Social determinants of health from a gender perspective in Venezuelan immigrant families living in Medellin, Colombia

Resumen

El objetivo del artículo es analizar los determinantes sociales de la salud (DSS) que afectan a familias migrantes venezolanas, a partir de las percepciones y los conocimientos de mujeres inmigrantes residentes en la ciudad de Medellín, Antioquia. La investigación es de corte cualitativo, exploratorio y descriptivo. Se entrevistaron nueve mujeres inmigrantes venezolanas. Entre los DSS identificados están los referidos al contexto socioeconómico y político, donde se evidenciaron políticas públicas restrictivas que dificultan el acceso a los servicios de salud. En la posición socioeconómica se observan empleos informales con bajos ingresos y condiciones precarias, así como barreras de tipo administrativo para el acceso a servicios sociales. Existen condiciones insuficientes de habitabilidad de las viviendas y hacinamiento, además de entornos contaminados, alto consumo de SPA y situaciones de discriminación y xenofobia que afectan la salud mental de las mujeres inmigrantes y sus familias. En conclusión, los DSS deben ser analizados de forma integral y con un enfoque interseccional para garantizar la equidad en el acceso a la atención médica, proteger la salud pública y promover la integración y el bienestar de los inmigrantes.

Palabras clave: determinantes sociales de la salud, migración internacional, familia, género, salud.

Abstract

The objective of this article is to analyze the social determinants of health (SDH) that affect Venezuelan migrant families, based on the perceptions and knowledge of immigrant women residing in the city of Medellin, Antioquia. The research is qualitative, exploratory and descriptive. Nine Venezuelan immigrant women were interviewed. Among the SDH identified were those related to the socioeconomic and political context, where restrictive public policies that hinder access to health services were evidenced. In the socioeconomic position, informal jobs with low income and precarious conditions are observed, as well as administrative barriers to access to social services. There are insufficient housing conditions and overcrowding, as well as polluted environments, high consumption of PAS and situations of discrimination and xenophobia that affect the mental health of immigrant women and their families. In conclusion, the SDH should be analyzed comprehensively and with an intersectional approach to ensure equity in access to health care, protect public health and promote the integration and well-being of immigrants.

Keywords: social determinants of health, international migration, family, gender, health.

Resumo

O objetivo do artigo é analisar os determinantes sociais da saúde (DSS) que afetam as famílias migrantes venezuelanas, com base nas percepções e no conhecimento das mulheres imigrantes que vivem na cidade de Medellín, Antioquia. A pesquisa é qualitativa, exploratória e descritiva. Foram entrevistadas nove mulheres imigrantes venezuelanas. Entre os DSS identificados estavam os relacionados ao contexto socioeconômico e político, onde foram encontradas políticas públicas restritivas que dificultam o acesso aos serviços de saúde. Na posição socioeconômica, observam-se empregos informais com baixa renda e condições precárias, bem como barreiras administrativas ao acesso aos serviços sociais. Há condições insuficientes de moradia e superlotação, bem como ambientes poluídos, alto consumo de PAS e situações de discriminação e xenofobia que afetam a saúde mental das mulheres imigrantes e de suas famílias. Em conclusão, os DSS devem ser analisados de forma abrangente e com uma abordagem interseccional para garantir a equidade no acesso à assistência médica, proteger a saúde pública e promover a integração e o bem-estar dos imigrantes

Palavras-chave: determinantes sociais da saúde, migração internacional, família, gênero, saúde

DOI del artículo: https://doi.org/10.26620/uniminuto.inclusion.11.3.2024.31-41

Introduction

The worsening economic, social, and political situation in Venezuela has led to a humanitarian crisis that has caused more people to decide to emigrate permanently from the country. According to a statement by the European Parliament (2018), an estimated 87% of the Venezuelan population lives in poverty and 61.2% in extreme poverty.

In this context, various reports agree that Colombia has become the main recipient of migrants (World Bank, 2018). According to Migración Colombia (2024), the number of Venezuelans in December 2023 was 2,864,796, of whom 490,304 were in an irregular situation.

