-squared). For random selection of the autochthonous population, SPSS.v. 12.0 for Windows was used.

Table 1 Socio-demographic variables of the study population. Spanish National Health Survey 2003
Country of origin Spanish population N Sex Men Women Age group (years) 1624 2534 3544 4554 5564 6574 75 and over Marital status ( ) Single/Divorced/Widow Married or living together Educational level ( ) No formal education Junior school High school University and higher education Occupational status Employed Unemployed Inactive Size of town Rural ( 10 000 inhabitants) Urban(>10 000 inhabitants) Monthly income ( ) 1200 euros >1200 euros

Immigrant population N %

468 536 172 398 261 108 30 17 18 452 552 64 480 276 184 795 40 169 138 866 318 394

46.6 53.4 17.1 39.6 26.0 10.8 3.0 1.7 1.8 45.0 55.0 6.4 47.8 27.5 18.3 79.2 4.0 16.8 13.8 86.2 44.7 55.3

234 268 86 202 126 55 15 10 8 168 334 60 198 155 89 424 34 44 69 433 228 115

46.6 53.4 17.1 40.2 25.1 11.0 3.0 2.0 1.6 33.5 66.5 12.0 39.4 30.9 17.7 84.5 6.8 8.8 13.8 86.2 66.5 33.5

Statistically significant differences (P < 0.05).

Results
Our sample comprised a total of 502 non-EU immigrants in Spain and 1004 autochthonous subjects. The response rate was 99.9% for the immigrant and 100% for the autochthonous population. As for the immigrants country of origin, 56% came from Latin America, 25.3% from Africa, 13.9% from European countries, and 4.8% from Asia. The distribution of the various socio-demographic characteristics of both populations is shown in table 1. Attention should be drawn to the statistically significant differences among the immigrant population in terms of educational level, marital status and monthly income, with the autochthonous population registering a higher percentage of citizens receiving an income of over 1200 euros per month. Analysis of comorbidity in the two populations showed that immigrants had a lower frequency of hypercholesterolaemia (P < 0.05) and allergy (P < 0.05) than the autochthonous population (table 2). With regard to perceived health and lifestyles, the autochthonous population (table 3) had significantly higher values for alcohol consumption and smoking than immigrants (P < 0.05). They also engaged in less physical exercise than the immigrant population (P < 0.05). On comparing differences in the use of health-care resources (table 4), the percentage of immigrants hospitalized in the

preceding 12 months was observed to be higher than that of the autochthonous population (11.4 vs. 8.2%, P < 0.05), yet no significant differences were observed in the use of other healthcare services. Moreover, when medical services used solely by the female population were examined, the percentage of women immigrants who reported undergoing a smear test (54.5%) proved to be significantly lower than that of autochthonous subjects (68.8%). A further noteworthy aspect was that the immigrant population consumed fewer medical drugs than the autochthonous population (42.6 and 49.9%, respectively), with these differences being statistically significant (P < 0.05). Selfmedication was also significantly lower (18.1% for immigrants vs. 23.1% for the autochthonous population), yet when the respective relative self-medication percentages were compared, these significant differences disappeared (46% for the autochthonous population vs. 42.5% for immigrants). When asked about influenza vaccination as a preventive measure, 11.8% of the immigrant vs. 9.6% of the autochthonous population had been vaccinated, though these differences were not statistically significant.

Discussion
Immigrants in Spain are essentially a young population,2023 who fall within the category of so-called economic immigrants24 and display characteristics similar to those of the autochthonous reference population and data agreeing with those of Spains National Statistics Institute (Instituto sticaINE) on country of origin,11 albeit Nacional de Estad with somewhat lower incomes, a circumstance in line with

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Table 2 Distribution of Spanish adult and immigrant population included in Spanish National Health Survey 2003, by comorbidity
Country of origin Spanish population N High blood pressure Yes No High cholesterol ( ) Yes No Diabetes Yes No Respiratory disease Yes No Heart disease Yes No Sore stomach Yes No Allergy ( ) Yes No Depression Yes No Obesity BMI 30 BMI > 30

Table 4 Use of sanitary resources among Spanish adult and immigrant population included in Spanish National Health Survey 2003
Country of origin

Immigrant population N %

Spanish population N %

Immigrant population N %

59 945 51 953 21 983 28 976 13 991 17 987 94 910 25 979 895 88

5.9 94.1 5.1 94.9 2.1 97.9 2.8 97.2 1.3 98.7 1.7 98.3 9.4 90.6 2.5 97.5 91.0 9.0

23 479 12 490 12 490 10 492 3 499 11 491 29 473 8 494 453 35

4.6 95.4 2.4 97.6 2.4 97.6 2.0 98.0 .6 99.4 2.2 97.8 5.8 94.2 1.6 98.4 92.8 7.2

Statistically significant differences (P < 0.05).

