1. Paul Dourgnon*, Yasser Moullan** * Institute for Research and Information in Health Economics (IRDES), France **University of Oxford

2.  Research framework and programme  Immigration, health and Social inequalities ◦ What do we know about migrants health? ◦ Why studying Obesity?  Data and Methods  Results and conclusions

3.  From research on Social Health Inequalities to the study of immigrants health and access to health care  The Eunam project: EU and North African Migrants: Health and Health Systems http://www.dkfz.de/en/molgen_epidemiology/EUNAM/EUNAM.html ◦ EU FP7 project 2011-2015 ◦ Pluridisciplinary, North and South Mediterranean teams

4.  Focus on overweight (OW) and obesity  A study of the differences in OW due to the country of arrival and/or the country of origin (Aculturation? Selection effects?)  An investigation on social inequalities in OW among immigrants groups in France, imported? Acquired? Specific?

5. Migration - Selection - Acculturation - Language gap - Isolation and Loss of Social Networks - Specific impact of SES (Human capital transferability, lower reservation wages, discrimination) - Access to Health System information - Indirect impact through access to job market, education, health care (…) due to legal context - Interaction with Public services Access to rights Medical interaction Country of Origin Economic, Social situation Health and Health system Health behaviors and cultural dimensions Host Country Access to health, to care, to insurance, to information Social and economic situation Working conditions Deprivation

6.  ( Khlat, Sermet, Laurier, 1998) : Migrants from Maghreb have better health status  (Mizrahi, Mizrahi, Wait, 1993) Better Health status in foreign immigrants, Worse Health Status in naturalized immigrants  (Attias-Donfut,Teissier, 2005 ) Worse health status among ageing migrants, health status negatively correlated with duration of stay Differences according to country of birth (Worse among southern Europe and Maghreb migrants vs. other migrants, better among Northern Europe and sub-Saharan migrants)²  Differences according to country of birth Worse among Europeans, better among non European (Lert, Melchior, Ville, 2007) According to country of origin GDP and HDI (Jusot, Dourgnon, 2011)

7.  A global Issue ◦ Increase in obesity prevalences ◦ Impact on health ◦ Impact on health systems sustainability  Strong Social gradients ◦ Low income countries (Monteiro, 2004):  Under-nutrition among the poor  Overweight more frequent among the whealthiest ◦ High income countries:  OW more frequent among the less well off  Less frequent among the healthiest  -> Education, occupation, labour force status (Marmot and Wilkinson 1999, Dunn and Dyck 2000, Cawley 2004)

8.  Do we observe differences in OW between migrants and natives?  If so are these differences explained by diferences in ◦ Demographics ? ◦ SES ?  And/or by factors linked to migration?  Selection effect?  Aculturation effect ? (Length of stay)  Origin country characteristics (GDP, HDI)  Destination country  Implications for public policies

9.  Econometric multivariate modelling : aiming at identyfying differences according to migration status controlling for differences in age, gender, SES;  Migration status:  Immigrants vs. natives  Naturalized vs. foreigners  According to the country of origin  Broad region (Europe, North Africa, Sub- saharan Africa,…)

10.  Self-reported measurement  Overestimation of height and underestimation of weight  Gender bias  Alternative measures but difficult to collect  WHO classification of BMI  Underweight⇒BMI<18,5  Normal ⇒ 18,5≤BMI<25  Overweight ⇒ BMI≥25  Pre-obese⇒ 25≤BMI<30  Obese⇒ BMI≥30

11.  General population (“ordinary households”)  Immigrants participation ◦ Langage ◦ Willingness to participate to surveys  Sample sizes  Self assessment bias  Information migration status

12. France: ESPS (IRDES) ◦ 3 waves:  2006, 2008 and 2010 ◦ 15,384 individuals ◦ 1,281 immigrants (8%)  Foreigners: 652 (51%)  Naturalized: 629 (49%) Spain: Encuesta Europea de Salud en Espana ◦ 2 waves:  2006/2007 and 2009 ◦ 38,200 individuals ◦ 3,563 immigrants (9%)  Foreigners: 2,705 (76%)  Naturalized: 858 (24%) Cross sectionnal dataset over 2 European countries:

13. Descriptive statistics Multivariate analysis

14.  France: Immigrants are more overweighted than natives  Spain: Immigrants are less overweighted than natives  Naturalized are closer to the natives  Women: North Africans and Sub-Saharans are more overweighted as compared to others immigrants

15. Table 2: Probit estimation of overweight prevalence for immigrants vs natives Table 3: Probit estimation of overweight prevalence for foreigners and naturalized immigrants vs natives

16. FRANCE - No "Healthy immigrant effect" SPAIN - "Healthy immigrant effect" among men - Long-established immigrants  Aculturation process (women) - « New » immigrants  Selection effect Men

17. Table 4: Probit estimation of overweight prevalence according to country of origin Effects of the country of origin

18. Effects of OW in the country of origin (1)

19. Effects of OW in the country of origin (2)

20.  Immigrant effect  Female are relatively more overweighted than men  Healthy immigrant effect for men in Spain only  « Assimilation effect » in France vs « Selection effect » in Spain  Decomposition effect  Difference in characteristics in Spain for women  Difference in coefficients in France  Country of origin  North African women are more overweighted than natives  Latin American women more overweighted than natives  Differences remain related to origin and destination countries Some conclusions

21.  OW mostly in women immigrants  And mostly among NA (France) and Latinas (Spain)  Aculturation in France vs. selection effect in Spain (?!)  No clear effect of HDI, GDP or Obesity prevalence in the country of origin

22.  Still in progress  No sufficient information on the length of stay  Need more destination countries