J Immigrant Minority Health DOI 10.1007/s10903-015-0197-x
ORIGINAL PAPER
Determinants of Subjective Social Status and Health Among Latin American Women Immigrants in Spain: A Qualitative Approach Ma Visitacio´n Sancho´n-Macias1 • Andreu Bover-Bover2 • Dolores Prieto-Salceda3 Marı´a Paz-Zulueta1 • Blanca Torres1 • Denise Gastaldo4
•
Springer Science+Business Media New York 2015
Abstract This qualitative study was carried out to better understand factors that determine the subjective social status of Latin Americans in Spain. The study was conducted following a theoretical framework and forms part of broader study on subjective social status and health. Ten immigrant participants engaged in semi-structured interviews, from which data were collected. The study results show that socioeconomic aspects of the crisis and of policies adopted have shaped immigrant living conditions in Spain. Four major themes that emerged from the analysis were related to non-recognition of educational credentials, precarious working conditions, unemployment and loneliness. These results illustrate the outcomes of current policies on health and suggest a need for health professionals to orient practices toward social determinants, thus utilizing evaluations of subjective social status to reduce inequalities in health. Keywords Social class Subjective social status Immigration Social determinants of health Healthcare disparities Qualitative research
& Ma Visitacio´n Sancho´n-Macias [email protected] 1
Departamento de Enfermerı´a, Escuela de Enfermerı´a, Universidad de Cantabria, Avda de Valdecilla s/n, 39008 Santander, Spain
2
Department of Nursing, University of Islas Baleares, Carretera de Valldemossa, km 7.5, 07122 Palma de Mallorca, Spain
3
Observatorio de Salud Pu´blica de Cantabria, Avda de Valdecilla s/n, 39008 Santander, Spain
4
Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, Canada
Background Current conditions of socioeconomic globalization have done much to potentiate the intensity of migration in several countries [1]. However, immigration is not considered in the development objectives of the millennium nor is it a systematic object of national development plans [2]. With many countries in economic crisis, among them, Spain, labor conditions have worsened, immigration policies have become more rigid, and social and health services have been restricted [3, 4]. These circumstances chiefly affect immigrants from low- and medium-income countries, 35 % of which occupy the poorest quintile of the income distribution, leading to an increase in health inequality [5]. The importance of socioeconomic status (SES) to human health is widely documented in the scientific literature. The social gradient in health, which has been reflected in numerous countries, indicates that as one descends in social position, progressive deterioration in health occurs [6, 7]. Examining this gradient has generally involved applying SES, which measures education and income levels and occupations. However, to determine the effect of social position on health, objective SES data are not sufficient. Rather, one must also consider perceptions of an individual regarding his or her position in society, which is known as subjective social status (SSS) [8, 9]. SSS considers social and psychological factors that SES does not account for. For example, factors derived from immigration contexts (stigma, discrimination, lack of opportunities, etc.) may be more central to determining social positions than objective data. If only objective data are taken into account, negative effects of social disadvantage on health may be undervalued [10].
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was achieved when no new significant themes were identified. The following inclusion criteria were used: women born in Latin America, because it is the largest group of immigrants in the region [17], in working age (16–65 years), with work experience in Spain. Participants were found through social-health centers and associations that provide services to immigrants. The data were collected by the first author (a PhD candidate who was trained in qualitative research methods) through semi-structured in-depth interviews. The interviews took place at the women’s place of residence. The study was carried out from 2010 to 2012.
A large body of quantitative research relates SSS to health outcomes. These studies show that SSS is related to low self-perceptions of health, higher mortality, depression, cardiovascular risk, diabetes, and respiratory disease [11]. Some authors note that SSS affects health outcomes to a greater degree than SES [12, 13]. Qualitative studies on factors that shape SSS among immigrants and their relation to health are needed. The purpose of this study was to identify determinants of social position identified by a group of Latin American immigrant women residing in Spain and to describe contextual factors that influence their social position and health. Study results were generated as part of a broader study on the influence of SSS on the health of immigrant women [14]. These determinants will help health professionals identify contextual factors that negatively affect health and thereby design interventions for reducing health inequality among the most disadvantaged groups, as in the case of immigrants.
Measures Health and demographic data were obtained prior to the interviews. The following subjects were explored: immigration process, socioeconomic situation, SSS, and perceptions of health (guide interview available on request). The interviews were recorded, registered twice, and then transcribed verbatim. Interviews were conducted until data saturation was achieved, and each interview lasted an average of 1 h. Finally, after documents were reviewed to ensure content veracity, other observations on the non-verbal behaviors of the interviewees were incorporated, including de tone of participant’s voices, their facial expressions and their body postures. This provided important contextual data which informed the analysis.