Table 3 Distribution of Spanish adult and immigrant population included in Spanish National Health Survey 2003, according to perception of health and lifestyle-related variables
Country of origin Spanish population N Self-assessment of health status Very good/Good Fair/Poor/Very poor Alcohol consumption ( ) Yes No Smoking habit ( ) Yes No Physical exercise ( ) Yes No

Medical consultation 1month 316 31.5 >1month 683 68.0 Never 5 0.5 Dental visit in preceding 3 months Yes 207 20.6 No 797 79.4 Hospitalization in preceding 12 months ( ) Yes 82 8.2 No 922 91.8 Emergency visit in preceding 12 months Yes 275 27.4 No 729 72.6 Gynaecologist visits Yes 438 81.7 No 98 18.3 Mammography Yes 177 33.0 No 359 67.0 Cytology ( ) Yes 369 68.8 No 167 31.2 Medications consumption ( ) Yes 501 49.9 No 503 50.1 Self-medication ( ) Yes 232 23.1 No 772 76.9 Influenza vaccination Yes 96 9.6 No 908 90.4

146 351 5 86 416 57 445 150 352 213 55 75 193 146 122 214 288 91 411 59 443

29.1 69.9 1.0 17.1 82.9 11.4 88.6 29.9 70.1 79.5 20.5 28.0 72.0 54.5 45.5 42.6 57.4 18.1 81.9 11.8 88.2

Statistically significant differences (P < 0.05).

Immigrant population N %

800 204 610 394 398 606 548 456

79.7 20.3 60.8 39.2 39.6 60.4 54.6 45.4

388 114 232 270 138 364 329 173

77.3 22.7 46.2 53.8 27.5 72.5 65.5 34.5

Statistically significant differences (P < 0.05).

findings reported in other studies undertaken in the United States and Canada.2528 In terms of health problems reported by the autochthonous population in 2003, we failed to find data to support the existence of a worse state of health among immigrants, inasmuch as they are present with diseases that are similar to those of the autochthonous population29 and, in some cases, e.g. hypercholesterolaemia or allergy, have significantly lower prevalence values. Although different studies, such as that conducted by the Report on the Mental Health in Europe

working group, alert to the vulnerability of this group against certain disorders, such as anxiety and depression16,17,3034 (both accompanied by a worse perception of health3536) this circumstance is not reflected in our study population. The lifestyle-related variables reported by the immigrant population indicate significantly less smoking and alcohol consumption than that of the Spanish population. We observed similar results in a study based on data drawn from the US National Health Survey, in which immigrants had a lower likelihood of consuming alcohol than did autochthonous subjects.3,37 Another study recently undertaken in Switzerland, whose immigrant population has sociodemographic characteristics similar to those of the immigrant population in Spain, reports alcohol consumption of 14.7% among immigrants compared with 23.9% among autochthonous subjects.38 Similarly, in line with data furnished by the Ontario Health Survey on the factors that influence smoking39 in the Canadian population (which showed 9.6% of immigrants vs. 17% of Canadian-born subjects to be smokers), immigrants in Spain smoke less than the autochthonous population, a situation also reflected in other recent studies.27,40 As for physical activity, immigrants register significantly higher percentages, in agreement with a study conducted by Dawson et al. in Sweden using data from the Swedish Survey of Living Conditions, in which the immigrant population reported engaging in more physical activity than the local Swedish population.41

