Caracterization of participants

Table 2 presents the sociodemographic characteristics of the participants: eight international immigrants, two directors of Family Health Centers, and the mayor of Coquimbo commune. The group of immigrants comprised mainly single women from Colombia, Peru, Argentina, Bolivia, and the Dominican Republic, who worked as waitresses or domestic workers and, in general, had completed secondary education or obtained a vocational associate degree; just one had a professional degree from a university. 

Case description and analysis 

The “Social and health vulnerability of international migrants using primary healthcare in a city in northern Chile” is described below on the basis of the information collected, and is supported by quotes from the participants. In turn, this situation is analyzed from four perspectives, which are summarized in Table 3.

Firstly, concrete and specific aspects are presented and analyzed: the social and demographic characteristics of migrants, social determinants of health, health risk factors, and health problems of the group studied. In order to characterize participating immigrants and their context, it is necessary to ascertain their current occupations and health needs. The motivational factors influencing migration are associated with the pursuit of job opportunities to improve migrants’ economic situation and personal development: “I’ve dreamt of leaving my country to get ahead” (Female interviewee 1, personal communication, November 2014), “a better life for my family” (Female interviewee 7, personal communication, December 2014). Migrants’ perception of the economic conditions in Chile also plays a part in their decision to emigrate. This has been shown in the realities described here and by ^{Marroni (2016)} , who stated that globalization drives population mobility between countries with disparate levels of development and the growth of diverse labor markets, and is part of the South-South migration phenomenon. 

Sadly, job expectations are not always met in receiving countries. The participants’ accounts reveal social conditions such as the lack of health insurance, low qualifications, low wages, sporadic and informal work (such as domestic services, traders, prostitution, waiting tables, etc.) and a need to share housing with one’s core social network (children, family members or friends). Several interviewees are single mothers and descended from Afro-Americans, and are separated or in dysfunctional family relationships: “Well, the people I’ve treated here, two immigrants with immigrant children, a Bolivian woman and a Mexican woman – yah – are in very, very difficult situations because they haven’t got a professional degree” (Female interviewee 6, personal communication, November 2014). Their poor saving capacity limits their ability to send money back to their country as a result of high living costs: “We spend a lot, ha, ha – what I mean is we can’t save anything” (Female interviewee 2, personal communication, October 2014). The participants’ descriptions clearly support the assertion made by ^{Elizalde et al. (2013)} in the sense that migrants are often devalued in the workforce; the skills they acquired in their countries of origin are not recognized and they resort to less stable work.

So far, the study suggests that the immigrant population using primary healthcare in the Coquimbo commune exhibits social and health vulnerability, primarily as a result of their working and socioeconomic conditions. This is in line with ^{Urzúa, Heredia, and Caqueo-Urízar (2016)} who establish a link between income and quality of life among immigrants in northern Chile, along with other factors like one’s family situation and relationship status, which also influence immigrants’ life trajectories according to ^{Stefoni, Bonhomme, Hurtado, and Santiago (2014)} . Similar conditions of psychosocial vulnerability have previously been described among migrants from other Latin American countries ( ^{Elizalde et al., 2013} ). 

As far as health needs and problems are concerned, the interviewees mention common self-reported conditions affecting themselves and close family members, such as colds, colon disorders, anxiety, obesity, vision problems, gallbladder problems, or high blood pressure: “I have a vision problem, that’s the prime concern for me” (Female interviewee 1, personal communication, November 2014), “I come for healthcare for him, I come for general treatment, care for my son and stomach pain, that’s the thing” (Female interviewee 7, personal communication, December 2014), “checkups for the boy and my wife who […] gave birth not long ago” (Male interviewee 3, personal communication, March 2015), “yah, my mom had surgery a little while ago, yah, she had everything removed, the colon is our biggest problem, and all my sisters, my mom and I all [suffer] from that” (Female interviewee 5, personal communication, October 2014).

Some immigrants and one Family Health Center director note cases of depression and symptoms such as irritability and fatigue. They consider themselves at risk due to their poor ability to adapt to a change in lifestyle: “Some people with depression […] because when they come here for the first time, in the first few months” (Male interviewee 9, personal communication, October 2014), “it also depends on the nationality, what I can say is that mental health is closely associated with acculturation, in my own case” (Female interviewee 6, personal communication, November 2014). These aspects of mental health support the meta-analysis conducted by ^{Jurado et al. (2016)} on the migrant population at a global level. Factors affecting emigrant vulnerability to the development of common mental disorders are their country of origin, being female, having a low level of education and social status, and one’s family situation and relationship status, as well as factors associated with the migration process such as language, acculturation, the need to migrate, and migration planning. Similarly, discrimination is identified as an aspect that may modulate the perception of mental issues such as high sensitivity and depression, as described by ^{Burman (2016)} in her study on Peruvian migrants in Santiago de Chile. 