Methods Design and Samples A qualitative investigation was conducted following procedures of grounded theory in a region of northern Spain. This is the most effective methodology for identifying individual perceptions [15]. The sample included 10 women who were selected following a strategy of purposeful sampling [16]. The sampling method was theoretical and sought variation in features that can affect social position, including age, educational level, salary, employment activity, perceptions of social positioning and health (see Table 1). Data were collected until data saturation was achieved. Data saturation was assured during the analysis phase. It
Analysis The analysis was conducted in an open, circular and dynamic manner [15]. Once the interviews were transcribed, they were reviewed to identify the most relevant themes
Table 1 Qualitative samples: description of participants Interviewees
Place of residence
Age
Educational level
Salary (€/month)
Employment activity
1. Colombia
Santander
44
University
499
Immigration project advisor
4
Regular
2. Peru 3. Bolivia
Santander Santander
43 24
University Technical instruction
1230 250–499
Domestic worker (various duties) Student and caretaker PTW
4 3
Regular Regular
4. Ecuador
Santander
41
Technical instruction
500
Caretaker (PTW)
7
Regular
5. Paraguay
Santander
40
Secondary
1000
Domestic worker (internal)
1
Regular
6. Ecuador
Colindres
40
Technical instruction
Unemployed
5
Good
7. Paraguay
Herrera
53
Secondary
1490
Domestic worker (internal)
7
Good
8. Colombia
Torrelavega
55
Secondary
1000
Volunteer geriatric assistant
6
Regular
9. Peru
Santander Malian˜o
54
Secondary
250–499
Domestic worker (various duties)
6
Good
35
Secondary
1000
Domestic worker (internal)
2
Regular
10. Ecuador
SSS subjective social status, PH perceived health, PTW part time work
123
SSS
PH
J Immigrant Minority Health
that had emerged in relation to principal determinants of SSS. The most significant sections of text were marked and coded based on the study objectives and following the method proposed by Strauss and Corbin [15]. These codes were then refined and assigned to previously established categories based on a review of existing literature. All interview segments that related to the designated subjects were then examined to identify how central themes interacted. This procedure was repeated until a pattern emerged from the data that allowed for the identification of SSS determinants. The ATLAS.ti software program was used to codify and arrange the data. To ensure validity and methodological rigor, researcher, data, method and source triangulation was employed [16]. The results obtained were shared with the interview participants (immigrants) to verify the findings. Information was triangulated by three researchers from other universities, including two socio-health center professionals and one professional responsible for an immigrant program. Method triangulation was carried out with the use of quantitative methodologies (published elsewhere) [18]. Finally, data were triangulated with scientific literature and official database results. Clinical Research Ethics Committee of Cantabria approval of the research protocol was obtained before data were acquired on September 4, 2009. Patient records were de-identified prior to the analysis. Participants received oral and written information on the study purpose, objectives and content. All participants signed letters of consent, confirming that they were informed of the study parameters. The participants were guaranteed anonymity and the opportunity to leave the study at any time.
Results A total of 10 women between 24 and 55 years of age participated in the study. All participants had lived in Spain for longer than 1 year and had been employed for at least 6 months of this time. All held high school diplomas, and four held a university degree. One participant had completed postgraduate studies in Spain, and the rest had not completed their degrees in Spain. Participant salaries varied between 250 and 1490 €/month. One participant was unemployed, one worked as a psychologist, one was a student of nursing, and the other seven women were employed as domestic workers (cleaners and caretakers for children or dependent persons). Three of the interviewees lived alone with the persons who had hired them as fulltime caretakers, and the other four worked hourly as cleaners or caretakers. The participants had emigrated from five different Latin American countries. Two were in an irregular situation at the time of the interview.
