Objective: To assess self-rated health and impairments for six large immigrant groups (Germany, Italy, Kosovo, Portugal, Serbia, Turkey) in Switzerland. Methods: We used population-based survey data from the Swiss Migrant Health Survey 2010 and the Swiss Health Survey 2007. The sample comprised permanent residents aged 17 - 64 years (n = 14,637). Multivariate logistic regressions have been used to estimate odds ratios (OR). Results: Ill health and activities of daily living (ADL) impairments were associated with older age in all groups. However, nationals from Turkey and nationals from Kosovo were substantially more likely than Swiss to report ill health (OR = 1.05; CI = 1.02 - 1.09; P = 0.001 and OR = 1.05; CI = 1.01 - 1.10; P = 0.016) and ADL impairments (OR = 1.06; CI = 1.03 - 1.09; P = 0.000 and OR = 1.04; CI = 1.01 - 1.07; P = 0.004) with increasing age. Furthermore, Portuguese women were more likely (OR = 2.65; CI = 1.40 - 5.03; P = 0.003) to report ill health than Swiss women. Conclusions: Immigrant-specific preventive and health promotion initiatives should target vulnerable immigrants from Turkey, Portugal, and Kosovo. Furthermore, groups with few economic and psychosocial resources in the general population of Switzerland should be more involved in interventions to reduce health risk.
In the context of immigration, ethnicity and country of origin has been shown to be associated with unfavour- able environmental health conditions, health opportunities, health behaviour and health outcomes. More specifi- cally, evidence suggests that immigrant status is associated with health adverse working conditions [
respect to health opportunities, several studies find poor health literacy, poor access to health services or poor utilization of health services among immigrants as compared to natives [
These findings suggest that immigrant groups may be very heterogeneous in some host countries and that the conventional Western conception of immigrants as vulnerable individuals characterized by low socio-economic status, working in unhealthy jobs, having poor health literacy and poor access to health services etc., may not necessarily be generalized. Established theoretical explanations on migration and health can account for such differences: social and cultural patterns from the country of origin shape physical activity, body images, dietary intake and food preferences [
The study is a population-based cross-sectional health survey carried out in 2007 and 2010 in Switzerland.
Data from the Swiss Immigrant Health Survey 2010 (SMHS) and the Swiss Health Survey 2007 (SHS) were obtained from the Swiss Federal Office of Public Health. The SMHS is a cross-sectional, population-based telephonic survey which intends to monitor health trends in a representative sample of immigrants and has been carried out in 2004 and 2010 so far. Due to economic constraints, the SMHS is limited to a selected number of nationalities. The core study population 2010 comprises permanent residents from Portugal, Turkey, Serbia and Kosovo (n = 1800). Participants aged 17 - 74 were chosen by stratified random sampling (gender, country of birth, duration of stay) from the database of the central immigration information system. The computer-aided telephone interviews were carried out in Portuguese, Turkish, Serbian, Albanian, German, and French. Data of Swiss, German and Italian nationals from the SHS 2007 were pooled with the SMHS data. The SHS intends to monitor health trends in a representative sample of all permanent residents in Switzerland. It was first conducted in 1992 and is repeated every five years. The 2007 sample included over 19,000 subjects aged 15 years or older. Subjects were randomly selected within private households and computer-aided telephone interviews were conducted in German, French and Italian. People who did not speak any of these languages or people who had insufficient language skills were excluded from the SHS. Immigrant participants in both surveys include immigrants and their children, i.e. permanent residents with a non-Swiss nationality.
The response rate of those in the initial SHS sample was 66.2%. 13.2% could not be contacted after numerous contact attempts and 20.6% refused to participate in the SHS. In the initial SMHS national samples, the response rates of nationals from Kosovo, Portugal, Serbia, and Turkey were 50.1%, 51.0%, 46.9%, and 50.8% respec- tively. 35.2% of nationals from Kosovo, 36.4% from Portugal, 30.8% from Serbia and 33.0% from Turkey could not be contacted after numerous contact attempts and 14.7%, 12.6%, 22.3% and 16.2% refused to participate in the SMHS.
