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Revista chilena de pediatría

Print version ISSN 0370-4106

Rev. chil. pediatr. vol.88 no.6 Santiago Dec. 2017

http://dx.doi.org/10.4067/S0370-41062017000600707 

ORIGINAL ARTICLE

Health inequality gap in inmigrant versus local children in Chile

Baltica CabiesesA 

Macarena ChepoB 

Marcela OyarteC 

Niina MarkkulaD 

Patricia BustosE 

Víctor PedreroF 

Iris DelgadoG 

A Social studies in health research programme, Facultad de Medicina Clínica Alemana Universidad del Desarrollo; Visiting scholar University of York. Social epidemiologist, PhD, Chile. Correspondence: Baltica Cabieses bcabieses@udd.cl.

B Social studies in health research programme, Facultad de Medicina Clínica Alemana Universidad del Desarrollo; Community health specialist, MSc(c), Chile.

C Social studies in health research programme, Facultad de Medicina Clínica Alemana Universidad del Desarrollo; Biostatistician, MSc(c), Chile.

D Social studies in health research programme, Facultad de Medicina Clínica Alemana Universidad del Desarrollo; MD, PhD, Chile.

E Health department, Servicio de Salud Metropolitano Occidente, kinesióloga, MSc(c), Chile.

F Social studies in health research programme, Facultad de Medicina Clínica Alemana Universidad del Desarrollo; Nurse, psychometrist, MSc, Chile.

G Centre of Epidemiology anf Health Policy, CEPS, Facultad de Medicina Clínica Alemana Universidad del Desarrollo; Mathematician, MSc, PhD(c), Chile.

Abstract:

Introduction:

Children and young international migrants face different health challenges compa red with the local population, particularly if they live in insecure environments or adverse social conditions. This study seeks to identify gaps in health outcomes of children between immigrant and local population in Chile.

Methods:

This study analyses data from three sources: (i) Born in Chile: Electronic records of antenatal visits from all municipal antenatal clinics of Recoleta in 2012; (ii) Growing up in Chile: Population survey “National Socioeconomic Characterization” (CASEN) from 2013 and (iii) Getting sick in Chile: Data of all hospital discharges in 2012, provided by the department of statistics and health information (DEIS) of the Ministry of Health.

Results:

(I) Born in Chile: Im migrants more frequently have psychosocial risk (62.3% vs 50.1% in Chileans) and enter later into the program (63.1% vs 33.4% enter later than 14 weeks of pregnancy). All birth outcomes were better among immigrants (e.g. caesarean sections rates: 24.2% immigrants vs % Chileans). (ii) Growing up in Chile: A higher proportion of migrant children is outside the school system and lives in multidi mensional poverty (40% immigrants vs 23.2% Chileans). (iii) Getting sick in Chile: Injuries and other external causes were more frequent cause of hospitalisation among migrants (23.6%) than the local population (16.7%) aged between 7 and 14 years.

Conclusions:

Addressing the needs of the children in Chile, regardless of their immigration status, is an ethical, legal and moral imperative.

Keywords: Inequality; Emigration and inmigration; Child; Health status

Introduction

In 2015, 244 millions of international immigrants in the world were recorded, 41% more than in 20001. It has been estimated that 37 million of those immigrants are younger than 20 years old, and most of them live in developing countries2. Recently, it has been recogni zed that the migratory condition can be an indicator of social vulnerability or social inequality in health inside of a country1,2,3,4,9,10 and that specific migratory variable, that can be modified or anticipate, can be of great im portance in this process8. The main factor that affect the health of international migrants are work condi tions, cultural barriers, access and use of health servi ces, previous conditions of their country of origin, resi dence time in the destination country (associated with phenomena of assimilation and acculturation), social processes of integration /exclusion and experiences of stigma and discrimination11,12,13.

The last childhood report of the United Nations 2016 (The State of the World’s Children 2016: A fair chance for every child) presents crucial information about the importance of being born and to grow up in a familiar, community and sociocultural environment, and also permanent, safe and healthy growth opportunities3. Children and young international migrants face different challenges in health, in comparison with the local population, specifically if they confront insecure environments or unfavorable social conditions. Cha llenges, such as the lack of access to medical attention and social services, also the exposure to an insecure neighborhood or to contaminants are known factors of risk for their health4. In addition, the immigration process is a source of many factors of psychosocial stress. Whether it is forced or voluntary, migrations imply the separation from their family and culture. In secure work conditions and other challenges without the support network and a habitual social capital expose them to higher levels of anxiety and challenges them to deal with social integration. Forced migration, resulting from a conflict, the economic insecurity o natural disasters, worsen the risks of mental health of international migrants, including children5,6,7.

