This study on the determinants of health and access to health services of the population Cantabria immigrant represents the first analysis of this kind conducted in our region with the aim to analyze and correct any disparities in health in this population. Multiple analysis from quantitative and qualitative methodologies was conducted in 2007 to
The study offered opportunity to investigate the perceptions and attitudes of all the diversity of participants who have troubled and provided possible solutions with specific recommendations and open questions seeking opportunities for dialogue and negotiation. At the same time has allowed us to explore and exploit the available sources of secondary information according to the potential. In this sense, we have found limitations to the quantitative analysis on the one hand due to the variability in terms of definitions and classification of foreign or immigrant status of the various secondary sources, as well as insufficient information to analyze the differences between groups. These conditions hamper the comparability between sources forced to redefine criteria for grouping data to facilitate analysis by region and country of origin. Moreover, the lack of representation of immigrant groups in the surveys at regional level hinders the understanding of issues relevant to health and living conditions of the immigrant population. Therefore, in the absence of information on the subject, this project decided to extend the qualitative research to have a greater diversity of actors involved to bring depth and multiple analysis.
The phenomenon of immigration begins to become important in Cantabria from 2000, reaching 6.5% of the total population in early 2009, even at a distance numbers and problems in relation to other regions. In this respect, the different actors involved in the study differ in their perception of the presence of the immigrant population in Cantabria, considering on one hand the health professionals and system administrators that there are still few immigrants in our region, while the very people and immigrant associations perceive the presence and numbers. However, when making projections looking both agree that the challenge now the immigrant population in Cantabria can be a problem, as in other regions, if not act in time.
Otherwise, the advantage brought by the different participants interviewed, including staff sector health system, compared to other regions with the highest burden of immigrants , is to learn from their experiences, anticipating problems through timely interventions. The speeches of the participants in the study agree well with that Focus on the presence of immigrants has shown some old flaws and needs of the system, thus making this new challenge into an opportunity to improve quality care for all the diversity of the population of Cantabria.
The immigrant population is initially perceived by the sector of health professionals as a heterogeneous group, which would be consistent with the recognition of the diversity that makes of immigrants on their own collective. However, public speeches constantly refer to people immigrants as a "whole", while they show that they are treated as such, without the public sector come to understand the differences in scale between the various immigrant groups.
Addressing inequalities in health of the immigrant population also puts into sharp focus the need for research on the determinants of health, with the difficulties and challenges that entails. We found one of the most important determinants of health and quality of life of the immigrant population is housing, which is accessible a major challenge because of the requirements for procurement, which even though some of them common to the indigenous population, mean greater difficulty for the immigrant population, as well as meet other requirements added by their immigration status. On the other hand, housing is an essential requirement for the registration, which in turn is essential to get
Moreover, and consistent with other studies in Spain, has been in the data presented in this report that immigrants on the one hand have a level of educated than the general population, and secondly, those with TSI, make similar use of emergency medical services and hospitalization indigenous people, except for income from obstetric reasons. The same study participants expressed the need to disseminate accurate information regarding the skills and capabilities of the immigrant population, as well as actual data disclose the use of services among the general population and among health professionals in particular, to remove the preconceived ideas for many people and professionals, based on myths or urban legends that have echoed some of the media and have been repeated through the popular tradition.
Regarding employment status, women generally have a rate of unemployment than men and contribute more to the economy, primarily through the work of caregivers in households Cantabria. In this sense there is a very common condition, mainly among women, with an average level of education and university perform tasks for which, although not trained, are over qualified, as are most common for the care of elderly or dependent. Ultimately this work creates problems of low self-esteem and frustration at not being able to satisfy their expectations for improvement.
The various stakeholders interviewed, immigrant groups, social agencies and health system staff make significant contributions throughout the study as to the health needs of immigrants, disagreeing and agreeing on some other, although from heterogeneous, as has been addressed. These discrepancies and conflicting optical provoke tensions between the various cultures of different immigrant groups with their particular needs and culture of the health system and its professionals, determined in part by its own rules and rhythms imposed by the administration.