Positive intervening factors were identified as emergent categories and are associated with the existence of support networks and self-care. As far as social acceptance and discrimination are concerned, the feeling of marginalization reported by immigrants is inconsistent with the directors’ claim that Chileans do not discriminate against migrants. On the one hand, one immigrant stated, “They won’t rent to us because we’re foreigners, they say we’ll damage their property or make a huge mess […] so it’s like we don’t have the same rights as those who were born here, in Chile” (Female interviewee 2, personal communication, October 2014), while another claimed, “The lower one’s level of education, the more discrimination there is. If you’re more highly educated, there’s less, but you can still sense it, I mean, it’s more subtle, I think” (Female interviewee 6, personal communication, November 2014). On the other hand, a director explained, “When they enter the system, they have exactly the same benefits as the Chilean population, they access the system as users, like those who take up employment […] there is no discrimination of any kind in that sense” (Male interviewee 9, personal communication, October 2014).

Acculturation is the process that leads human groups to integrate culturally into a society. In that sense, ^{Berry’s (2008)} model posits four strategies from the perspective of a minority group integrating into a society: 1) assimilation: the minority group does not wish to preserve its culture but rather become permanently absorbed into the new one; 2) separation: the new group does not wish to lose its own culture and avoids engaging with others; 3) integration: both groups wish to preserve their own cultures, but do engage with each other; and 4) marginalization: there is little interest both in preserving one’s own culture and in engaging with others. Acculturation strategies are important for migrants’ adaptation process and mental health ( ^{Urzúa et al., 2016} ). For the study participants, the process of assimilating to the Chilean culture included two components: on the one hand, a tendency toward separation, as a result of the ability to construct networks with other immigrants to solve or deal with problems: “We get together on public holidays or Sundays, for instance, but sadly, we don’t have a place, a room, that’s what we need […] we may be able to get one though” (Female interviewee 1, personal communication, November 2014). The second component is assimilation through efforts to adapt: “Leaving the family is a difficult process, isn’t it? […] Learning from you, because when you arrive in a new culture, you don’t know what’s acceptable and what’s not, the norms, so much, there’s so much in a culture […] adapting is tough. Cultural pressure, meaning that the dominant culture always takes precedence over the immigrant’s culture, makes it difficult to engage and form relationships” (Female interviewee 6, personal communication, November 2014). Regarding the capacity for integration, ^{Urzúa, Vega, Jara, Trujillo, and Muñoz (2015)} remark that social integration boosts a group’s quality of life in their study on immigrants in northern Chile. However, according to ^{Berry (2008)} , this strategy requires the participation of the receiving society – in this case, Chileans. In this sense, integration may be facilitated when a positive view is taken of immigrants’ professional qualifications; one user of a health center, an immigrant with a professional degree, stressed the value of higher or professional qualifications: “I think being a professional gives you certain advantages because you have a degree, or access, obviously, although the conditions in my field are not the best” (Female interviewee 6, personal communication, November 2014). 

Self-care is a reflection of participants’ positive attitude and may act as a protective factor for health, as participants pointed to concerns over improving their diet, skills for handling stress and anxiety, and guarding against sexually transmitted infections (STIs): “I think that having healthy habits, for example, practicing sport and eating a balanced diet that combines foods from different food groups […] that’s what I try to do” (Female interviewee 6, personal communication, November 2014), “the most important thing is making sure I don’t get HIV some day […] that’s most important! Yes, that’s the main thing really” (Female interviewee 5, personal communication, October 2014). They also showed a willingness to receive psychological care at the Family Health Center to overcome a difficulty or contingent problem: “I ask for help; that is to say, I ask my sisters to come with me to the Community Mental Health Center (Cosam) […] to be seen, yah, to see what’s up, what’s the matter” (Female interviewee 5, personal communication, October 2014). This positive attitude toward self-care was also described by ^{Cabieses et al. (2012)} , who point to a greater use of prenatal and gynecological services by migrants compared to the Chilean population, which should be taken into account by healthcare staff to encourage preventive behavior both among migrants and the broader community. Studies conducted on the immigrant population in the United States show that immigrants exhibit less risk of diabetes in young people and less risk of STIs in Latin American women ( ^{Jaacks, L.M. et al., 2012} ; ^{Ojeda et al., 2009} ). It is possible that a sense of having less access to healthcare leads to a positive self-care attitude. In this sense, diet should be pointed out as a protective factor; ^{Concha (2015)} remarks that certain immigrants (for example, Peruvians) eat a more balanced diet than the Chilean population. 