These risk factors result in adverse outcomes for the health of international migrant children. Accor ding to the datum in the literature, children born from mothers with a history of migration have a higher in cidence of fetal death, neonatal mortality, premature delivery and low birthweight8,9,10,11. The status of physical health of migrant children after birth has been studied less accurately; however, there is evidence of a higher prevalence of dental caries, some infectious diseases10,12 and obesity13. Mental health problems and psychoso cial integrity problems have also been reported14,15. It is important to recognize that various studies have been focused in the mental health of this group, but it has been difficult to obtain conclusive results due to the different methodologies of study, definitions, and con text of the international migrants among the studied countries16.

Besides the differences in the factors of risk and the state of health, the use of health services in migrant families can differ from the local population. The re asons for this are diverse and include, for example, di fferent patterns of disease, different ways of accessing the health system, economic and social variability, and the partial or total healthcare coverage. In fact, syste matic reviews have reported a reduced use of the pre natal health services between pregnant immigrants8,17. There are few studies of the use of health services by in ternational migrant children. In Switzerland, children of migrant families have a significant major use of the hospital services and of intensive care than local popu lation10. In Spain, a study made in 2009 showed that children from migrant families had, significantly, less chronic diseases, while the perceived state of health, according to the auto-evaluation of the parents or keeper, was worse if both parents were immigrants18. Differences in the use of sanitary services between immigrant children and locals can be analyzed by other socioeconomic factors, such as poverty and ethnic origin19,20,21.

According to the international evidence, health issues and the use of health services by migrants children can be summarized in: (i) the difficult ac cess and the unfamiliarity with the new health care system, (ii) language barriers, (iii) differences in the expectations and perceived needs by this migrants, (iv) differences in the payment capacities of health-related costs and (v) cultural differences of the defi nitions of diseases and the expected treatments. The few available studies of migrant children indicate that language barriers22 and the expectations of parents regarding the health system6 are particularly relevant. Concerning this last topic, a qualitative study of Po lish families in Scotland shows that migrant parent’s concerns about the health services are likely to affect their beliefs and child behaviors23.

The purpose of this study is to identify the existing gaps in results of childhood health (up to 14 years) between the international migrant population and the Chilean population, based on three available sources of quantitative information: (i) Born in Chile: Datum of a prenatal consultation obtained from 4 primary health center in the commune of Recoleta (2012), (ii) Growing up in Chile: Datum of a population survey CASEN 2013 and (iii) Getting sick in Chile: hospital discharges datum in 2012. It is expected that this stu dy will contribute with unpublished evidence of the difference between the health of migrant children and Chilean children, in favor of a more inclusive society and more respectful of diversity, as well as a health system more cautious of the compliance of the in ternational declarations regarding the healthcare for children.

Methodology

An analytical quantitative study focused on com paring the differences of access, use of services and re sult of international migrant’s health versus children born in Chile. This study is part of the objectives of the project Fondecyt 11130042 “Developing Public Health Intelligence in Primary Care for Internation Immi grants in Chile: A Multi-Methods Study” (2013-2017), whose purpose is to create new knowledge about life conditions, access to health services and results of in ternational migrant’s health in Chile (approval from the Ethics Committee of the Faculty of Medicine UDD and the Ethics Committee of Conicyt).

1. Born in Chile: Quantitative datum of prenatal consultation 2012

The quantitative datum of the prenatal consul tation was obtained from anonymous electronic re gisters of female users of all CESFAM of municipal administration of the commune of Recoleta, during 2012 (Cristo Vive was excluded since it depends on a foundation). Said registers belong to a database of the Chile Crece Contigo program, complemented with the register of each attendant of the CESFAM program for women. This database contains sociodemographic antecedents, obstetric antecedents, and maternal morbidity, as well as variables related to the actual pregnancy control and to the final result of the birth. To analyze the database, women with health benefits that assisted with newborns, woman with more than 70% of their observations in blank and women with multiple pregnancies were excluded, reaching a database for the analysis of 1,272 cases, of which 11,012 where Chilean and 260 (20.4%) were international migrants. This database was handed in anonymized by the Department of Health of the Mu nicipality of Recoleta.