Determinants of SSS Identified by Immigrant Women The results indicate that women experience a series of problems related to socioeconomic and political issues that shape their opportunities and living conditions in Spain. Chief determinants of SSS found are related to non-recognition of educational and professional credentials, precarious labor conditions, unemployment, discrimination, and loneliness. ‘‘This is Not What They Said to Me’’ The women’s expectations had not been fulfilled. While the interviewees had hoped to earn and save money to send to their families and to begin future projects, they came across a different reality. While the women’s educational levels were either medium or high, their labor opportunities have been limited as they have faced barriers in validating foreign degrees or broadening educational credentials in Spain. Only one interviewee had succeeded in registering her degree after considerable effort. Having to study in order to register my degree … please … eight subjects in some disciplines I had never seen … it was a huge amount of work. Precarious Work and Low Salaries The interviewees explained that they cannot complain about their working conditions because they need to work and fear termination. They are aware of the current economic crisis and feel disadvantaged by limited work opportunities. I complain, I say it … but what do they say? That if I don’t like it, leave, because there is plenty of work; because I accepted this job, and I agreed to work for 24 hours, not the hours that I feel like working. Well, OK, perfect … I accept it. The women work as both caretakers and homemakers. They find this work stressful, with long days of work, and receive little support from family members of the persons whom they care for. I can’t because I am here 24 hours a day and then I cannot go out unless someone comes … The women feel that the families they work for ascribe low value to their work despite responsibilities they are afforded in senior care and despite the long work hours that they dedicate. The interviewees’ salaries are low and are in some cases insufficient to attend to the basic needs of their families. Of
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those interviewed, only two earned more than 1000 €/month, three earned between 500 and 900 €/month, and the rest earned between 250 and 500 €/month, with the exception of one who was unemployed and not receiving welfare benefits. Most of the women interviewed had families that financially depended on them, whether in their country of origin or in Spain. Consequently, some interviewees expressed feeling conflicted between their precarious jobs and family obligations, as they prioritize sending remittances to better their families’ situation.
are thus scarce, and the loss of psychological protection provided by the family causes great emotional upset.
It’s not what people think – here, everything I earn I send to them …
The results show that the chief determinants of SSS among immigrant women are related to objective factors of social positioning such as non-recognition of educational credentials, precarious working conditions, unemployment, and low salaries. In addition, psychosocial factors related to immigrant experiences may be negatively influencing perceptions of their social positioning, including discrimination, lacking social support and unfulfilled expectations of life in Spain. All of these factors have been aggravated by the economic crisis that Europe has experienced since 2008 [2]. These results are congruent with other studies on SSS determinants [12, 19, 20], which show the existence of psychosocial factors related to life satisfaction, future opportunities, and financial security, and these must be considered in evaluating social positioning and health. These factors are primordially relevant among immigrant populations given their low SSS and experiences of social rejection in societies that receive them. All of the factors discussed are conditioned by the socioeconomic and political context of the Eurozone. Through this study, as in others [1, 2, 21, 22], we identified the influence of macro-structural factors (globalization, public policies, cuts to the welfare state, etc.) on individual living conditions and social positions. Economic uncertainty arising from the crisis together with austerity measures, restrictive immigration policies, and the decline of the welfare state in the European Union increasingly threaten the health of many Europeans and of the most vulnerable groups in particular [3, 23, 24]. A gradient relationship between SSS and health has been found in many studies [7, 10, 19, 25, 26]. Low SSS contributes to an increase in internal stressors, resulting in behaviors that are damaging to health. At the same time, perceptions of social inequality better predict health than absolute income levels, illustrating the importance of psychosocial factors to reducing health inequality [6]. The study results show how social determinants of health can affect SSS and how SSS can serve as a mediator between social determinants and health results. For example, unemployment, precarious labor conditions, low salaries, discrimination, or the loss of social support (social
While quality of the interviewees’ lives has worsened overall, the participants believe that their children’s lives have improved, principally from a material point of view. Beliefs held among the interviewees that they have to sacrifice their wellbeing and be held responsible for everything that happens to their family has negative effects on the women’s health.
