As expected, this study showed a higher prevalence of several diseases, such as hypertension and diabetes in older age groups. More interestingly, almost all the illnesses considered showed a higher overall prevalence among the Moldovan immigrant women than among the Italian controls. The former made more use of health care services than the latter too. An association also emerged between health literacy level and both lifestyle and recourse to health care services.
Our sample of Moldovan immigrant women included a sizable proportion who were overweight (30.5%), or obese (17.7%). These figures are higher than the 22.1% for overweight and 10.1% for obesity among Italian women, but only half the percentages for Moldovan women in their home country, where 60.1% are overweight and 31% are obese (22). Another finding concerns the clustering of higher BMIs in the older age groups, while the younger immigrant women had lower BMIs. This may be a sign of an adaptive effect, with the immigrants’ lifestyles, such as their dietary habits, approaching those of their adopted country. Another possible interpretation of this phenomenon, however, is that women lose weight after migrating because of the hard living and working conditions they find in their adopted country.
The answers to our questionnaire indicate that less than one in five Moldavan immigrant women are smokers – a proportion almost in line with the Italian reference figure (21.3%) - and the prevalence of smokers was similar in all age groups. The Moldovan women’s reported alcohol consumption was moderate-to-high (nearly 1.5 UA a day), and one in three of our respondents exceeded the recommended limit for women (1 UA a day). In its “Global Alcohol Report” for the Republic of Moldova, the WHO indicated that alcohol consumption by women over 15 years old averaged 2 units/day (23). Our results suggest that our Moldovan immigrant women drink less than their counterparts at home, and slightly more than Italian women in the same age range, whose average alcohol consumption is 1 UA a day (24).
Concerning physical exercise, half of our sample reported engaging in some form of physical exercise in their free time, but one in three said they never did so. This level of sedentariness is higher than reported by Moldovans in their own country, which is 24.5% for adults generally.
As for the overall health status of our sample, there was a noticeably higher prevalence of several diseases compared with the Italian reference values. We identified a more than twofold self-reported prevalence of hypertension, arthritis/arthrosis, cervical disorders, diabetes, and allergies, and a threefold prevalence of lumbar disorders, depression and anxiety. If we look at the reported prevalence of allergies (36% for the Moldovan group versus 14.8% for the Italian controls), this may reflect the numerous studies in the literature indicating that migration to a highly-industrialized country favors the development of respiratory allergies in immigrants (25,26). As regards lumbar and cervical disorders, back pain has been found directly related to mental health disorders and stress in fact stress could contribute to the onset or the persistence of chronic pain (27). Another plausible explanation for these conditions is work-related, given the large proportion of our respondents who were home care workers and cleaners (jobs that involve the manual lifting of sometimes heavy loads). Analyzing our women by age group, the ratio for the prevalence of Moldovan and Italian women with lumbar disorders declines linearly from 6.3 for the younger women to 1.7 for the older age groups. The same trend could be seen for hypertension, for which the ratio went from 10 for the younger women to 1.3 for the older age groups.
Depression was reported by more than 10% of our Moldovan sample, with a slightly higher prevalence in the intermediate age groups. This is three times higher than the prevalence of 4.3% reported by a sample of 1827 Italian women living in the north-east of the country (16). This difference is more evident among the younger age groups, the prevalence ratio being 7.2 in the youngest age group and dropping gradually to 1.2 for the older women. When we investigated the issue of anxiety, the prevalence of this condition was a remarkable five times higher in the Moldovan women aged 45–54 and 55–64 than in their Italian counterparts, as opposed to a twofold prevalence in the other age groups. Analyzing symptoms usually associated with anxiety, depression and burnout (18) we found quite a high overall prevalence of daily headache, trouble sleeping, and extreme fatigue, possibly as a direct consequence of underlying stress. These symptoms were distributed throughout our Moldovan sample, with no significant differences between the various age groups considered. This could be also explained by high prevalence of chronic pain as described above, in fact chronic pain could be emotionally stressful (27). Chronic pain in fact is known to change the levels of stress hormones and these can affect your mood, thinking and behavior. Moreover, chronic pain can affect ability to function at home or work making also difficult to participate in social activities and hobbies, which could lead to decreased self-esteem. In addiction, chronic pain could provide sleep disturbances, fatigue, trouble concentrating, decreased appetite. These negative changes can dampen overall mood; and this can result in depression and anxiety. In addiction vulnerability to stress has already been described in migratory groups, especially for Eastern European citizens migrating westwards (28). The stress of migration per se can lead to depression and anxiety (29) or somatization (30) which are frequently underestimated. Such conditions of malaise can also be carried to the migrants’ home countries when they return. In fact, increasing attention is being paid to what has been called the “Italy syndrome”, which is a sort of psycho-social distress suffered by Eastern European migrant women (31,32).
When questioned about their recourse to health care services, our sample of Moldovan women of all ages reported a large number of visits to GPs and specialists. This can be interpreted as a sign of their integration, and proof of the good functioning of the Italian NHS. The proportions of women reportedly seeing a GP or a specialist in the previous month, or being hospitalized in the previous year were 47.6%, 37.2% and 12.2%, respectively. These figures are much higher than those of our Italian controls, which were 35.6%, 22.2% and 6.7%, respectively.
The proportion of Moldovan immigrant women of suitable screening age who reporting having undergone HPV testing or a PAP smear at least once in their life was much the same as for their Italian counterpart (88.8 vs 87.8%). The cumulative proportions of Moldovan and Italian women who had undergone a mammography at least once in their lives was also very similar (90.1% vs 91.3%) (16).
Our Moldovan immigrant women’s health literacy was judged to be good, bearing in mind the potential language barriers imposed by migration, as discussed in the literature (33,34). This reflects our sample’s generally high level of formal education, consistently with the reportedly well-functioning school systems of Eastern Europe (35). On the other hand, our study findings show that the Moldavan immigrant women’s health literacy only partly influenced their lifestyles, mainly as regards smoking (which was twice as prevalent among women with a lower health literacy level). An association between a lower health literacy level and a greater nicotine dependence has already been amply documented in the literature (11,36–38). Our study found no correlation between health literacy and BMI, alcohol consumption or physical exercise. Health literacy was a determinant of primary health care service use, however: respondents with a higher health literacy level visited GPs and specialists twice as often as those whose health literacy was limited, and made considerably greater use of screening programs (mammography and PAP smears or HPV tests), while recourse to Emergency Departments and hospitalizations was similar for the two sub-groups. There have been reports of a different, sub-optimal use of health care services by less health-literate individuals, especially in the case of immigrants (39,40). The impact of our results can be summarized in two points. First, Moldavan immigrants in Italy have a good health literacy level overall, comparable with that of Italy’s autochthonous population(41); and individuals’ health literacy was confirmed as a determinant of their attitude to smoking and to the use of some health care services (34). Bearing these findings in mind, adequate programs to improve health literacy in the general population - with a view to promoting healthy lifestyles - would be useful but need not target Moldovan immigrants specifically (42–44). Second, Moldovan immigrant women seem to have more health issues than their Italian counterparts, so this immigrant population should be a target of prevention programs - focusing on promoting a healthy amount of physical exercise, for instance, and providing appropriate (biopsychosocial) education on how to prevent lumbar pain.