Through measurements of frequencies, sociode mographic characteristics, use of prenatal controls, risk factors in the result of pregnancy and birth, inclu ding co-morbidities and biopsychosocial risk (EPSA questionnaire), both in immigrant population (who possesses a nationality other than Chilean) and in Chi lean population were described. In addition, comparations between said populations were made at 95% confidence (T-test and Fisher’s exact test, according to the number of observations, and Chi-square test).

2. Growing up in Chile: Quantitative datum from population survey CASEN 2013

An anonymous population survey “Caracteriza ción Socioeconómica Nacional” (CASEN), developed by the Ministry of Social Development every 2-3 years and can be download from the internet by free. It mea sures the socioeconomic status of every household in the country and it represents residents in private ho mes in 324 communes of 15 regions in the country, excluding around 15 communes that are hard to ac cess and institutionalized persons. This survey used a stratified probability sampling19. By 2013, this survey had 66,725 surveyed households, corresponding to the information of 212,346 Chileans, 3,555 immigrants and 2,590 persons who preferred not to report their migratory status (lost datum and excluded datum from this analysis). Using factors of expansion for the population representation, those represent 16,689,377 Chileans and 354,581 immigrants (96.6% and 2.1%, respectively). According to CASEN 2013 datum, there are 4,718,494 children and teen under 18 in Chile, out of that 1.4% are migrants and a 1.2% of the cases were not possible to determine their nationality. In this da tabase, people who said that their mother did not live in Chile at the moment of their birth (first generation immigrants) are considered immigrants.

In the analysis, they did estimations of the sociode mographic profile of the migrant and Chilean popula tion (measures of key trends and dispersion or propor tions according to the variable) and comparison bet ween said populations at 98% confidence, taking into account the complex design of the sample.

3. Getting sick in Chile: Quantitative datum of hos pital discharges 2012

The analysis of hospital discharges provides infor mation, such as morbidity, use, supply, demand, and quality of the health care services25. From the point of view of access and use of health services, the obtained indicators from hospital discharges (HD) are impor tant to recognize and adjust the health services to the needs of different population’s subgroups26. The data base of the hospital discharges in 2012, provided by the Department of Statistics and Health Information, Mi nistry of Health, contains information about gender, age, nationality, residence and health insurances, along with information of the hospitalization, such as diagnosis, discharge status or death, surgical interventions, days of hospitalization and information of the insta llation where the HD was emitted. In this database, persons whose nationality was different from Chilean were considered immigrants. It is important to men tion that the analysis unit of this database of hospital discharges 2012 is the discharge itself, not the patient. It is worth pointing out that there might be more than one discharge per person, which is common in persons with chronic and severe conditions. Although, this is highly unlikely in the case of a result of a birth.

They estimated frequency measurements, with a test of comparison of proportion with a significance le vel of 0.05%, for the hospital characteristics (discharge status, surgical intervention, and diagnosis, according to the ICD-10) and sociodemographic of the hospital discharges, by migratory conditions and age.

Results

1. Born in Chile

From the female users of the Chile Crece Contigo (ChCC) program, of all CESFAM of the commune of Recoleta during 2013, 20.4% (n = 260) were female in ternational migrant, and most of them (80.8%) were from Peru, followed by Colombia (4.5%), Haiti, Bo livia, Dominican Republic, Argentina, and Ecuador. The average age was slightly higher in immigrant wo men than in Chilean women (27 and 26, respectively). From Chilean women that assisted to the program, 20.1% (203 cases) were younger than 19, a number that is almost twice the percentage of immigrant wo men in the same situation, 10.8% (28 cases). The num ber of married immigrant women or with a partner, in comparison with Chilean women, is higher (68.5% and 54.7%), they also report that they have a higher level of secondary education or higher education that Chilean women. 28,8% of female immigrant did not have health insurance, only 0.8% of Chilean women did not have health insurance (p < 0.001).

There were no differences of importance in parity of immigrant and Chilean woman. On the contrary, it is possible to observe that 29% (n = 76) of immigrant reported one or more abortion in their life, while Chi lean women have a percentage of 18% (n = 188).

There were no important differences in the rates of derivations to the secondary level among immigrant and Chilean women (Table 1). High blood pressure was slightly more common in the migrant population, while gestational diabetes was more common in Chi lean woman. Immigrant showed a higher proportion of biopsychosocial risk (immigrant, 62.3%, and Chi lean, 50.1%), although, there is a bigger proportion of Chilean woman in a severe risk (immigrant, 2.7%, and Chilean, 8.3%). It is possible to observe a higher percentage of immigrant women with depression than Chilean woman, although this difference was not sta tistically significant.