In the SMHS, contact attempts were less successful and refusals—with the exception of nationals from Serbia —were less likely as compared to the SHS. Several factors may account for these differences. First, subjects in the SMHS were contacted and interviews conducted in their respective native language whereas subjects in the SHS had to have sufficient French, German or Italian language skills in order to participate. Selection bias due to insufficient language skills may have been mitigated in the SMHS, i.e. refusal rates were lower because the selection process is less likely to favour immigrants who are well-integrated, well-educated and have been living in Switzerland for a long period of time. Second, potential SMHS participants may have been more difficult to contact because they were younger on average and younger subjects may tend to spend more time outside their homes (school, work, leisure). However, we have no data to substantiate these hypotheses because nationality and other important sociodemographic characteristics were not recorded for the initial SHS and SMHS samples.
The pooled sample represents 58.2% of the immigrant population as well as nationals from Switzerland. Of the 1.7 million immigrants in Switzerland, 17.0% are Italian, 14.9% are German, 12.0% are Portuguese, 5.4% are French, 3.6% are Spaniards, 6.9% are from Serbia, 4.1% are Turkish and 3.3% are from Kosovo [
For the purpose of this study, the initial pooled sample was further narrowed down to include only subjects 17 - 64 years old because only few immigrants in the SMHS sample were over 64 years old. The total sample size amounts to 14,637. The sample size by nationality and further characteristics of the pooled SMHS and SHS sample is shown in
Health status, the first target outcome of this study, was derived from self-reported data. Participants were asked to report their health by answering the question: “In general, how would you rate your health? (very good, good, fair, poor, very poor)”. Subjects who rated their health status as fair, poor or very poor were assigned to the ill health category, subjected who rated their health status as very good or good were assigned to the good health category. ADL impairments, the second target outcome of this study, was also derived from self-reported data. Participants were asked to report ADL impairment within the last 6 months by answering the question: “During the last six months, how much have you been limited by a health problem in your activities of daily living? (not at all limited, somewhat limited, severely limited)”. Subjects who reported to be somewhat or severely limited were then assigned to the category with and the remaining subjects to the category without ADL impairments.
For the primary predictor, the country of origin, the following nationalities were considered: Portugal, Turkey, Serbia, Kosovo, Germany, Italy and Switzerland. Double citizens who acquired the Swiss nationality through naturalization were considered Swiss. Covariates included: age (measured in whole years), gender (male/female), socio-economic status (SES) and dwelling zone. SES comprised three indicators: education (basic, secondary, and university), employment (economically active [no/yes]), and housing situation (rooms per person). Urbanity comprised two categories: rural area and urban area. Urban areas included isolated cities (≥10,000 inhabitants) and urban agglomerations (≥20,000 inhabitants); all other areas were assigned to the category rural area. Furthermore, two psychosocial resources—sense of mastery and social support—were selected as covariates because of their relevance when coping with stressful life events such as diseases and impairment [
. Frequency distribution and central tendency for variables in the sample of subjects aged 17 - 64 years by nationality (Swiss Immigrant Health Survey 2010 & Swiss Health Survey 2007)a.
N = 14,637 (sample size) | Portugal (449) | Turkey (644) | Serbia (455) | Kosovo (648) | Germany (324) | Italy (369) | Switzerland (11,748) | |
---|---|---|---|---|---|---|---|---|
% | % | % | % | % | % | % | ||
Self-reported healthb | ||||||||
Very good, good, fair | 80.1 | 77.9 | 84.8 | 90.4 | 94.4 | 79.9 | 89.7 | |
Poor, very poor | 19.9 | 22.1 | 15.2 | 9.6 | 5.6 | 20.1 | 10.3 | |
ADL impairment | ||||||||
Not at all limited | 81.7 | 68.5 | 74.2 | 80.1 | 74.2 | 74.4 | 76.6 | |
Somewhat/severely limited | 18.3 | 31.5 | 25.8 | 19.9 | 25.8 | 25.6 | 23.4 | |
Gender | ||||||||