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In Spain, the immigrant population, both legal and illegal, enjoys access to public health care, so that one cannot speak of this group having difficulties in access to health-care services. a 2003 country brief, This is reflected in the Informe Espan which shows that 82% of immigrants know where to obtain information on health care and 62.7% make satisfactory use of social services.42 Our results show no greater overall use of health services by immigrants or patterns of use substantially different to those of the autochthonous population.17 While these findings are in line with research conducted in countries with similar health-care systems,5,24 certain changes in the use of specific health-care resources are nevertheless beginning to be detected, such as those reported by Stronks et al.7 in a study undertaken in the Netherlands, where access to more specialized health care was found to be lower in the immigrant group (4.2 vs. 8.3% for autochthonous subjects), and by Szczepura, in a study undertaken in the UK.14 Other authors, however, have reported the difficulties of and inequalities faced by immigrants in access to health services,3 e.g. Frisbie et al.,43 who state that 32% of immigrants compared with 22.7% of US subjects had not visited a doctor in the preceding year, percentages much higher than those for immigrants to Spain. This circumstance is aggravated when the immigrant is an illegal alien in the country of residence.4,44 It should be stressed that we observed a significantly higher percentage of hospitalizations among the immigrant than among the autochthonous population (11.4 vs. 8.2%). These findings are in line with those reported by Sanz et al.29 for Spain, albeit with percentages higher than ours (23%), but differ from the data reported in the hospital-admissionbased study by Cots et al.,45 in which 9.1% of all admissions attended in the study hospital were foreign nationals. Other studies, such as that conducted using a health survey in Amsterdam,7 reflect that the immigrant population registers a lower percentage of hospitalizations than the autochthonous population (4.8% for Turkish immigrants vs. 6.8% for the autochthonous population). In contrast, Dunn et al.26 using data from the Canadian National Population Health Survey, observed practically equal hospitalization rates on comparing the immigrant with the autochthonous population (11.4 vs. 11%). These rates are identical to those of immigrants in Spain but higher than those observed in the study by Cacciani et al.46, undertaken in Italy with data from the Italian Hospital Information System. The percentage of women immigrants who had had a smear test was significantly lower than that of Spanish women (54.5 vs. 68.8%). We found higher results in the telephone-surveybased study by Carrasquillo et al.47 on the use of cervical cancer screening tests among a representative sample of all women immigrants in the United States (73% in immigrant women vs. 89% in autochthonous women). Lastly, immigrants in Spain report consuming fewer medical drugs than the autochthonous population (42.6 vs. 49.9%). In this respect, the recent study by Lasser et al. which used the Joint Canada/US Survey of Health to compare access to care, health status and health disparities between the two different health systems, reported no difficulties in access to essential medicines among both US and Canadian immigrants, although the probability of forgoing a required medicine for financial reasons was twice as high in the USA as in Canada, OR: 2.12 (1.732.59).48 This finding may be due to the existence of a universal-coverage-style health system that attenuates health inequalities, including access to medication, a situation that is rarely found in other countries with other types of health systems.49 There are a number of possible study limitations. First, the use of unvalidated self-declared data means that we cannot

forget that some responses could be socially conditioned. Second, another possible limitation of the NHS is that the validity of the questions used to classify subjects according to the health-status variables has not been evaluated. Third, the immigrant population included in the National Health Survey may have been living in Spain for longer. Lastly, the initial response rate to the 2003 NHS was 67%; therefore, the existence of possible non-response bias must be considered. According to the National Statistics Institute (INE), the initial non-response rate was slightly higher among males, non-Spanish subjects, and those in the 4065 age group.13 In conclusion, ours is the first study to use a nationally representative sample of the immigrant population in Spain. Immigrants display better lifestyle-related parameters, in that they consume less alcohol, smoke less, and do more physical exercise than the autochthonous population. As for the use of health-care resources, while immigrants register higher percentages of hospitalization than the autochthonous population, there is no evidence of excessive and inappropriate use of other health-care resources. Accordingly, the health-related needs of immigrants are comparable to those of the autochthonous population: what could generate inequalities, however, would be socio-cultural, language and economic differences.

Acknowledgement
This study forms part of a research project funded by F.I.S. (Fondo de Investigaciones Sanitarias-Health Research Fund) from the Carlos III Institute of Public Health.

Key points
 The health of the immigrant population has become a relevant topic from a public-health standpoint.  The immigrant population display better lifestylerelated parameters, in that they consume less alcohol and smoke less than their Spanish counterparts.  There is no evidence of excessive and inappropriate use of other health-care resources for the immigrant population.