Discrimination is Part of Daily Life All of the women, with the exception of one, expressed feeling discriminated against in Spain. Some expressed that perceptions of interpersonal discrimination have become part of daily life. The interviewees chiefly perceived these experiences in the labor environment through having their labor undervalued and poorly remunerated and in being offered fewer rights than the Spanish. There are many people who treat you badly. Why? Because you are from abroad. No matter how much education you have, you will always be the foreigner. You will always be the one they look down upon. Although all interviewees possessed a health card and had been granted free access to the Health System, they identified barriers in health care access, including barriers in communication with professionals, culture shock, and appointment times incompatible with working schedules. I experienced shock here because … well, in my country I guess they have male nurses as well, but here a male nurse treated me … this was a problem, clearly … of course, I was expecting a woman and out came a man … I have not gone back (to the office) since last year. Loneliness All of the women interviewed with the exception of one underwent the immigration process alone. Social relations
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I, for example, cried for six months without stopping. You have the weekend to relax, but I didn’t relax because I missed my children. I missed them, and didn’t even know where to go …
Discussion
J Immigrant Minority Health
determinants of health) can negatively affect perceptions of social positions while limiting people’s abilities to control their lives and achieve well-being. Thus, in improving SSS, some negative effects of Social Determinants of Health may be attenuated, improving the lives of numerous individuals and mitigating health inequality, one the most pressing issues currently facing the field of Public Health [27]. The results highlight that health professionals must focus on social determinants by evaluating questions related to income, education, employment, residence, discrimination, social support, etc. Given the effect of social perceptions on health, SSS evaluation should also be conducted, and especially for immigrants, as traditional methods (education, occupation and income) do not fully reflect their socioeconomic position. This study presents limitations related to the nature of fieldwork. The sample was obtained from organizations that deliver social services to immigrants and thus excludes women who do not use these services; this limits the study’s transferability. Further, it will be necessary to consider immigrants from non-Latin American countries in future studies. Although the study was conducted in the Spanish context, the study results are relevant to health professionals in other regions given the extension of the economic crisis throughout the Eurozone and the overall increase in inequality worldwide.
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6. 7.
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Conclusions
12.
Chief determinants of SSS coincide with social determinants of health and are conditioned by socioeconomic and political conditions. Globalization, the economic crisis, neoliberal policies that are being adopted in Europe, and other structural factors reinforce social stratification by class, gender and ethnicity, affecting the quality of life of immigrants. Corresponding interventions should address policies at the local, national and global level. At the same time, interventions must focus on improving SSS trends to limit the negative effects of Social Determinants of Health and health inequality. Future investigations must identify intervention approaches that effectively increase SSS and that address SSS and Social Determinants of Health trends in different communities. Conflict of interest
None.
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References 19. 1. International Organization for Migration. World migration report 2013: Migrant well-being and development—the seventh report
in IOM’s World migration report (WMR) series. 2013. http:// www.iom.int/cms/wmr2013. Mladovsky P, Rechel B, Ingleby D, McKee M. Responding to diversity: an exploratory study of migrant health policies in Europe. Health Policy. 2012;105(1):1–9. Rechel B, Mladovsky P, Ingleby D, Mackenbach JP, McKee M. Migration and health in an increasingly diverse Europe. Lancet. 2013;381(9873):1235–45. Royal decree—law 16/2012 of April 20, on urgent measures for guaranteeing the sustainability of the National System of Health and improving the quality and safety of it is services (in Spanish). http://www.boe.es/boe/dias/2012/04/24/pdfs/BOE-A-2012-5403. pdf. Davies A, Basten A, Frattini C. Migration: A social determinant of the health of migrants. 2006. http://ec.europa.eu/ewsi/UDRW/ images/items/docl_9914_392596992.pdf. Marmot M. Status syndrome. A challenge to medicine. JAMA. 2006;295(11):1304–7. Adler N, Stewart J. Health disparities across the lifespan: meaning, methods, and mechanisms. Ann N Y Acad Sci. 2010;1186:5–23. Adler N, Singh-Manoux A, Schwartz J, Stewart J, Matthews K, Marmot M. Social status and health: a comparison of British civil servants in Whitehall-II with European- and African-Americans in CARDIA. Soc Sci Med. 2008;66(5):1034–45. Wolff LS, Subramanian S, Acevedo-Garcia D, Weber D, Kawachi I. Compared to whom? Subjective social status, selfrated health, and referent group sensitivity in a diverse US sample. Soc Sci Med. 2010;70(12):2019–28. de Castro AB, Gee GC, Takeuchi DT. Examining alternative measures of social disadvantage among Asian Americans: the relevance of economic opportunity, subjective social status, and financial strain for health. J Immigr Minor Health. 2010;12(5): 659–71. Adler N, Stewart J. The MacArthur scale of subjective social staus. 2007. http://www.macses.ucsf.edu/research/psychosocial/ subjective.php. Singh-Manoux A, Adler N, Marmot MG. Subjective social status: its determinants and its association with measures of ill-health in the Whitehall II study. Soc Sci Med. 2003;56(6):1321–33. Singh-Manoux A, Marmot M, Adler N. Does subjective social status predict health and change in health status better than objective status? Psychosom Med. 2005;67(6):855–61. Sancho´n-Macias MV. Influence of subjective social status on the health of Latin American immigrant women residing in the Community of Cantabria (in Spanish). Doctoral thesis. University of the Balearic Islands, Spain. 2013. http://www.tesisenred.net/ handle/10803/97301. Strauss A, Corbin J. Bases of qualitative research: techniques and procedures for developing grounded theory. Colombia: Universidad de Antioquia; 2002 (in Spanish). Caldero´n C, Fernandez de Sanmamed MJ. Qualitative research in primary care. In: Martin ZA, Cano PJF, editors. Primary care: concepts, organization, and clinical practice. 6th ed. Barcelona: Elsevier; 2008. p. 211–40 (in Spanish). National Institute of Statistics. Basic demographic indicators. Series 2002–2011. Data valid until 18 June 2013 (in Spanish). Spain. http://www.ine.es/daco/daco42/idb/idb.htm. Sancho´n-Macias MV, Prieto-Salceda D, Bover-Bover A, Gastaldo D. Relationship between subjective social status and perceived health among Latin American immigrant women. Rev Lat Am Enfermagem. 2013;21(6):1353–9. Operario D, Adler N, Williams D. Subjective social status: reliability and predictive utility for global health. Psychol Health. 2004;19(2):237–46.