A second level of analysis – from a specific and abstract perspective – identifies aspects associated with healthcare and access to such care. In this regard, the study brings to light scant knowledge of social and health benefits, both among immigrants and care providers. One finding is an urgent need for records of migrant users and the care they receive. Directors and migrants themselves state that health services have little information on immigrant users or beneficiaries, and point to immigrants’ lack of knowledge of the Chilean healthcare system. This is illustrated by these comments by the mayor of the commune of Coquimbo:

We haven’t quantified it, we don’t have any current measurements because the system gives you numbers and we’re working on a case-by-case basis […] we need a reliable record of which […] how many […] which population we’re talking about and the true demographic characteristics of that population, how many are children, how many are elderly […] and we also need to know who is covered by the public health system and who isn’t, who receives healthcare privately or through social aid” (Male interviewee 11, personal communication, January 2015). 

One Family Health Center director remarked that “in the last participatory diagnosis I saw, which was pretty well done and is from 2013, no mention was made of the immigrant population” (Male interviewee 2, personal communication, January 2015). Although health officials are aware that there is a significant number of migrants, they lack any special health strategies geared toward this population.

Moreover, it is clear that migrants are unfamiliar with the Chilean health system: “Well, when I was giving birth, I was kind of scared because I didn’t know if I’d be charged, perhaps a million, I don’t know how much […] that’s what I was told, it costs about that much […] and I don’t have that kind of money, I’m a single mother” (Female interviewee 10, personal communication, February 2015). These examples are in line with ^{Burgos and Parvic (2010)} ; a lack of information on healthcare and health benefits can jeopardize rights when access to care is restricted, whether this due to migrant beneficiaries’ unfamiliarity with the system, health workers’ lack of information on migrants’ rights, or fear on the part of migrants with irregular status.

Healthcare costs in Chile are high, notably because the public system is unable to meet demand. In the study, participants cited the lack of their own resources to cover medical costs, and congestion in the health service due to high demand: “The wait time is too long, we wait too much, we need to be seen as soon as possible and we have to wait a long time” (Female interviewee 1, personal communication), “you don’t receive care for the problem you have” (Female interviewee 5, personal communication, November 2014), “physically you don’t have the space to do it, so now we have a problem whereby professionals have to take turns in the same examination room, so it can’t grow because it’s limited by everything and a load of issues” (Male interviewee 2, personal communication, October 2014). 

In light of this, it was observed that migrant users prefer the service provided by the health system in their country of origin, primarily due to the costs, form of healthcare, conditions under which referrals are made, and state-sponsored dental and drug coverage: “Likewise, in my own case, I’m considering traveling with my daughter, perhaps to Bolivia, my country, to treat her eyesight, get her lens prescription looked at, and there’s the dental problem too, in this country it’s too expensive” (Female interviewee 1, personal communication, November 2014), “Hmm! Unlike the health system we have back in our country, which gives you greater coverage for medicine, specialist care, financially speaking, because you pay very little in Colombia, depending on your social background, and it’s not like that here, here everything costs money […] the thing is that Chile is a very expensive country in every respect” (Female interviewee 6, personal communication, November 2014). It is clear that the health sector has not sufficiently adapted to meet the needs of this population, leading to a preference for the healthcare system in the country of origin. 