References
1 Gushulak B, MacPherson D. The basic principles of migration health: population mobility and gaps in disease prevalence. Emerg Themes Epidemiol 2006;3:3. Mohanty S, Woolhandler S, Himmelstein D, et al. Health care expenditures of immigrants in the United States: a nationally representative analysis. Am J Public Health 2005;95:14318. Kandula NR, Kersey M, Lurie N. Assuring the health of immigrants: what the leading health indicators tell us. Annu Rev Public Health 2004;25:35776. Kullgren JT. Restrictions on undocumented immigrants access to health services: the public health implications of welfare reform. Am J Public Health 2003;93:16303. Wu Z, Penning MJ, Schimmele CM. Immigrant status and unmet health care needs. Can J Public Health 2005;96:36973. Vissandjee B, Hemlin I, Gravel S, et al. Cultural diversity in Montreal: a range of public health challenges. Sante Publique 2005;17:41728. Stronks K, Ravelli ACJ. Reijneveld. Immigrants in the Netherlands: equal access for equal needs?. J Epidemiol Community Health 2001;55:7017. Saxena S, Eliahoo J, Majeed A. Socioeconomic and ethnic group differences in self reported health status and use of health services by children and young people in England: cross sectional study. Br Med J 2002;325:520.

3 4

5 6 7 8

Health of immigrants in Spain

507

Hjern A, Haglund B, Persson G, Rosen M. Is there equity in access to health services for ethnic minorities in Sweden? Eur J Public Health 2001;11:14752.

10 McKay L, Macintyre S, Ellaway A. Migration and Health: A review of the International Literature. Medical Research Council 2003;12:1206. Available from http://www.msoc-mrc.gla.ac.uk/Publications/pub/ occasional_MAIN.html [accessed 15th Jun 2006]. stica. Explotacio stica del Padro n Estad n 11 Instituto Nacional de Estad Municipal a 1 de enero de 2005. Datos definitivos. Madrid: 2006. Available from: http://www.ine.es/inebase/cgi/ um?M%2Ft20%2Fe260%2Fa2005%2F&Opcaxis&N&L0 [accessed 15th Jun 2006]. 12 Eurostat. Population and Social Conditions. Available from http://epp. eurostat.ec.europa.eu/portal/ page?_pageid1073,46587259&_dadportal&_schemaPORTAL&p_ product_codeKS-NK-06-008 [accessed 15th Jun 2006]. stica. Encuesta Nacional de Salud de Espan a 13 INE. Instituto Nacional de Estad 2003 (Spanish Nacional Health Survey 2003). Available from http:// www.ine.es/en/metodologia/t15/t1530419_en.pdf. [Accessed 30th june 2006]. 14 Szczepura A. Access to health care for ethnic minority populations. Postgrad Med J 2005;81:1417. 15 Sundquist J. Migration, equality and access to health care services. J Epidemiol Community Health 2001;55:6912. 16 Carta M, Bernal M, Ardoy MC, Haro-Abad JMand the Report on the Mental Health in Europe working group.. Migration and mental health in Europe (the state of the mental health in Europe working group: appendix 1). Clin Pract Epidemol Ment Health 2005;31:113. a de Olalla P. Health and immigration: new situations and 17 Jansa JM, Garc challenges. Gac Sanit 2004;18(Suppl 1):20713. guez J. Immigrant population and 18 Guerrero-Espejo A, Colomina-Rodr communicable diseases. Rev Esp Salud Publica 2004;78:56570. 19 Jansa JM. Immigration and aging: new challenges in Public Health. Gac Sanit 2006;20(Suppl 1):1014. 20 Singh GK, Miller BA. Health, life expectancy and mortality patterns among immigrant populations in the United States. Can J Public Health 2004;95:11421. 21 Weinick RM, Jacobs EA, Stone LC, et al. Hispanic healthcare disparities: challenging the myth of a monolithic Hispanic population. Med Care 2004;42:31320. 22 Newbold K, Patel A. Use of dental services by immigrant Canadians. J Can Dent Assoc 2006;72:143. 23 Tobias A, Soriano JB, Chinn S, et al. Symptoms of asthma, bronchial responsiveness and atopy in immigrants and emigrants in Europe. Eur Respir J 2001;18:45965. 24 Ministerio de trabajo y asuntos sociales. Observatorio permanente de la n. Extranjeros con tarjeta o autorizacio n de residencia en vigor a inmigracio 31 de marzo de 2006. Available from http://extranjeros.mtas.es/es/general/ fuente_comentario_mar06.html [Accessed 30th june 2006]. 25 Dey AN, Lucas JW. Physical and mental health characteristics of US- and foreign-born adults: United States, 19982003. Adv Data 2006;369:119. 26 Dunn JR, Dyck I. Social determinants of health in Canadas immigrant population: results from the National Population Health Survey. Soc Sci Med 2000;51:157393. a D, Pan J, Jun HJ, et al. The effect of immigrant generation 27 Acevedo-Garc on smoking. Soc Sci Med. 2005;61:122342. 28 Dunlop S, Coyte PC, McIsaac W. Socio-economic status and the utilisation of physicians services: results from the Canadian National Population Health Survey. Soc Sci Med 2000;51:12333.