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J Immigrant Minority Health 20. Franzini L, Fernandez-Esquer M. The association of subjective social status and health in low-income Mexican-origin individuals in Texas. Soc Sci Med. 2006;63(3):788–804. 21. Cundiff JM, Smith TW, Uchino BN, Berg CA. Subjective social status: construct validity and associations with psychosocial vulnerability and self-rated health. Int J Behav Med. 2013;20(1):148–58. 22. Labonte´ R, Schrecker T. Globalization and social determinants of health: promoting health equity in global governance (part 3 of 3). Glob Health. 2007;3:7. 23. Navarro V. Neoliberalism as a class ideology; or, the political causes of the growth of inequalities. Int J Health Serv. 2007;37(1):47–62.
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24. Guruge S, Khanlou N, Gastaldo D. Intimate male partner violence in the migration process: intersections of gender, race and class. J Adv Nurs. 2010;66(1):103–13. 25. World Health Organization. World conference on social determinants of health. Closing the gap: policy into practice on social determinants of health. 2011. http://www.who.int/sdhconference/ discussion_paper/en/. 26. Benach J, Muntaner C, Tarafa G, Valverde C. Social services are on sale and so is our health. Barcelona: Icaria; 2012 (in Spanish). 27. Corte´s I, Gonzalez B. The economic-financial crisis and health in Spain. Evidence and viewpoints. SESPAS report 2014. Gac Sanit. 2014;28(Suppl 1):1–6 (in Spanish).
ORIGINAL PAPER
Determinants of Subjective Social Status and Health Among Latin American Women Immigrants in Spain: A Qualitative Approach Ma Visitacio´n Sancho´n-Macias1 • Andreu Bover-Bover2 • Dolores Prieto-Salceda3 Marı´a Paz-Zulueta1 • Blanca Torres1 • Denise Gastaldo4
•
Springer Science+Business Media New York 2015
Abstract This qualitative study was carried out to better understand factors that determine the subjective social status of Latin Americans in Spain. The study was conducted following a theoretical framework and forms part of broader study on subjective social status and health. Ten immigrant participants engaged in semi-structured interviews, from which data were collected. The study results show that socioeconomic aspects of the crisis and of policies adopted have shaped immigrant living conditions in Spain. Four major themes that emerged from the analysis were related to non-recognition of educational credentials, precarious working conditions, unemployment and loneliness. These results illustrate the outcomes of current policies on health and suggest a need for health professionals to orient practices toward social determinants, thus utilizing evaluations of subjective social status to reduce inequalities in health. Keywords Social class Subjective social status Immigration Social determinants of health Healthcare disparities Qualitative research
& Ma Visitacio´n Sancho´n-Macias [email protected] 1
Departamento de Enfermerı´a, Escuela de Enfermerı´a, Universidad de Cantabria, Avda de Valdecilla s/n, 39008 Santander, Spain
2
Department of Nursing, University of Islas Baleares, Carretera de Valldemossa, km 7.5, 07122 Palma de Mallorca, Spain
3
Observatorio de Salud Pu´blica de Cantabria, Avda de Valdecilla s/n, 39008 Santander, Spain
4
Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, Canada
Background Current conditions of socioeconomic globalization have done much to potentiate the intensity of migration in several countries [1]. However, immigration is not considered in the development objectives of the millennium nor is it a systematic object of national development plans [2]. With many countries in economic crisis, among them, Spain, labor conditions have worsened, immigration policies have become more rigid, and social and health services have been restricted [3, 4]. These circumstances chiefly affect immigrants from low- and medium-income countries, 35 % of which occupy the poorest quintile of the income distribution, leading to an increase in health inequality [5]. The importance of socioeconomic status (SES) to human health is widely documented in the scientific literature. The social gradient in health, which has been reflected in numerous countries, indicates that as one descends in social position, progressive deterioration in health occurs [6, 7]. Examining this gradient has generally involved applying SES, which measures education and income levels and occupations. However, to determine the effect of social position on health, objective SES data are not sufficient. Rather, one must also consider perceptions of an individual regarding his or her position in society, which is known as subjective social status (SSS) [8, 9]. SSS considers social and psychological factors that SES does not account for. For example, factors derived from immigration contexts (stigma, discrimination, lack of opportunities, etc.) may be more central to determining social positions than objective data. If only objective data are taken into account, negative effects of social disadvantage on health may be undervalued [10].