Male | 50.1 | 50.0 | 49.9 | 49.7 | 51.9 | 55.3 | 45.9 | |
Female | 49.9 | 50.0 | 50.1 | 50.3 | 48.1 | 44.7 | 54.1 | |
Education | ||||||||
Basic | 55.9 | 40.2 | 30.6 | 46.8 | 1.5 | 24.9 | 7.4 | |
Secondary | 37.0 | 38.2 | 56.4 | 49.8 | 37.7 | 61.8 | 63.5 | |
University | 7.1 | 21.6 | 13.0 | 3.4 | 60.8 | 13.3 | 29.1 | |
Economically active | 82.2 | 53.0 | 75.0 | 59.9 | 88.3 | 75.1 | 79.7 | |
Urbanityd | ||||||||
Urban area | 78.2 | 88.5 | 82.4 | 74.7 | 76.5 | 83.5 | 66.0 | |
Rural area | 21.8 | 11.5 | 17.6 | 25.3 | 23.5 | 16.5 | 34.0 | |
Sense of masterye | ||||||||
Low | 22.8 | 22.8 | 20.6 | 13.8 | 16.9 | 30.7 | 21.6 | |
Medium | 32.6 | 28.0 | 27.8 | 17.0 | 38.7 | 36.9 | 42.3 | |
High | 44.6 | 49.2 | 51.6 | 69.2 | 44.4 | 32.4 | 36.1 | |
Length of residencef | ||||||||
<10 years | 49.7 | 62.0 | 48.1 | 62.2 | 63.3 | 9.7 | ||
10 - 19 years | 28.5 | 13.8 | 30.8 | 29.9 | 18.8 | 7.2 | ||
≥20 years | 21.8 | 24.2 | 21.1 | 7.9 | 17.9 | 83.1 | ||
mean (SD) | mean (SD) | mean (SD) | mean (SD) | mean (SD) | mean (SD) | mean (SD) | ||
Age (years) | 35.6 (12.2) | 33.8 (10.5) | 33.3 (12.4) | 29.0 (10.7) | 40.8 (10.7) | 43.1 (11.9) | 43.0 (13.0) | |
Housing (rooms/person) | 1.1 (0.6) | 1.2 (0.5) | 1.1 (0.4) | 0.9 (0.4) | 2.1 (1.0) | 1.8 (1.0) | 2.0 (1.0) | |
Social supportg | 4.0 (0.7) | 3.9 (0.8) | 4.2 (0.6) | 4.1 (0.6) | 3.8 (0.6) | 3.8 (0.8) | 3.9 (0.7) | |
aFigures refer to percentage or arithmetic mean and standard deviation (SD) within nationality. bIn general, how would you rate your health? (very good, good, fair, poor, very poor). cDuring the last six months, how much have you been limited by a health problem in your activities of daily living? (not at all limited, somewhat limited, severely limited). dClassification according to the Swiss Federal Statistical Office. Urban areas include isolated cities (≥10,000 inhabitants) and urban agglomerations (≥20,000 inhabitants). eBased on the brief version of the Pearlin coping questionnaire. fNumber of years passed since immigration to Switzerland (non-Swiss nationals only). gBased on the SMHS 5-item social support index (higher values indicate more social support).
The original expansion weights of the SMHS and SHS were used for all population estimates. The weights take into account the different sampling strategies which have been used to sample immigrants and Swiss nationals and they allow correct estimates of population parameters for immigrants and Swiss nationals.
We used STATA Version 12.1 for all statistical analyses. Multivariate logistic regression was employed to as- sess the factors associated with ill health and ADL impairments. We reported adjusted odds ratios (OR), 95% confidence intervals (CI) and P-values. OR were adjusted for age, gender, the interaction between age and gen- der, socio-economic status (including educational level, employment, number of rooms/person), nationality, and the interaction between nationality and age and the interaction between nationality and gender. To incorporate information on the appropriate weights and sampling units for correct variance estimation, all statistical analyses were carried out using STATA’s command for complex surveys (svy prefix). Statistical significance was estab- lished at P ≤ 0.05.
Adjusting for all covariates, we found no main effect of nationality for men, i.e. immigrant men and Swiss men were equally likely to report ill health where as Portuguese women were more likely and German women were less likely to report ill health than Swiss women (
In order to control for potential acculturation effects, length of time in Switzerland (years) was added as a co- variate to the model previously discussed and the model was re-estimated using immigrant data only. However, length of time in Switzerland had no statistically significant association with ill health (results not shown).
Adjusting for all covariates, we found that Turkish men and Portuguese men were less likely to report ADL im- pairment than Swiss men where as immigrant women from different nationalities and Swiss women showed tistical significance (
Probability of ill health by age, gender and nationality*. *All other covariates held constant (education = secondary, rooms/person = 1.5, economically active = yes, region = rural area, sense of mastery = medium, social support = 4.0). Significant differences between Swiss and immigrants from Turkey (P = 0.001) and immigrants from Kosovo (P = 0.016)
. Multivariate logistic regression of ill health and ADL impairmentsa.