In this sense, migratory status is associated with social vulnerability and specific migratory variables, known as social determinants of health (SDH), that is, the dimensions related to how people live, work, or study, which can affect their health (Valentine et al., 2006). SDH include macroeconomic aspects—politics and culture—intermediate variables related to social status in a population, and individual factors—lifestyle, genetic predisposition, and housing conditions (Cabieses et al., 2017). A country’s health system is also a DSS, in terms of access opportunities and the effective use of benefits in a differentiated manner according to socioeconomic status (Valentine et al., 2006).

It should be clarified that migration does not necessarily imply a health risk. The conditions encountered during the migration process expose people to greater risks and increase their biological, social, psychological, economic, and cultural vulnerability, bearing in mind that most migrants are young and healthy (IOM, 2020). However, far from their cultural, family, and community contexts, and sometimes due to conditions imposed by their destination communities, migrants often change their behavior and adopt new practices, take on new risks to their sexual and reproductive health (Restrepo, 2017), may be more vulnerable to alcoholism and drug use (Restrepo and Villegas, 2023), suffer changes in their diet, and are forced to remain in spaces without adequate sanitation, drinking water, among other things. Migrants are also unaware of their rights, which maximizes their fear of the authorities, employers, and society in general, thus allowing exploitation and discrimination (IOM, 2020).

The Venezuelan migrant population in Colombia has specific characteristics that must be considered in order to address their health needs. According to Profamilia (2020), “the Venezuelan migrant and refugee population arrives in Colombia with unmet health and education needs that exceed the existing social support structures, including the health system and public and private institutions” (p. 15). These characteristics are compounded by intermediate determinants that generate health inequalities, such as income, since 65% of migrants (especially those in an irregular situation) earn less than the minimum monthly wage and 11% have been victims of labor exploitation (Ministry of Health and Social Protection, 2019).

In terms of social status, the monthly income of Colombian nationals was 60% higher than that of the Venezuelan population (National Statistics Department [DANE], 2019). Additionally, there are intermediate determinants that can be grouped into material circumstances (housing conditions, availability of food, work, education, and health services); biological factors; and behavioral, psychosocial, and cultural factors—habits and lifestyles—(Ministry of Health and Social Protection, 2012). These DSS influence the fact that “Venezuelan migrants face several health problems, including mental health issues, difficulties in effectively accessing the health system—which would be serious in the case of patients with chronic diseases—food insecurity, and sexual exploitation” (Fernández and Luna Orozco, 2018, p. 1).

In summary, some studies comparing ethnic populations and migrant populations have shown that there are disparities in health and disease between these groups and the general population (Glenday et al., 2006; Goulão et al., 2015; Kumar et al., 2006). Consequently, immigrants tend to rapidly acquire chronic disease patterns from the host country and have higher mortality and morbidity rates linked to nutrition-related diseases in their countries of origin (Alarcão et al., 2020), where DSS have a direct influence.

Methodology

The study aimed to analyze DSS from a gender perspective in Venezuelan immigrant families residing in the city of Medellín, for which a qualitative, exploratory, and descriptive research design was developed. Semi-structured interviews were used as a qualitative research technique. Atlas.ti software was used to organize and analyze the content of the interviews. The study sample was intentional and non-probabilistic, and did not respond to a strict question of design and planning, but rather to the fact of considering the saturation of the information collected (Ortega-Bastidas, 2020) based on depth, privileging quality over quantity.

Regarding ethical considerations, an informed consent form was drawn up that provided participants with accurate information about the objectives and scope of the research and the potential benefits and risks of participating in it, as well as aspects related to the confidentiality and anonymity of the information. The research was approved by the UNIMINUTO Regional Research Ethics Committee, Antioquia-Chocó section.

Results and Discussion

Employment and Economic Income

Incomes are below the minimum monthly wage, which can affect people’s access to a balanced diet, quality housing, and private services. The IOM (2021) mentions that, normally, irregular migrants can only access jobs that violate their labor and health rights. These jobs are characterized by long working hours, low wages, and no social protection. This situation leads migrants to seek employment in sectors of the economy such as commerce (including restaurants and hotels), agriculture (various branches of traditional agricultural production), and construction (Guzmán, 2014).