The first substantive issue in terms of impact on their health and living conditions that refer to the immigrants is continuous, as we have seen, the migration process. The diversity of backgrounds and socio-economic conditions of immigrants through their migratory routes marked by its possibilities and priorities in the recipient country and region. The degree of temporality or continuity in the same stores also directly proportional to their level of integration into the new society. The difficulties experienced by immigrants in this process and alienation, as opposed to the concept of integration, which can be derived of it undoubtedly has an effect on their mental health.
The migration process is therefore in the view of the various social, as inseparable from the health of people who migrate. By contrast, the health professionals perceived as distinct, not going to discuss the possible psychosocial impact on their patients, and thus considering a health care problem. This lack of psychosocial view of an important part of professional health system is constructed as a Gordian knot that debate on both immigrant and social institutions, emphasizing the importance of building a model that responds to the need for comprehensive care claiming the immigrants from a biopsychosocial perspective on health care compared to the dominant biomedical model.
Both immigrant associations and immigrant women are not considered associated with mental health and occupational health (both seen as closely related) as their major health problems, prioritizing the need for more health coverage in this regard. On the other hand, social institutions, and especially the trade unions highlight the influence of working conditions on mental health, while in the speeches of health professionals working conditions appear more as influencing the relationship of immigrants with the health system. However, despite not specifically relate to mental health, the professional sector stands out as the main demands of the immigrant population visits the consequences of work, such as accidents and osteo-articular problems in men, and derivatives work associated with child care, dependent elderly and in women.
also because of what the immigrants, mainly women, perceive the system as little attention to psychosocial factors of health, identifies the major difficulty in the doctor-patient relationship. Social institutions by their more affected side interaction with staff of health centers primary care, in the instance of the counter where you take the first approach to the health system. Consideration, both by the immigrants as associations, more impersonal treatment in their countries of origin raises the importance of the influence health systems of reference of the immigrant population in their perception of English health model and to a greater or lesser acceptance or rejection. In sum, while immigrants generally have a good opinion of the quality of the English health system, it gets a lower score in the subject of intercultural awareness and understanding, quality of treatment and proximity to its customers.
Moreover, the public sector see the influence of the health systems of countries of origin in the form of relationship of immigrants with the health system. The use of emergency services as "gateway" to the system, difficulties in language and communication, and scant respect to the operating rules of the system are more problems identified by health personnel.
access to health care becomes a common axis for all actors involved in the study. While immigrants and social institutions is posed in terms of difficulty in access requirements, assuming a stumbling block to the attention health professionals most perceived as easy, being in the minority who believe that there are barriers of different kinds, such as those above, would be difficult to access the system. All actors agree to note however that this represents a problem for those illegal immigrants or undocumented.
An important point of consensus among all stakeholders and practitioners interviewed, which is closely related to access to the system, the aforementioned lack of information, first people immigrants in terms of culture and structure of the health system, and other professionals as to the linguistic, ethnic and cultural diversity of immigrant groups who come to the health system, and a lack of knowledge of English legislation regarding the care to them. This suggests a mutual ignorance on which it is necessary to intervene. This match showed a series of training needs on both sides, with suggestions notable contribution to the formation of the "other", in particular, from a cultural perspective, from immigrants to health personnel.
As a result of misrepresentation is shown a plurality of answers that affects both patients and professionals, as it can demand the execution of more processes or more call time, generating a feeling of discomfort or dissatisfaction in both.
Problems of access to health care involve a deployment, in the words of all social and professional, informal strategies to address the care and service provision to the immigrant population. While such strategies vary, having more to do with the professional and institutional ownership, what is clear is the shared effort to ensure that immigrants do not go without the necessary health care. These informal channels to meet the demands leave each other with the feeling of putting "patches" that do not solve the underlying problem and does nothing to promote the quality of care and patient monitoring. Simultaneously, social organizations argue that the lack of formal policies and concrete actions results in the saturation of their organizations in the demand for services by the population immigrant and health system. Claim that in many cases manifest entities are not prepared to meet.
the end, all the agents interviewed agree on the same question: if we all make the effort and resolve through informal channels, why not do so formally? In this sense there is some consensus that the informal strategies or practices do not contribute to raising more staff, or promote the institutionalization of rules and unification of criteria. On the contrary, the promotion of "informal" contribute arbitrary maintain customized according to the possibilities and wishes of each person, which can lead to generate unrest and inequality. For this reason the general demand is greater consensus, coordination, and standardization of performance criteria and procedures.