Table 1 Proportion of risk factors for the development or termination of pregnancy in women users of the Chile. Grows with you program, CESFAM Recoleta 2012, according to migratory condition. 

A late admission to the program was more com mon in pregnant migrants, after 14 weeks of pregnancy (33.4% in Chilean women and 63.1% in an immigrant woman) (Table 2). This difference remained even after the stratification, to determine if women started their controls in CESFAM or if they were transferred from another center.

Table 2 Use of antenatal program of pregnant women members of the Chile Grows with you program, at the commune of Recoleta during the year 2012, according to the migratory condition. 

On the other hand, at the end of the pregnancy, 4.3% of women were transferred to another center and only 10.9% did not go to their controls after the birth. Immigrant women have significantly better results at birth, less premature births, fewer newborns with low weight and cesarean births or forceps (Figure 1). This remained even after stratifying by age, referral to High-risk pathological obstetrics clinic (COPAR), late access to maternal consultation and biopsychosocial risks.

Figure 1 Use of the Chile Grows with you program, of four primary care facilities at the commune of Recoleta during the year 2012, according to the migratory condition.  

2. Growing up in Chile

Most of the infant population in Chile are 7-15 years old, including immigrants; however, the number of immigrant children is significantly higher (49.6% of the total amount of migrant children). In the local populations, differences by gender do not exceed 5 percentual points in any age group, while in the migrant population, the group of children younger than 1 year is strictly formed by males (65.5%). On the other hand, in the group of 1-6 years, there is a higher number of females (66-65%) (Table 3).

Table 3 Sociodemographic profile of the population of migrant versus Chilean children, CASEN 2013. 

Regarding the level of education, there is a hig her proportion of migrant children (79.5%) in the scholar system than Chilean children (64.2%) in the group of 1-6, while in the next groups there are more Chileans the scholar system. The reasons for parents to decide not to send their children to school vary in the age group. Parents in the 1-6 group consider that it is not necessary (Chilean parents: 74% and migrant parents: 57.4%) or they do not trust in the care (migrant parents: 16% and Chilean parents: 3.4%). In the 7-14 group, the migrant population commonly indicate that “they do not know” or they “will not an swer” and Chileans indicate that because of disability. Lastly, in the 15-18 group is because they are looking for a job (41.7%), on the other hand, Chileans indi cate that because they already finished their studies (22.5%) and on second place because they are loo king for a job (19.7%). Regarding the socioeconomic status, more than 50% of migrant children, between 1 and 6 years, come from multidimensional poor households (i.e. households with 25% or more poor wellbeing indicators), which correspond to double the number of Chileans. This phenomenon still has small variations up to the 15-18 group. Finally, 3.4% of immigrants younger than 7 years were malnouris hed or in risk of malnourishment (against a 2.3% in Chileans) and 1.7% had overweight or obesity (aga inst 13.8% in Chileans).

3. Getting sick in Chile

During 2012, there were a total of 1,659, 654 of hospital discharges in Chile, and 0.5% corresponded to the international migrant population. From the to tal number of discharges of children younger than 18, 0.19% were international migrant patients (666 hospi tal discharges) (Table 4). From the hospital discharges, 46% were children from 15 to 18, while Chileans were only 21.1%.

Table 4 Hospital discharges of patients under 14 years old according to migratory condition, Chile 2012. 

From the distributions of hospital discharges of migrant patients between ISAPRE (Private system), FONASA (Public system) and no insurance were all similar, around 30%. However, this situation is diffe rent in hospital discharges of children younger than 1 (66.2% FONASA, 26.1% ISAPRE and 19.5% without insurance).

Transversally, one of the most common causes of hospital discharges in children younger than 18 was because of diseases of the respiratory system. Mi grant children from 7 to 14 showed a higher propor tion of hospital discharges due to neoplasm (12.1% against 5.5%) and congenital malformations (9.3% against 4.2%), while immigrants between 1 and 6 had more discharges due to consequences of external causes (23.0% against 12.8%) and children younger than 1 had more discharges due to problems in the prenatal period (54.9% against 40.2%). It is surpri sing that besides the attention, both in children of 1 and from 7 to 14, the proportion of discharges due to respiratory problems was lower in immigrants that in Chileans (12.7% against 28.9% and 8.6% against 14.2%, respectively). Lastly, it points out that the high percentage of discharges due to pregnancy in females younger than 15 and 18 in both populations (Table 4).