If there is no one to cover the costs of food and housing, being an irregular migrant is quite serious. Economic vulnerability is what most impacts health. (Interviewee 3, personal communication, September 4, 2023)

Women’s low incomes do not allow them to lead healthy lives for themselves and their families due to their income, which comes mainly from the informal sector, as irregular migration status becomes a barrier to accessing formal employment. However, informal employment contrasts with the fact that most of the women interviewed have professional or high school degrees, which should allow them to access better working conditions. Nevertheless, irregular immigration status is a limitation to accessing formal work, even though migrants have the skills and abilities to perform certain job activities. In addition, immigrant women may face a double workload as they try to balance work responsibilities with domestic and caregiving responsibilities. This can lead to stress, fatigue, and a lack of time to take care of their own health.

Education and Culture

In some cases, even when they have completed high school and university studies, as in the case of the interviewees, women often resort to self-medication and traditional or folk remedies to deal with their families’ health problems. The same has been evidenced in other studies where immigrants express “their preference for trying to solve health problems through their own means, either by using personal or family knowledge acquired through experience, or by trying out new ad hoc options” (Lamarque and Moro, 2020, p. 7).

Many self-medicate, and the other option is to find a place or care where they can be treated for free. If it is an emergency, pregnant women with advanced diabetes, advanced cancer, those people are treated, but those who are not eligible have to pay or self-medicate or find places where they can be treated for free. (Interviewee 1, personal communication, September 14, 2023)

These types of situations must be analyzed from the perspective of health trajectories or therapeutic itineraries, understood as the processes that people adopt to deal with the onset of a health problem (Sindzingre, 1985). This set of processes that families use to deal with discomfort, pain, or illness are related to their culture and the way they perceive their own lives, such that the decisions they make in the face of illness may be conscious or unconscious, autonomous or mediated by third parties. Thus, it can be said that both education and cultural aspects directly influence the strategies immigrants use in seeking health and curing diseases (Perdiguero, 2006). Elements such as cultural beliefs and habits, previous experiences in the country of origin, and personal and family expectations in the destination country come into play. In this regard, some of the interviewees referred to God as part of the healing process; they pointed to evil forces, specifically witchcraft, as the cause of illness, and in other cases, they considered that the care provided by health professionals did not meet their expectations, as it did not conform to the standards they were accustomed to in Venezuela. All the above highlights the complexity of the health sector in a migration context, as personal, social, cultural, and institutional factors will be decisive in the health conditions of immigrants.

Health Services

Lack of access to timely medical care can hinder the diagnosis and treatment of diseases, as well as increase the risk of complications and uncontrolled chronic diseases. Lack of access to preventive health services can affect the ability to maintain good health in the long term (WHO, 2008). For women, maintaining their physical and mental well-being in terms of sexual and reproductive health should be considered a priority.

The interviewees believe that health services in Colombia are not provided efficiently and, as a result, they resort to other ways of solving their health problems. Sometimes they consult a pharmacist or pay for an appointment with a private doctor, if they have sufficient financial resources.

I haven’t had any trouble accessing healthcare, but if the healthcare system doesn’t treat us, we can always go to the pharmacy and buy medicine. Also, it takes a long time to get an appointment, both for Colombians and Venezuelans. It’s better to go to private doctors. (Interviewee 6, personal communication, September 13, 2023)

Consequently, Venezuelan immigrants do not regularly use health services in Colombia. Instead, the family takes charge of diagnosing, treating, and curing illnesses that may affect its members, depending on the severity of the condition and their economic, social, and individual resources. “The family represents the only possible space for intervention in health, giving its caregiving functions an even more important value than formally established or professionalized systems” (Haro-Encias, 2000, cited in Lamarque and Moro, 2020, p. 8).

Family healthcare processes depend on the family’s own dynamics and the resources it has available to deal with illness. It should be noted that women in the household are responsible for caring for other members when they fall ill, and it is they who are familiar with the administrative processes for accessing healthcare services or who have traditional knowledge for treating certain illnesses.

Condiciones de vida

Housing conditions are inadequate due to health problems—exposure to environmental pollution, lack of hygiene and basic sanitation—and potential risks to the safety of women and their families. In this regard, living in inadequate environments can increase vulnerability to infectious and respiratory diseases, as well as mental health problems due to stress and insecurity (Marmot and Wilkinson, 2006).