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J Immigrant Minority Health
was achieved when no new significant themes were identified. The following inclusion criteria were used: women born in Latin America, because it is the largest group of immigrants in the region [17], in working age (16–65 years), with work experience in Spain. Participants were found through social-health centers and associations that provide services to immigrants. The data were collected by the first author (a PhD candidate who was trained in qualitative research methods) through semi-structured in-depth interviews. The interviews took place at the women’s place of residence. The study was carried out from 2010 to 2012.
A large body of quantitative research relates SSS to health outcomes. These studies show that SSS is related to low self-perceptions of health, higher mortality, depression, cardiovascular risk, diabetes, and respiratory disease [11]. Some authors note that SSS affects health outcomes to a greater degree than SES [12, 13]. Qualitative studies on factors that shape SSS among immigrants and their relation to health are needed. The purpose of this study was to identify determinants of social position identified by a group of Latin American immigrant women residing in Spain and to describe contextual factors that influence their social position and health. Study results were generated as part of a broader study on the influence of SSS on the health of immigrant women [14]. These determinants will help health professionals identify contextual factors that negatively affect health and thereby design interventions for reducing health inequality among the most disadvantaged groups, as in the case of immigrants.
Measures Health and demographic data were obtained prior to the interviews. The following subjects were explored: immigration process, socioeconomic situation, SSS, and perceptions of health (guide interview available on request). The interviews were recorded, registered twice, and then transcribed verbatim. Interviews were conducted until data saturation was achieved, and each interview lasted an average of 1 h. Finally, after documents were reviewed to ensure content veracity, other observations on the non-verbal behaviors of the interviewees were incorporated, including de tone of participant’s voices, their facial expressions and their body postures. This provided important contextual data which informed the analysis.
Methods Design and Samples A qualitative investigation was conducted following procedures of grounded theory in a region of northern Spain. This is the most effective methodology for identifying individual perceptions [15]. The sample included 10 women who were selected following a strategy of purposeful sampling [16]. The sampling method was theoretical and sought variation in features that can affect social position, including age, educational level, salary, employment activity, perceptions of social positioning and health (see Table 1). Data were collected until data saturation was achieved. Data saturation was assured during the analysis phase. It
Analysis The analysis was conducted in an open, circular and dynamic manner [15]. Once the interviews were transcribed, they were reviewed to identify the most relevant themes
Table 1 Qualitative samples: description of participants Interviewees
Place of residence
Age
Educational level
Salary (€/month)
Employment activity
1. Colombia
Santander
44
University
499
Immigration project advisor
4
Regular
2. Peru 3. Bolivia
Santander Santander
43 24
University Technical instruction
1230 250–499
Domestic worker (various duties) Student and caretaker PTW
4 3
Regular Regular
4. Ecuador
Santander
41
Technical instruction
500
Caretaker (PTW)
7
Regular
5. Paraguay
Santander
40
Secondary
1000
Domestic worker (internal)
1
Regular
6. Ecuador
Colindres
40
Technical instruction
Unemployed
5
Good
7. Paraguay
Herrera
53
Secondary
1490
Domestic worker (internal)
7
Good
8. Colombia
Torrelavega
55
Secondary
1000
Volunteer geriatric assistant
6
Regular
9. Peru
Santander Malian˜o
54
Secondary
250–499
Domestic worker (various duties)
6
Good
35
Secondary
1000
Domestic worker (internal)
2
Regular
10. Ecuador
SSS subjective social status, PH perceived health, PTW part time work
123
SSS
PH
J Immigrant Minority Health