The third dimension of the analysis is general and concrete, which in this case refers to the way the Chilean health system is organized and how local strategies for migrant healthcare are developed. In this regard, the Family Health Center directors and the mayor of the commune expressed their interest in addressing community demand and a willingness to organize consultations with other services in cases of violence or where social work is required: “If we go and visit them, they’re kind of reluctant to receive people. So they’re really quite particular, but all the same, we try to ensure the different health teams work where they should” (Female interviewee 10, personal communication, February 2015). Although this shows a concern, on an invidual level, for providing care for migrants, fulfilling their needs calls for tailored strategies to treat the most prevalent conditions (greater mental health coverage, sexual health checkups and guidance) and psychosocial support for life-threatening limit-situations. Some approaches, particularly with respect to children, were described by ^{Vásquez-De Kartzow (2009)} . As for strategies to improve the situation of migrants with respect to healthcare, ideas were proposed to bring health teams closer to the community: “I think that, maybe, the clinic could bring together the immigrants from my country and […] to improve care” (Female interviewee 1, personal communication, November 2014), “it would be like legalizing or helping foreigners more, so we have social secrurity, regardless of whether we have an employment contract” (Female interviewee 2, personal communication October 2014).

It should be mentioned that there are several health systems in Chile, and these vary depending on individuals’ economic condition. The public system serves most of the population, including the most vulnerable sectors. In this sense, the healthcare provided to migrants is shared with underprivileged locals due to their economic and social conditions. As a consequence, the perceived problems in public healthcare, and specifically at the primary level, are shared by Chileans and immigrants, and the frequency of healthcare problems reported by immgrants in the ^{2013 CASEN} survey is very similar to figures mentioned by Chilean users of the system ( ^{Ministry of Social Development, 2003} ). Considering that the health system is a fundamental step in social integration ( ^{Concha, 2015} ) and that the primary level is a model for bringing health services to communities, any public policy or strategy to improve and enhance primary healthcare will benefit both Chilean citizens and migrants.

Lastly, from a general and abstract perspective, it is worth analyzing aspects associated with public policy. Migration and health policies, including the right to health, fall under this category. These three aspects are closely related, given that the Chilean constitution stipulates that citizens have the right to choose their system of healthcare (public or private insurance) provided they hold an employment contract. In this sense, both Chilean and foreign workers with a contract (and their legal dependents) are entitled to healthcare and insurance under similar conditions, depending on income. This means, then, that documented migrants with an employment contract enjoy the same access to health and healthcare as Chileans in similar conditions. Citizens without an employment contract, on the other hand, fall under the category of indigentes (destitute people) and must use the public health system, thus losing the right to choose. As for migrants, participants’ accounts reveal an indeterminate number of undocumented migrants in a vulnerable and degenerate socioeconomic situation, who are unfamiliar with the healthcare system, making it difficult to use the support available effectively: “I live with […] women from foreign countries, we don’t have social security […] the money we earn is just enough for the rent, nothing else” (Female interviewee 2, personal communication, October 2014). The situation described supports the claims made by ^{Cabieses, Pickett, and Tunstall (2012)} in the article “What are the living conditions and health status of those who don’t report their migration status?” From a structural perspective, the differential in social and health vulnerability may therefore result from irregular migratory and work status, which prevents them from being identified by the system, marginalizing them for the purposes of healthcare. Nonetheless, a revision of the regulations provides a way out of this impasse through Decree No. 67 by the ^{Ministry of Health of Chile (2015a)} , by which irregular immigrants, or those without a visa or documents, become beneficiaries of Fonasa. However, many are unaware of this possibility, so one relevant proposal would be to disseminate this information on available health benefits. In this sense, the Ministry of Health of Chile has implemented pilot programs for migrant healthcare in three cities in the north of the country and two communes in the capital, Santiago de Chile ( ^{Ministry of Health of Chile, 2015b} ). However, such efforts seem inadequate in places where migrants are already arriving, as the system is ill-prepared to offer healthcare in line with the specific needs of this population group, as is the case in the city of Coquimbo.

It should be mentioned that the research has some limitations. Firstly, it is exploratory and nested within a larger study, limiting methodological flexibility. Similarly, the exploratory nature of the study limited the development of theories that may provide a more in-depth explanation of immigrants’ social and health vulnerability. However, insight was gained into the factors that influence this vulnerability from the perspectives used to analyze this situation (shown in Table 3). Although the study was conducted across a commune, through its qualitative and explorative nature, it seeks to draw on participant discourse to understand migrants’ situation rather than generalize it. It is also worth considering that health vulnerability associated with public policy and the organization of the system are a problem at a national level in Chile. As far as healthcare and associated resources are concerned, the situation in the commune under study is similar to that found in other cities or urban communes in the country, where primary-level healthcare is also managed by the municipality, and governed by the same funding system and regulations ( ^{Ministry of Health of Chile, 2012} ; ^{Subsecretariat of Health Aid Networks [Subsecretaría de Redes Asistenciales], 2015} ).