Ill health | Impairment | |||||
---|---|---|---|---|---|---|
Variable | OR | P > z | 95% CI | OR | P > z | 95% CI |
Age | 1.04 | 0.000 | 1.02 - 1.05 | 1.01 | 0.007 | 1.00 - 1.02 |
Gender | ||||||
Male | 1.00 | reference | 1.00 | reference | ||
Female | 1.89 | 0.102 | 0.88 - 4.08 | 1.36 | 0.184 | 0.86 - 2.16 |
Gender × age | 0.99 | 0.072 | 0.97 - 0.00 | 1.00 | 0.697 | 0.99 - 1.01 |
Nationality | ||||||
Swiss | 1.00 | reference | 1.00 | reference | ||
Portuguese | 0.54 | 0.373 | 0.14 - 2.08 | 0.27 | 0.026 | 0.09 - 0.85 |
Turkish | 0.44 | 0.218 | 0.12 - 1.63 | 0.23 | 0.007 | 0.08 - 0.68 |
Serbian | 1.12 | 0.876 | 0.28 - 4.49 | 2.76 | 0.069 | 0.92 - 8.26 |
Kosovar | 0.28 | 0.216 | 0.04 - 2.11 | 0.41 | 0.123 | 0.13 - 1.27 |
German | 0.28 | 0.350 | 0.02 - 4.12 | 3.34 | 0.112 | 0.76 - 14.76 |
Italian | 0.32 | 0.345 | 0.03 - 3.45 | 0.87 | 0.863 | 0.17 - 4.38 |
Nationality × age | ||||||
Portuguese | 1.03 | 0.055 | 1.00 - 1.06 | 1.02 | 0.104 | 1.00 - 1.05 |
Turkish | 1.05 | 0.001 | 1.02 - 1.09 | 1.06 | 0.000 | 1.03 -1.09 |
Serbian | 1.02 | 0.129 | 0.99 - 1.05 | 0.98 | 0.123 | 0.96 - 1.01 |
Kosovar | 1.05 | 0.016 | 1.01 - 1.10 | 1.04 | 0.004 | 1.01 - 1.07 |
German | 1.03 | 0.263 | 0.98 - 1.10 | 0.98 | 0.192 | 0.94 - 1.01 |
Italian | 1.03 | 0.249 | 0.98 - 1.08 | 0.99 | 0.767 | 0.96 - 1.03 |
Nationality × gender | ||||||
Portuguese | 2.65 | 0.003 | 1.40 - 5.03 | 1.56 | 0.115 | 0.90 - 2.73 |
Turkish | 1.49 | 0.238 | 0.77 - 2.87 | 0.78 | 0.377 | 0.45 - 1.35 |
Serbian | 0.93 | 0.866 | 0.42 - 2.06 | 1.13 | 0.708 | 0.59 - 2.16 |
Kosovar | 1.37 | 0.502 | 0.54 - 3.45 | 0.87 | 0.669 | 0.45 - 1.67 |
German | 0.12 | 0.015 | 0.02 - 0.66 | 0.90 | 0.774 | 0.43 - 1.88 |
Italian | 2.49 | 0.061 | 0.96 - 6.47 | 1.57 | 0.312 | 0.66 - 3.74 |
Education | ||||||
Basic | 1.00 | reference | 1.00 | reference | ||
Secondary | 0.65 | 0.001 | 0.51 - 0.83 | 0.80 | 0.036 | 0.65 - 0.99 |
University | 0.44 | 0.000 | 0.33 - 0.60 | 0.79 | 0.044 | 0.62 - 0.99 |
Housing (rooms/person) | 1.02 | 0.689 | 0.93 - 1.12 | 1.05 | 0.186 | 0.98 - 1.12 |
Economically active | ||||||
No | 1.00 | reference | 1.00 | reference | ||
Yes | 0.43 | 0.000 | 0.36 - 0.52 | 0.63 | 0.000 | 0.55 - 0.73 |
Urbanity | ||||||
Urban area | 1.00 | reference | 1.00 | reference | ||
Rural area | 0.93 | 0.502 | 0.77 - 1.14 | 1.02 | 0.766 | 0.89 - 1.17 |
Sense of masteryb | ||||||
Low | 1.00 | reference | 1.00 | reference | ||
Medium | 0.39 | 0.000 | 0.31 - 0.47 | 0.66 | 0.000 | 0.57 - 0.78 |
High | 0.24 | 0.000 | 0.19 - 0.30 | 0.46 | 0.000 | 0.39 - 0.54 |
Social supportc | 0.72 | 0.000 | 0.63 - 0.82 | 0.89 | 0.031 | 0.81 - 0.99 |
Constant | 0.45 | 0.078 | 0.19 - 1.09 | 0.66 | 0.172 | 0.37 - 1.20 |
N | 11,649 | 10,714 |
aWeighted data of 17 - 64-year-old subjects, Swiss Immigrant Health Survey 2010 & Swiss Health Survey 2007. Ill health (1/0): 1 = self-rated health. very poor, poor or fair; 0 = self-rated health very good or good. Impairment (1/0): 1 = somewhat/severely limited inactivities of daily living during the last 6 weeks; 0 = not at all limited. bBased on the brief version of the Pearlin coping questionnaire. cBased on the SMHS 5-item social support index (higher values indicate more social support).