that had emerged in relation to principal determinants of SSS. The most significant sections of text were marked and coded based on the study objectives and following the method proposed by Strauss and Corbin [15]. These codes were then refined and assigned to previously established categories based on a review of existing literature. All interview segments that related to the designated subjects were then examined to identify how central themes interacted. This procedure was repeated until a pattern emerged from the data that allowed for the identification of SSS determinants. The ATLAS.ti software program was used to codify and arrange the data. To ensure validity and methodological rigor, researcher, data, method and source triangulation was employed [16]. The results obtained were shared with the interview participants (immigrants) to verify the findings. Information was triangulated by three researchers from other universities, including two socio-health center professionals and one professional responsible for an immigrant program. Method triangulation was carried out with the use of quantitative methodologies (published elsewhere) [18]. Finally, data were triangulated with scientific literature and official database results. Clinical Research Ethics Committee of Cantabria approval of the research protocol was obtained before data were acquired on September 4, 2009. Patient records were de-identified prior to the analysis. Participants received oral and written information on the study purpose, objectives and content. All participants signed letters of consent, confirming that they were informed of the study parameters. The participants were guaranteed anonymity and the opportunity to leave the study at any time.
Results A total of 10 women between 24 and 55 years of age participated in the study. All participants had lived in Spain for longer than 1 year and had been employed for at least 6 months of this time. All held high school diplomas, and four held a university degree. One participant had completed postgraduate studies in Spain, and the rest had not completed their degrees in Spain. Participant salaries varied between 250 and 1490 €/month. One participant was unemployed, one worked as a psychologist, one was a student of nursing, and the other seven women were employed as domestic workers (cleaners and caretakers for children or dependent persons). Three of the interviewees lived alone with the persons who had hired them as fulltime caretakers, and the other four worked hourly as cleaners or caretakers. The participants had emigrated from five different Latin American countries. Two were in an irregular situation at the time of the interview.
Determinants of SSS Identified by Immigrant Women The results indicate that women experience a series of problems related to socioeconomic and political issues that shape their opportunities and living conditions in Spain. Chief determinants of SSS found are related to non-recognition of educational and professional credentials, precarious labor conditions, unemployment, discrimination, and loneliness. ‘‘This is Not What They Said to Me’’ The women’s expectations had not been fulfilled. While the interviewees had hoped to earn and save money to send to their families and to begin future projects, they came across a different reality. While the women’s educational levels were either medium or high, their labor opportunities have been limited as they have faced barriers in validating foreign degrees or broadening educational credentials in Spain. Only one interviewee had succeeded in registering her degree after considerable effort. Having to study in order to register my degree … please … eight subjects in some disciplines I had never seen … it was a huge amount of work. Precarious Work and Low Salaries The interviewees explained that they cannot complain about their working conditions because they need to work and fear termination. They are aware of the current economic crisis and feel disadvantaged by limited work opportunities. I complain, I say it … but what do they say? That if I don’t like it, leave, because there is plenty of work; because I accepted this job, and I agreed to work for 24 hours, not the hours that I feel like working. Well, OK, perfect … I accept it. The women work as both caretakers and homemakers. They find this work stressful, with long days of work, and receive little support from family members of the persons whom they care for. I can’t because I am here 24 hours a day and then I cannot go out unless someone comes … The women feel that the families they work for ascribe low value to their work despite responsibilities they are afforded in senior care and despite the long work hours that they dedicate. The interviewees’ salaries are low and are in some cases insufficient to attend to the basic needs of their families. Of
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those interviewed, only two earned more than 1000 €/month, three earned between 500 and 900 €/month, and the rest earned between 250 and 500 €/month, with the exception of one who was unemployed and not receiving welfare benefits. Most of the women interviewed had families that financially depended on them, whether in their country of origin or in Spain. Consequently, some interviewees expressed feeling conflicted between their precarious jobs and family obligations, as they prioritize sending remittances to better their families’ situation.
are thus scarce, and the loss of psychological protection provided by the family causes great emotional upset.