29 Sanz B, Torres AM, Schumacher R. Sociodemographic characteristics and use of health services by the immigrant population residing in a district of the Community of Madrid. Aten Primaria 2000;26:3148. M. Depression and s M, Barro Lugo A, Fons Mart 30 Barro Lugo S, Saus Aru anxiety in irregular immigrants. Aten Primaria 2004;34:504. 31 Ochoa Mangado E, Vicente Muelas N. Depressive syndromes in the immigrant population. Rev Clin Esp 2005;205:1168. 32 Pumariega AJ, Rothe E, Pumariega JB. Mental health of immigrants and refugees. Community Ment Health J 2005;41:58197. 33 Hsu E, Davies CA, Hansen DJ. Understanding mental health needs of Southeast Asian refugees: historical, cultural, and contextual challenges. Clin Psychol Rev 2004;24:193213. 34 Gilgen D, Maeusezahl D, Salis Gross C, et al. Impact of migration on illness experience and help-seeking strategies of patients from Turkey and Bosnia in primary health care in Basel. Health Place 2005;11:26173. 35 Gerritsen AA, Bramsen I, Deville W, et al. Physical and mental health of Afghan, Iranian and Somali asylum seekers and refugees living in the Netherlands. Soc Psychiatry Psychiatr Epidemiol 2006;41:1826. 36 Murphy EJ, Mahalingam R. Perceived congruence between expectations and outcomes: implications for mental health among Caribbean immigrants. Am J Orthopsychiatry 2006;76:1207. 37 Johnson TP, VanGeest JB, Cho YI. Migration and substance use: evidence from the US National Health Interview Survey. Subst Use Misuse 2002;37:9412. 38 Baleydier B, Damsa C, Schutzbach C, et al. Comparison between Swiss and foreign patients characteristics at the psychiatric emergencies department and the predictive factors of their management strategies. Encephale 2003;29:20512. 39 Georgiades A, Boyle MH, Duku E, Racine Y. Tobacco use among immigrant and nonimmigrant adolescents: individual and family level influences. J Adolesc Health 2006;38:443.e17. 40 Singh GK, Siahpush. Ethnic-immigrant differentials in health behaviors, morbidity and cause-specific mortality in the United States: an analysis of two national data bases. Hum Biol 2002;74:83109. 41 Dawson AJ, Sundquist J, Johansson SE. The influence of ethnicity and length of time since immigration on physical activity. Ethn Health 2005;10:293309. n Encuentro. ISBN 84-89019-16-9. Available a 2003. Fundacio 42 Informe Espan from http://www.fund-encuentro.org/Informes/In-2003.htm [Accessed 30th June 2006]. 43 Frisbie WP, Cho Y, Hummer RA. Immigration and the health of Asian and Pacific Islander adults in the United States. Am J Epidemiol 2001;153:37280. 44 Torres A, Sanz B. Health care provision for illegal immigrants: should public health be concerned? J Epidemiol Community Health 2000;54:4789. C, et al. Profile of the hospital case mix of the 45 Cots F, Castells X, Olle immigrant population in Barcelona, Spain. Gac Sanit 2002;16:37684. 46 Cacciani L, et al. Hospitalisation among immigrants in Italy. Emerg Themes Epidemiol 2006;3:4. 47 Carrasquillo O, Pati S. The role of health insurance on Pap smear and mammography utilization by immigrants living in the United States. Prev Med 2004;39:94350. 48 Lasser KE, Himmelstein DU, Woolhandler S. Access to care, health status, and health disparities. Results of a cross-national population-based survey. Am J Public Health 2006;96:13007. 49 Haas JS, et al. Variation in access to health care for different racial/ethnic groups by the racial/ethnic composition of an individuals county of residence. Med Care 2004;42:70714.

Received 30 October 2006, accepted 18 December 2006