I have a neighbor who uses marijuana and smokes on his balcony, and his balcony faces my window, and obviously that smell is super harmful to my baby and to us. In terms of health, it does harm to us: it damages our lungs and makes us passive addicts. (Interviewee 3, personal communication, September 4, 2023)

Overcrowding is evident in the homes of Venezuelan immigrant families, as on average there is only one room for every four people. In some cases, there are two rooms for five people. Overcrowding is defined as when the number of occupants in a dwelling exceeds the capacity of the available space, whether measured by rooms, bedrooms, or surface area. This has negative consequences for physical and mental health (PAHO, 2022).

A home is considered “overcrowded” not only because of the number of people sharing the dwelling, but also because of their age, the relationship between them, and their gender (PAHO, 2022). Rooms are often shared by men and women of different ages—in some cases, parents and children, or other relatives or friends who have been taken in. The lack of adequate space can affect sleep quality, emotional well-being, and family interactions, which in turn can have a negative impact on the physical and mental health of women and their families (Cluter and Lleras, 2006).

I live in just one room. The bathroom, the kitchen, everything is shared; it’s a hotel with several rooms. I share with strangers. There are three floors, with about 30 rooms. (Interviewee 1, personal communication, September 4, 2023)

Overcrowding could be explained by families’ limited income, as more than half of the women participating earn less than the current legal minimum wage in Colombia, forcing them to live in homes with insufficient space for their needs. Families cannot afford a place that is in good condition and offers better living conditions.

In general, the characteristics of the homes where immigrant women live in Medellín correspond to those identified in other studies involving lower purchasing power (Martínez Veiga, 1999). The type of housing they can access is generally subdivided into rooms that can be occupied by one or more families, or by a group of people who share the rental costs (Algaba, 2003; Martínez Veiga, 1999).

Residential Environment

Migrants commonly settle in the most marginalized and vulnerable areas of cities because housing prices are much lower there due to safety, quality, and space concerns (Martínez Veiga, 1999). This leads to poor housing conditions, overcrowding, and environmental pollution.

Pollution and the small amount of trash that is thrown on the street, particularly on the hill... (Interviewee 6, personal communication, September 13, 2023)

Abeldaño et al. (2014) reveal a prevalence of alcohol and tobacco consumption among people living in geographical areas with unfavorable economic conditions, as these are often the areas most affected by violence. The use of psychoactive substances (PAS) becomes a way of coping with trauma and stress. Unfortunately, these conditions are present in the areas where the immigrant women interviewed reside, which could affect their health and that of their family members.

Social problems include the use of psychoactive substances, mainly marijuana and cocaine, which is done in full view of all children. (Interviewee 3, personal communication, September 4, 2023)

In addition, the DSS of the population involve environmental conditions, mainly pollution and urbanization (Salvatierra Martínez et al., 2019).

The pollution from the blue jeans, at least one who suffers from asthma. My daughter was hospitalized for 10 days. Yes, it does have a big impact. (Interviewee 6, personal communication, September 13, 2023)

In general, the immigrant women interviewed highlighted three fundamental problems related to pollution. The first is respiratory diseases. This situation particularly affects children and adolescents and is aggravated by factors such as lack of access to adequate medical care, poor housing conditions, and location in areas with high pollution levels. A second problem relates to mental health, as environmental degradation can cause stress, anxiety, and depression, compounded by economic difficulties and the process of adapting to the Colombian context. The third problem concerns children’s health, as children and adolescents are particularly vulnerable to the effects of air pollution, which can affect their physical and cognitive development because they are at greater risk of respiratory and allergic diseases.

Social Cohesion

Immigrant women and their families may face social isolation due to their distance from family and community networks. The lack of support networks can increase their stress and vulnerability to mental and physical health problems.

Although the family is the primary personal and social support network and seeks to meet the basic physical and psychological needs of its members, according to Aguilera (2008),

The modern family has changed from its more traditional form in terms of functions, composition, life cycle, and the role of parents. The only function that has survived all the changes is that of being a source of affection and emotional support for all its members. (n.p.)

Changes in families due to migration also reflect their capacity for flexibility, which is evident in the modification of their structures, rules, dynamics, and functions (Wagner, 2011), including demands in health matters. For example, in the case of illness of one of the household members,

The more the family manages to adapt to that event and all the processes that will be necessary from that point on, the more flexible that structure will be, leading to adaptation and, consequently, to the concept of family health in that systemic perspective. (Scorsolini-Comin, 2022, n.p.)