Given this need to standardize and systematize criteria simpler procedures, we propose jointly by immigrant groups and social institutions need to adapt and flexibility to the situations of immigrants, looking than for a English person represents only an administrative process for an immigrant can be very expensive or difficult to obtain.
This approach to adaptation is more complex perspectives found in relation to who should adapt to what or whom. On the one side mainly system professionals believe are the immigrants who arrive in our community who must adapt to our lifestyle and health system. In the opposite discourse are social institutions arguing the need for the system and professionals must adapt to the unique needs of the population
Also as regards the adaptation of the health system in terms of resources, both human and technical and material to the new demands, all the agents interviewed agree on the need for progressive growth of resources as populations grow, understanding a sector of people interviewed that the current economic crisis the country (at the time of closure of this study) may slow the adaptation.
One of the formulas found by different agents interviewed, but again approached from different approaches is the need of a figure who "help" both for immigrants to make proper use of the system, as the various professional levels of care needs, improving the quality of
In sum, the recommendations made by individuals and associations immigration and social organizations covering more than macro to micro as those of professionals, ranging from the first directed at the policy level in order to cross over the entire administration (municipal and autonomous) from the following approaches:
- Promoting citizenship of immigrants from an intercultural and gender
- awareness at all levels of government
- access to both registration and the overall system
- Improve interagency coordination
- open spaces for participation by immigrant groups
In a more specific order, the recommendations of the health system include:
- universalize health card
- Promote a more comprehensive health care to improve mental health care and labor
- most professional Integrating psychology and social work in health services
- Promote intercultural training between the different professional levels, with input from the immigrant population
- Include figure mediator in intercultural health system
The recommendations of the health system staff on the other hand are more focused towards the facilitation of their professional work, while some clearly differentiated by professional groups. Generally include the following:
§ Improving information to users regarding immigrant health system
§ standardize and guarantee access to the same
§ assist with language translation and interpretation processes
§ Unify and standardize performance criteria
§ Establish monitoring protocols
§ improve coordination between levels
§ Obtain relevant information regarding aspects lifestyles of different groups of immigrants (reproduction, nutrition, etc.).
This amount of recommendations made by the different groups that have participated in this study are the product of a reflection from different and complementary visions, sometimes agreed, reflecting the different needs of each other to achieve a common goal which is to improve health care for people immigrants in Cantabria. The consensus or middle ground between the various actors and sectors should make us reflect on the need for open spaces for participation and negotiation of proposals for solutions to the problems faced by different actors. These spaces were not provided in the course of the investigation but were suggested by some participants at different times tried to visualize and understand the possible perspectives of "others."
The aim of this study help to generate relevant information about the determinants of health and greatest needs of immigrant communities living in Cantabria with the ultimate goal to encourage improvements or necessary changes in policies, plans, programs and services to ensure equity in health in our country, has been oversized by the experiences and discourses of the actors involved.
Beyond the information generated during the course of the study we have witnessed a process of opening and generated small changes in different participating agents from different ideologies and views on the phenomenon of immigration, have ventured to leave the space for thought, more comfortable and lived uncomfortably, to another of reflection, dialogue and confrontation with its own positions. Have awakened new interest and as such have started to open doors to new areas of knowledge or ignorance to which it is necessary to provide continuity. Have opened new channels of communication between actors and new needs have arisen. Thus, there has been a process of awareness in some cases, a curiosity in others, discomfort in some, but never indifference. Has begun to walk a path that can not be undertaken without the participation of all sectors involved in health
The full report is available on the website www.ospc.es OSPC in the projects section.
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