Discussion

This is one of the first studies that describe the health of migrant children in Chile, using three sour ces of quantitative information. Given that the migrant child population grows gradually in Chile, it is impor tant to determine their condition of life and sickness. Even if the available information is limited, it certainly allows to answer some questions and to create a new working hypothesis that could be tested in the future. The studies of the international migrant population are of broad utility for the public health27 by allowing to compare population with different genes and races, and various socio-cultural and political experiences, which at some point will change their social and envi ronmental surrounding, getting used to the host cou ntry.

This study shows that a high percentage of preg nant migrant women do not have health insurance, they also start their controls late and have a higher psychosocial risk than Chilean women. Despite this, migrant women have better birth results. Regarding the sociodemographic profile, the higher number of migrant children in multidimensional poverty and the higher percentage of scholars (15-18 years) do not fi nish their studies significantly stand out. In the hos pitalization analysis, it is possible to observe a high percentage of children without health insurance. Re garding the hospital discharges differences between the migrant and Chilean population, those that stand out are respiratory problems, where the proportion in migrants is lower than in Chileans and in traumatisms and other external causes, such as neoplasm and con genital malformations, where the proportion in mi grants is almost the double of the Chilean population in some age groups.

It is interesting to note that, despite the existence of more pregnancy risk factors in the migrant popu lation (late access and psychosocial risk) and the simi lar obstetric profile, migrant women have better birth results than Chilean women. Only 24% of the births are by cesarean section (against 34% in Chilen women) and only 28% present a problem (against 44% in Chi lean woman). It is important to develop a major re search of these paradoxical results that apparent effect of “healthy migrant”, which can be explained by the differences on age, natural selection of healthier mi grants that manage to get to Chile or by other social processes of protection of health as a social resource.

It is important to integrate these results from a so cial perspective of the health. The high proportions, both in pregnant women and immigrant children without health insurance, are alarming because this population has the risk of not being able to access to health services on allow the access to health services in an irregular status. Another alarming finding the high rate of traumatism in migrant children is almost 25% of the hospital dis charges among children from 1 to 6 years, compared with 13% of Chilean children. This might be related to the higher multidimensional poverty that migrant children experience, including poor living conditions, dangerous or violent neighborhood, the need to leave college and start working, among others.

This study has information from various sources, which increases its efficacy, but it still has some limi tations. It is possible that there is bias in the selection of all databases, associated with the way in which the international migrant population is defined and mis takes in the register for the purpose of the analysis. In the analysis of the hospital discharges, it is impossible to clarify if the obtained results effectively reflect the information of the prevalence of morbidities or if they are consequences of a differentiated use of the health services among the migrant and Chilean population. Lastly, some central variables in the relation between migration and health, such as the socioeconomic status and residence time, among others, were unavailable, so it was impossible to elaborate a more detailed analysis.

The world has made great improvements to reduce the infant mortality, to send children to schools and to lift them out of poverty. Principally, the obstacles to getting to these children are not of technical nature, but an issue related to political commitment. Histori cally, Chile has been making outstanding health efforts in this field; however, we still need to update our defi nitions and indications, which is our infant population of interest, including the international migrant popu lation, which we do not know much about, that has been increasing during the last years. This study ex pects to contribute in this topic by generating evidence of life conditions, life, and hospitalizations of Chilean and migrant Children, and to look after the needs of children in Chile, regardless of their migratory status. It is an ethical, legal and moral imperative. This is the only way to minimize and prevent disfavorable condi tions for the healthy development of every person in our country30,31.

Ethical Responsibilities

Human Beings and animals protection: Disclosure the authors state that the procedures were followed ac cording to the Declaration of Helsinki and the World Medical Association regarding human experimenta tion developed for the medical community.

Data confidentiality: The authors state that they have followed the protocols of their Center and Local regu lations on the publication of patient data.

Rights to privacy and informed consent: The authors have obtained the informed consent of the patients and/or subjects referred to in the article. This docu ment is in the possession of the correspondence author.

Financial Disclosure: Authors state that no economic support has been asso ciated with the present study.

Conflicts of Interest: Authors declare no conflict of interest regarding the present study.

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Received: February 07, 2017; Accepted: June 08, 2017

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