It’s not what people think – here, everything I earn I send to them …
The results show that the chief determinants of SSS among immigrant women are related to objective factors of social positioning such as non-recognition of educational credentials, precarious working conditions, unemployment, and low salaries. In addition, psychosocial factors related to immigrant experiences may be negatively influencing perceptions of their social positioning, including discrimination, lacking social support and unfulfilled expectations of life in Spain. All of these factors have been aggravated by the economic crisis that Europe has experienced since 2008 [2]. These results are congruent with other studies on SSS determinants [12, 19, 20], which show the existence of psychosocial factors related to life satisfaction, future opportunities, and financial security, and these must be considered in evaluating social positioning and health. These factors are primordially relevant among immigrant populations given their low SSS and experiences of social rejection in societies that receive them. All of the factors discussed are conditioned by the socioeconomic and political context of the Eurozone. Through this study, as in others [1, 2, 21, 22], we identified the influence of macro-structural factors (globalization, public policies, cuts to the welfare state, etc.) on individual living conditions and social positions. Economic uncertainty arising from the crisis together with austerity measures, restrictive immigration policies, and the decline of the welfare state in the European Union increasingly threaten the health of many Europeans and of the most vulnerable groups in particular [3, 23, 24]. A gradient relationship between SSS and health has been found in many studies [7, 10, 19, 25, 26]. Low SSS contributes to an increase in internal stressors, resulting in behaviors that are damaging to health. At the same time, perceptions of social inequality better predict health than absolute income levels, illustrating the importance of psychosocial factors to reducing health inequality [6]. The study results show how social determinants of health can affect SSS and how SSS can serve as a mediator between social determinants and health results. For example, unemployment, precarious labor conditions, low salaries, discrimination, or the loss of social support (social
While quality of the interviewees’ lives has worsened overall, the participants believe that their children’s lives have improved, principally from a material point of view. Beliefs held among the interviewees that they have to sacrifice their wellbeing and be held responsible for everything that happens to their family has negative effects on the women’s health.
Discrimination is Part of Daily Life All of the women, with the exception of one, expressed feeling discriminated against in Spain. Some expressed that perceptions of interpersonal discrimination have become part of daily life. The interviewees chiefly perceived these experiences in the labor environment through having their labor undervalued and poorly remunerated and in being offered fewer rights than the Spanish. There are many people who treat you badly. Why? Because you are from abroad. No matter how much education you have, you will always be the foreigner. You will always be the one they look down upon. Although all interviewees possessed a health card and had been granted free access to the Health System, they identified barriers in health care access, including barriers in communication with professionals, culture shock, and appointment times incompatible with working schedules. I experienced shock here because … well, in my country I guess they have male nurses as well, but here a male nurse treated me … this was a problem, clearly … of course, I was expecting a woman and out came a man … I have not gone back (to the office) since last year. Loneliness All of the women interviewed with the exception of one underwent the immigration process alone. Social relations
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I, for example, cried for six months without stopping. You have the weekend to relax, but I didn’t relax because I missed my children. I missed them, and didn’t even know where to go …
Discussion
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determinants of health) can negatively affect perceptions of social positions while limiting people’s abilities to control their lives and achieve well-being. Thus, in improving SSS, some negative effects of Social Determinants of Health may be attenuated, improving the lives of numerous individuals and mitigating health inequality, one the most pressing issues currently facing the field of Public Health [27]. The results highlight that health professionals must focus on social determinants by evaluating questions related to income, education, employment, residence, discrimination, social support, etc. Given the effect of social perceptions on health, SSS evaluation should also be conducted, and especially for immigrants, as traditional methods (education, occupation and income) do not fully reflect their socioeconomic position. This study presents limitations related to the nature of fieldwork. The sample was obtained from organizations that deliver social services to immigrants and thus excludes women who do not use these services; this limits the study’s transferability. Further, it will be necessary to consider immigrants from non-Latin American countries in future studies. Although the study was conducted in the Spanish context, the study results are relevant to health professionals in other regions given the extension of the economic crisis throughout the Eurozone and the overall increase in inequality worldwide.
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Conclusions
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Chief determinants of SSS coincide with social determinants of health and are conditioned by socioeconomic and political conditions. Globalization, the economic crisis, neoliberal policies that are being adopted in Europe, and other structural factors reinforce social stratification by class, gender and ethnicity, affecting the quality of life of immigrants. Corresponding interventions should address policies at the local, national and global level. At the same time, interventions must focus on improving SSS trends to limit the negative effects of Social Determinants of Health and health inequality. Future investigations must identify intervention approaches that effectively increase SSS and that address SSS and Social Determinants of Health trends in different communities. Conflict of interest
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