similar odds of reporting ADL impairments, i.e. none of the nation-specific odds ratios for women attained sta- were equally likely to report ADL impairments with increasing age. However, nationals from Turkey and natio- nals from Kosovo were substantially more likely than Swiss to report ADL impairments with increasing age (
So far, population-based studies on health status and ADL impairments among immigrants in Switzerland are rare and have been based mainly on data of the SHS [
To our knowledge, the present study is the first study which used the SMHS 2010 data to assess self-reported health and ADL impairments among immigrants and hence used a survey which had been especially designed to collect public health related data on immigrants in Switzerland. Since all SMHS interviews were conducted in the subjects’ respective native languages, selection bias due to insufficient language skills has been mitigated.
Overall, we found that ill health and ADL impairments were unevenly distributed among immigrants in Switzerland. Turkish and Kosovar immigrants were consistently more likely to report ill health and ADL im- pairments than Swiss with increasing age, i.e. older immigrants from these two countries more often than Swiss
Probability of impairment (ADL) by age, gender and nationality*. *All other covariates held constant (education = secondary, rooms/person = 1.5, economically active = yes, region = rural area, sense of mastery = medium, social support = 4.0). Significant differences between Swiss and immigrants from Turkey (P = 0.000) and immigrants from Kosovo (P = 0.004)
reported ill health and ADL impairments. Moreover, Portuguese women were more likely and German women were less likely to report ill health whereas women from Italy, Serbia, Turkey, and the Kosovo did not signifi- cantly differ from Swiss women. No significant differences between immigrant and Swiss women were found in the likelihood to report ADL impairments. Furthermore, the likelihood to report ill health did not significantly differ between immigrant and Swiss men. Similarly, reported ADL impairments did not significantly differ be- tween immigrants from Serbia, Germany, Italy, and the Kosovo and Swiss men whereas Portuguese and Turkish men were less likely than Swiss men to report ADL impairments. In general, these results suggest that older im- migrants from Turkey and the Kosovo as well as women from Portugal are at a particular risk of ill health and/or ADL impairments. Consequently, vulnerable immigrant groups in Switzerland should be addressed with immi- grant-specific preventive and health promotion initiatives. Generally, our results are in line with previous studies that found no significant differences in self-reported health between German immigrants and Swiss but reported lower levels of health for immigrants from Turkey, Portugal, and the Former Yugoslavia which included immi- grants from Kosovo and Serbia [
Furthermore, previous studies find that higher socio-economic status [
Limitations in the present study need to be considered when interpreting the findings. First, even though self- rated health is strongly associated with mortality [
In sum, our results suggest that older immigrants from Turkey and the Kosovo as well as women from Portugal were at a particular risk of ill health and/or ADL impairments. Furthermore, poor health and ADL impairments were consistently associated with low socioeconomic status, low sense of mastery and little social support. Immigrant-specific preventive and health promotion initiatives should therefore target these immigrant groups. Furthermore, groups with few economic and psychosocial resources in the general population of Switzerland should be more involved in interventions to reduce health risk.
The authors declare that they have no conflict of interest.
This study was supported by the Swiss Federal Office of Public Health and the Swiss Federal Office for Migration, grant number 09.005923/704.0001/-330.