Thus, the family is the primary setting for caring for immigrants’ health issues, and it is its flexibility that allows it to cope with these situations. However, it should be noted that caregiving and prevention responsibilities fall almost exclusively on women, while men contribute financially to cover medication and medical care costs when necessary.

Support networks are essential in the field of health, as it is necessary to create new family and social ties or networks among friends, fellow countrymen, and nationals to improve quality of life and generate new strategies for dealing with different problems, including health issues. Social support networks have a direct influence on the well-being of Venezuelan immigrants and their families, as they offer emotional and psychological support, especially in situations of stress, isolation, and adaptation to the new context in Colombia.

We Venezuelans help each other, because not everyone has a job, but we all have the same rights. (Interviewee 1, personal communication, September 4, 2023)

This type of support can help reduce anxiety, depression, and other mental health issues among immigrants and enable them to adequately manage these situations on an individual and family level. It can also provide them with access to health resources and services and material support to improve their living conditions.

I live with other people I met here in Medellín. There are three of them, just acquaintances. We share the household expenses. (Interviewee 2, personal communication, September 4, 2023)

Therefore, family and social support networks play a fundamental role in the mental and physical health and well-being of immigrant women and their families, which coincides with studies that argue that migrant individuals and organizations have a good understanding of the difficulties they face and have the ability to intervene in informal settings, as well as organize care and distribute health resources through social networks (Carruth et al., 2021).

Psychosocial Factors

Among the most significant impacts of discrimination, stigma, and xenophobia on immigrant women is stress, as they constantly face situations where they are treated unfairly or excluded because of their nationality. This can have a long-term negative effect on their mental and physical health.

We are the same people. I don’t know why they discriminate against me and call me “veneca.” We are immigrants, and they reject us for being migrants. (Interviewee 1, personal communication, September 4, 2023)

Experiences of discrimination can cause feelings of anxiety, depression, and hopelessness in immigrant women, which add to their constant concern about their irregular immigration status and lack of financial resources to meet their family’s basic expenses.

I went to the doctor because my eyes hurt a lot, and he said that it wasn’t a general medicine issue, that it had to be treated by an ophthalmologist. What can I take? What drops can I use? He replied, “No, I won’t tell you anything because you are Venezuelan, and I have to watch my back.” Make an appointment with an ophthalmologist, and since then I haven’t been able to see a doctor. (Interviewee 8, personal communication, September 4, 2023)

Furthermore, some instances of discrimination originate from healthcare professionals and staff at institutions that provide medical services, creating barriers to healthcare access for the migrant population. In this regard, stigmatizing and prejudiced attitudes on the part of healthcare personnel can lead immigrants to discontinue their medical and pharmacological treatments, not seek healthcare services when they need them, and instead opt for other strategies to address their health problems.

According to Candanoza (2021), there are “three important variables: perceived discrimination, psychological well-being, and coping strategies among Venezuelan migrants residing in Colombia” (p. 9). Immigrant women perceive discrimination from nationals and foreigners, a lack of job opportunities, and the absence of social support networks, which undermines their mental and physical health and well-being and leaves them in a state of greater vulnerability, exposed to situations of exploitation and marginalization that violate their rights.

Immigrant women face barriers to accessing mental health services due to their irregular immigration status and, consequently, their inability to enroll in the Colombian health system. In addition, there is a lack of awareness of mental health care pathways, and they fear being stigmatized, which further hinders their ability to seek support for physical and mental health problems affecting them or their family members. The results are consistent with other studies that affirm that discrimination has a negative effect on the mental health of international migrants, as they may experience both social and psychosocial vulnerability, experiencing symptoms of anxiety and depression (Blukacz et al., 2020).

Conclusions

To improve the health and well-being of Venezuelan immigrant communities in Colombia, it is essential to adopt a comprehensive and intersectional approach to analyzing SDH. This involves ensuring equality in access to healthcare, addressing stigma and discrimination, and promoting inclusive policies that facilitate their integration and well-being. Social cohesion and family support also play a crucial role in mitigating the negative impacts generated by these determinants, underscoring the importance of building strong support networks to promote health and well-being in immigrant families.

Statements

References

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Derechos

Artículo de investigación / Research Article / Artigo de pesquisa